Mixed Mitral Valve Disease

Definition, Etiology, Clinical FeaturesTop

Mixed mitral valve disease refers to coexisting mitral stenosis (MS) and mitral regurgitation (MR).

Etiology: Rheumatic disease, less frequently degenerative or endocarditic lesions.

Clinical features are similar to that of MS and MR, and depend on which of these hemodynamic lesions is dominant (see Mitral Stenosis; see Mitral Regurgitation). Most frequently the systolic murmur typical of MR is prominent and may mask the soft rumble typical of MS. The first heart sound may be increased in intensity.

DiagnosisTop

Diagnostic Tests

See Mitral Regurgitation; see Mitral Stenosis.

In patients with hemodynamically significant combined MS and MR, chest radiography reveals enlargement of the left atrium and ventricle (also the right ventricle if the valve disease is severe and chronic) and features of pulmonary congestion, less frequently pulmonary hypertension. In patients with dominant MS, the size of LV may be normal.

TreatmentTop

General approach:

1) If there is a dominant valve lesion (stenosis vs regurgitation), management is generally determined by the dominant lesion.

2) Mixed disease may not be clearly classified as severe based on the stenosis or regurgitation components independently; however, these may remain symptomatically and prognostically important. Decisions on structural interventions may be complex and require expert assessment.

Management principles:

1) Pharmacologic treatment of heart failure.

2) Antithrombotic treatment in patients with atrial fibrillation.

3) Prevention of infective endocarditis and of recurrent rheumatic disease (see Acute Rheumatic Fever).

4) Invasive treatment: Patients with coexisting moderate or severe MR are ineligible for percutaneous valvuloplasty in the case of mitral pathology of rheumatic origin. Generally, treatment usually involves mitral valve replacement when severe symptoms persist despite medical therapy.