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Otto et al 2020 ACC/AHA Guideline for the Management of Valvular Heart Disease Circulation. 2021;143:e72–e227. DOI: 10.1161/CIR.0000000000000923 February 2, 2021 e137 CLINICAL STATEMENTS AND GUIDELINES AVR does not reduce secondary MR is unknown. With SAVR, the mitral valve can be inspected and addressed, unlike with TAVI, where the mitral valve is left untreated. An alternative approach to patients with AS and secondary MR is to perform TAVI first, and if symptoms remain with persistent severe MR, mitral TEER can be performed if there is suitable anatomy.6 The transcatheter approach would be preferred if the patient is at high to prohibitive surgical risk. 10.2.3 Intervention for Mixed MS and MR Mixed MS and MR often occurs in patients with rheumatic valve disease. Occasionally, mixed MS/MR can occur in patients with severe mitral annular calcification. Asymptomatic mixed disease may be benign because MS protects the LV from the severe volume overload of pure MR. However, if symptoms attributable to mixed mitral disease occur, they are likely because of increased LA pressure from combined increased LA inflow from MR and obstruction to outflow from the LA. An enlarged LA, a high transmitral gradient, or direct measurement of a high LA or pulmonary artery wedge pressure suggest a valvular basis for the patient’s symptoms. In such cases, mitral valve replacement may be necessary if therapy with diuretics do not relieve symptoms, but it should be performed only in patients who have severe limiting symptoms 10.2.4 Intervention for Mixed MS and AR Combined MS and AR usually result from rheumatic heart disease. When they occur concomitantly, MS is usually the more severe lesion. However, because MS limits LV filling, it may reduce the stroke volume presented to the aortic valve, in turn reducing the apparent severity of AR.1,2 Furthermore, MS reduces the LV cavity size for any degree of AR, causing further potential underestimation of AR severity. In this regard, contrast aortography visualizes AR flow, instead of the echocardiographic visualization of AR velocity of flow, and may be helpful, as is precise assessment of AR regurgitant fraction. In patients who have continued severe symptoms not responsive to diuretics, intervention with valve surgery should be pursued. If mitral anatomy is favorable, options are PMBC to treat the MS, followed by AVR or SAVR and open mitral commissurotomy. In this way, the increased mortality risk of double valve replacement is avoided.3 10.2.5 Intervention for Mixed MS and AS Almost always the product of rheumatic heart disease, the combination of MS and AS can be very confusing to the clinician. When either lesion is severe, it may limit cardiac output, resulting in reduced flow to the other valve, which reduces transvalvular gradient, leading to underestimation of lesion severity. Echocardiography and invasive hemodynamics are usually necessary to fully assess the severity of each lesion and to decide on appropriate intervention. 11 PROSTHETIC VALVES 11.1 Evaluation and Selection of Prosthetic Valves 11.1.1 Diagnosis and Follow-Up of Prosthetic Valves Recommendations for Diagnosis and Follow-Up of Prosthetic Valves Referenced studies that support the recommendations are summarized in Online Data Supplement 34. COR LOE Recommendations 1 B-NR 1. In patients with a surgical or transcatheter prosthetic valve and in patients who have had valve repair, an initial postprocedural TTE study is recommended for evaluation of valve hemodynamics and ventricular function.1–4 1 C-EO 2. In patients with a prosthetic valve or prior valve repair and a change in clinical symptoms or signs suggesting valve dysfunction, repeat TTE is recommended. 1 C-LD 3. In patients with a prosthetic valve replacement or prior valve repair and clinical symptoms or signs that suggest prosthetic valve dysfunction, additional imaging with TEE, gated cardiac CT, or fluoroscopy is recommended, even if TTE does not show valve dysfunction. 2a C-LD 4. In patients with a bioprosthetic surgical valve, TTE at 5 and 10 years and then annually after implantation is reasonable, even in the absence of a change in clinical status. 2a C-LD 5. In patients with a bioprosthetic TAVI, TTE annually is reasonable. Table 21. AS/MR Mixed Valve Disease Severe AS Severe MR Surgical Risk Procedure SAVR candidate Primary MR Repairable valve Low intermediate SAVR Surgical mitral valve repair SAVR candidate Primary MR Valve not repairable Low intermediate SAVR Surgical mitral valve replacement TAVI candidate Primary Repairable valve High prohibitive TAVI Mitral TEER* SAVR candidate TAVI candidate Secondary MR Low intermediate SAVR Surgical mitral valve repair/mitral valve replacement or TAVI Mitral TEER* TAVI candidate Secondary MR High prohibitive TAVI Mitral TEER* *Consider TEER as a later staged procedure if symptoms and severe MR persist after treatment of the AS. AS indicates aortic stenosis; MR, mitral regurgitation; SAVR, surgical aortic valve replacement; TAVI, transcatheter aortic valve implantation; and TEER, transcatheter edge-to-edge repair. Downloaded from http://ahajournals.org by on October 7, 2026