Table 3.18-9. Characteristics of multivalvular disease

Multivalvular disease



Surgical treatment



Chronic MR causes pulmonary hypertension, leading to RV dilation and secondary TR

Apical systolic murmur caused by MR and lower sternal border murmur of TR

Mitral repair or replacement with tricuspid valve repair or annuloplasty

MR most commonly the dominant lesion; at times relief of MR alone may result in decrease in TR


AS leads to LV afterload challenge or strain and secondary MR; impaired aortic valve outflow can further aggravate MR

Ejection murmur radiating to carotid arteries and murmur caused by MR radiating to axilla

Simultaneous aortic valve replacement and mitral repair or replacement

MR may be reduced after aortic valve replacement (or TAVI) without specific mitral valve intervention


AR leads to LV dilation and secondary MR

Apical systolic murmur caused by MR and diastolic murmur caused by AR

Simultaneous aortic valve repair or replacement and mitral repair or replacement

AR frequently dominant; in such cases it is difficult to distinguish primary from secondary MR due to LV enlargement; at times treatment of AR alone may relieve significant MR due to LV dilation caused by chronic AR


MS leads to pulmonary hypertension and secondary regurgitation of anatomically normal tricuspid valve; in some patients tricuspid valve also affected by rheumatic fever

Typical signs of MS and holosystolic murmur (more prominent during inspiration) caused by TR

Mitral valve replacement (or mitral valvuloplasty) and tricuspid annuloplasty

Hemodynamically significant TR may improve following mitral valve valvuloplasty (or surgery) without specific surgical treatment of the tricuspid valve


MS restricts blood inflow to LV and aggravates the drop of cardiac output caused by AS

Typical signs of MS and murmur caused by AS (less prominent than in isolated AS)

Simultaneous replacement of both valves

Percutaneous balloon mitral valvuloplasty in patients with significant AS may result in pulmonary edema


Impaired LV filling from left atrium is compensated by reverse blood flow through aortic valve

Typical signs of MS and diastolic murmur along left sternal border

Before surgical treatment of aortic valve percutaneous balloon mitral valvuloplasty should be considered

MS reduces LV volume overload and can mask AR

AR, aortic regurgitation; AS, aortic stenosis; LV, left ventricle; MR, mitral regurgitation; MS, mitral stenosis; RV, right ventricle; TAVI, transcatheter aortic valve implantation; TR, tricuspid regurgitation.