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Otto et al 2020 ACC/AHA Guideline for the Management of Valvular Heart Disease February 2, 2021 Circulation. 2021;143:e72–e227. DOI: 10.1161/CIR.0000000000000923 e136 CLINICAL STATEMENTS AND GUIDELINES 10.2 Timing of Intervention for Mixed VHD 10.2.1 Intervention for Mixed AS and AR Recommendations for Timing of Intervention for Mixed AS and AR Referenced studies that support the recommendations are summarized in Online Data Supplement 33. COR LOE Recommendations 1 B-NR 1. In symptomatic patients with combined AS and AR and a peak transvalvular jet velocity of at least 4.0 m/s or a mean transvalvular gradient of at least 40 mm Hg, AVR is recommended.1,2 1 C-EO 2. In asymptomatic patients with combined AS and AR who have a jet velocity of ≥4.0 m/s with an LVEF <50%, SAVR is recommended.1,2 Synopsis The indications for AVR in patients with combined AS and AR and a peak transvalvular jet velocity of ≥4.0 m/s are the same as for patients with severe isolated AS. Recommendation-Specific Supportive Text 1. Currently, isolated moderate AS or moderate AR is placed in Stage B, progressive disease for which no therapeutic action is indicated. However, some patients with moderate mixed disease develop symptoms that stem from their valve disease. Formerly, the argument was raised that if there were no AR, the aortic jet velocity and gradient would be correspondingly lower and would not meet the definitions for severe AS, and obviously there would be only moderate AR by definition. Therefore, no action was recommended. However, recent data suggest that the natural history of moderate mixed disease behaves similarly to that of pure severe AS1,2 and that moderate mixed disease has a mortality risk similar to that of pure severe AS. Thus, valve replacement is warranted for the symptomatic patient if the patient’s data fulfill any of the criteria for severe AS. The decision about whether to proceed with TAVI versus SAVR is discussed in Section 3.2.4.2. 2. For patients with mixed moderate AS/AR who have developed LV dysfunction, as evidenced by an LVEF of <50%, and who have no other reason for LV dysfunction, valve disease is presumed to be the cause. In such patients, SAVR is indicated.1,2 10.2.2 Intervention for Mixed AS and MR Patients with combined AS and MR present a difficult and complex decision-making process. There are many potential different scenarios and nuances involved to arrive at the optimal approach for an individual patient, which needs to be made by an MDT with shared decision-making with the patient. Overall, patients with severe AS and severe primary MR are best treated with SAVR and mitral valve surgery unless the surgical risk is high or prohibitive. If there is a high or prohibitive surgical risk, a staged procedure, with TAVI followed by mitral TEER, can be effective. If there is severe AS and severe secondary MR, either SAVR and mitral valve surgery or a staged approach with TAVI followed by mitral TEER are options. Because there are limited data to support COR, the writing committee has created a table that provides the reader with a perspective on possible interventions in these complex patients (Table 21). Evaluating the short- and long-term outcomes of these approaches will be important. These proposed procedures are based on the following: • Many patients with AS also have significant MR that is attributable to either organic (primary) causes or LV remodeling (secondary MR). AVR for AS reduces LV pressure, thereby reducing the pressure gradient that propels volume across the incompetent mitral valve. Although it is reasonable to expect that AVR would reduce MR by reducing LV systolic pressure, this fails to occur in many cases. Not surprisingly, primary MR is more likely to persist after AVR than is secondary MR because AVR does not correct intrinsic mitral valve disease.1–5 Therefore, in patients with both AS and MR who are at a low or intermediate surgical risk, it is reasonable to address both valves with surgery. This is particularly true if the mitral valve can be repaired.1 • For patients with both AS and severe primary MR in whom the mitral valve cannot be repaired, a decision about treatment of the MR will need to be made by the MDT, taking into consideration multiple factors, including the additive risk of a mitral valve replacement. Mitral TEER at a later date may be an option but is likely to have a suboptimal result if the valve cannot be surgically repaired. Thus, double valve replacement with both AVR and mitral valve replacement would be an option if they can be performed at an acceptable level of risk, given that the outcome of the MR after AVR is uncertain. • Patients with severe AS who are at high to prohibitive surgical risk are best served by TAVI. As noted previously, primary MR may not improve after AVR.2–5 If symptoms persist after TAVI and if there is suitable anatomy, percutaneous mitral repair can be performed, which can reduce MR and improve symptoms.6 • For patients with AS who have secondary MR, the fate of MR after SAVR or TAVI is uncertain.2–5,7–10 Although secondary MR is more likely to improve after AVR than is MR attributable to primary mitral valve disease, secondary MR does not improve or may even worsen after AVR in many cases.7–10 The mechanism by which reduction in LV pressure after Downloaded from http://ahajournals.org by on October 7, 2026