Clinical Outcomes Varied Among Patients With Mixed Aortic Valve Disease

Outcomes for patients with mixed aortic valve disease (MAVD) were comparable to severe aortic stenosis and preserved ejection fraction, according to data published in the Journal of the American College of Cardiology.

Currently, there are few clinical recommendations for patients with combined aortic stenosis and aortic regurgitation. Therefore, researchers conducted a study to determine the adverse event occurrence defined by the New York Heart Association functional class III/IV symptoms, aortic valve replacement, or cardiac death. They compared the event rate of MAVD to both isolated aortic stenosis and aortic regurgitation.

Asymptomatic patients with moderate MAVD and a left ventricular ejection fraction ≥50% were included in the study. MAVD was defined as a combination of moderate aortic stenosis and aortic regurgitation. Patients were followed at Mayo Clinic from 1994 to 2013, and all patients had at least 2 years of clinical and echocardiographic follow-up.

Patients were compared to 3 control groups each comprised of 117 patients matched by age and sex, including an isolated moderate aortic regurgitation group, a moderate aortic stenosis group, and a severe aortic stenosis group.

Adverse events occurred in 77% of patients, which included symptom development (69%), aortic valve replacement (67%), and cardiac death (4%). Predictors of adverse events included older age (hazard ratio [HR]: 1.71 per decade; 95% confidence interval [CI]: 1.38-1.97 per decade; P=.001) and relative wall thickness >0.42 (HR: 2.01; 95% CI: 1.86-2.33; P=.002).

At 5 years, the adverse event rate in the MAVD group was 71%, compared with 68% in the severe aortic stenosis group (P=.49). However, the MAVD group had a significantly higher rate of adverse events compared with the moderate aortic stenosis group (71% vs 31%; P<.0001) as well as the moderate aortic regurgitation group (71% vs 22%; P<.0001) at 5 years.

Among the MAVD patients, the adverse event rate increased at 3, 5, and 7 years to 40%, 71%, and 84%, respectively. Researchers also observed that a subgroup of MAVD patients with concentric hypertrophy tended to become symptomatic and required aortic valve replacement, even without any progression in the severity of aortic valve disease.

“On the basis of these findings, we recommend that patients with moderate MAVD be followed every 6 to 12 months and monitored closely for rapid progression of valve disease or development of symptoms, similar to patients with isolated severe AS. Early valve replacement may be considered for MAVD patients without comorbidities in centers with low risk for such procedures,” the authors of the study concluded.

They also noted “that it would be inappropriate to apply guideline recommendations for isolated moderate AS or moderate AR to this population. Additionally, a subset of moderate MAVD patients with concentric hypertrophy can become symptomatic even in the absence of severe aortic valve disease.”

The authors suggested that future studies focus on long-term follow-up to determine effective timing for valve replacement in patients with moderate MAVD.

Reference

Egbe AC, Luis SA, Padang R, Warnes CA. Outcomes in moderate mixed aortic valve disease. Is it time for a paradigm shift? J Am Coll Cardiol. 2016;67(20):2321-2329. doi: 10.1016/j.jacc.2016.03.509.