Multivalvular Disease

Definition, Etiology, Pathogenesis Top

Multivalvular disease affects ≥2 venous or arterial valves; in general order of descending frequency in the contemporary European or North American practice:

1) Mitral regurgitation (MR) and tricuspid regurgitation (TR).

2) Aortic stenosis (AS) and MR.

3) Aortic regurgitation (AR) and MR.

4) AS and TR.

5) Mitral stenosis (MS) and AR.

6) MS and AS.

Detailed descriptions of individual valvular diseases: see Aortic Regurgitation; see Aortic Stenosis; see Mitral Regurgitation; see Mitral Stenosis; see Tricuspid Regurgitation.

Previously multivalvular disease with secondary effects on the left ventricle and the left atrium used to be mainly caused by rheumatic heart disease (eg, MS and AS); however, with ageing populations (and increased use of antibiotics in childhood and youth), degenerative or functional MR with secondary TR as well as degenerative AS with secondary MR or TR are increasingly common.

Clinical Features and Diagnosis Top

In general, the predominant clinical features are caused by the hemodynamically more severe lesion; however, assuming similar degrees of valvular severity, symptoms are related to the disease of the more proximal (upstream) valvular lesion (eg, AS in combined AS/MR). The primary valve lesion can create secondary (“back pressure”) effects on the secondary valve lesion (eg, chronic severe MR [or AS] leading to right ventricular dilation, secondary functional TR, and pulmonary hypertension). In advanced multivalvular disease, symptoms of heart failure are often present, and are accompanied by secondary hemodynamic effects on the cardiac chambers (eg, chronic severe AR leading to left ventricular and left atrial dilation and secondary functional MR). Features of various types of multivalvular disease: Table 1.

The diagnostic workup of multivalvular heart disease is not significantly different from that of individual valvular lesions.

Treatment Top

To establish indications for surgical treatment, the clinical and hemodynamic significance of the components of multivalvular heart disease must be assessed. Any defect assessed separately may not be severe enough to warrant surgical treatment; however, when combined, these may have significant hemodynamic consequences that require surgery. In some cases it may not be necessary to replace all the affected valves (eg, surgical treatment of severe AS may, by relieving afterload challenge to the left ventricle, relieve secondary functional MR). Double-valve replacement is generally associated with higher perioperative and long-term risks, owing to a more complex surgical technique and longer cardiopulmonary bypass times, compared to single valve repair or replacement (with or without coronary artery bypass graft); thus, whenever feasible, repair is often preferred (eg, mitral valve repair for severe myxomatous mitral regurgitation with concomitant tricuspid valve annuloplasty for secondary TR). It is important to recognize that management of multivalve disease is essentially an “evidence-free zone,” and thus recommendations in the most current guidelines are brief and consensus-based.

TablesTop