title: Outcomes in Moderate Mixed Aortic Valve Disease: Is it Time for a Paradigm Shift?
abstract: A direct comparison of outcomes between moderate mixed aortic valve disease (MAVD) and isolated aortic stenosis (AS) or aortic regurgitation (AR) has not been performed, making evidence-based recommendations difficult in patients with MAVD.
  
  
  
  This study sought to determine adverse event (AE) occurrence (the primary endpoint), defined as New York Heart Association functional class III/IV symptoms, aortic valve replacement, or cardiac death, and to compare AE rates between MAVD and isolated AS or AR.
  
  
  
  Asymptomatic patients were identified with moderate MAVD and an ejection fraction ≥50% and were followed at Mayo Clinic from 1994 to 2013. Moderate MAVD was defined as a combination of moderate AS and moderate AR. Age- and sex-matched control groups were selected with isolated moderate AR (n = 117), moderate AS (n = 117), or severe AS (n = 117).
  
  
  
  At 9.1 ± 4.2 years of follow-up, patients with moderate MAVD (n = 251) had a mean age of 63 ± 11 years, 73% were male, and 38% had bicuspid valve. AE occurred in 193 (77%) patients in this group, including symptom development (69%), aortic valve replacement (67%), and cardiac death (4%). Predictors of AE were older age (hazard ratio [HR]: 1.71 per decade; 95% confidence interval [CI]: 1.38 to 1.97 per decade; p = 0.001), and relative wall thickness >0.42 (HR: 2.01; 95% CI: 1.86 to 2.33; p = 0.002). AE rates were similar in the MAVD and severe AS group (71% vs. 68% at 5 years; p = 0.49), but were significantly higher compared with the moderate AS and AR groups.
  
  
  
  MAVD patients had outcomes comparable to those with severe AS, and preserved ejection fraction and should be monitored closely for symptoms.
authors.affiliation: Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota.
authors.forename: Alexander C
authors.initials: AC
authors.lastname: Egbe
authors.affiliation: Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota.
authors.forename: Sushil A
authors.initials: SA
authors.lastname: Luis
authors.affiliation: Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota.
authors.forename: Ratnasari
authors.initials: R
authors.lastname: Padang
authors.affiliation: Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota. Electronic address: warnes.carole@mayo.edu.
authors.forename: Carole A
authors.initials: CA
authors.lastname: Warnes
mesh_terms: D000367:Age Factors; D001021:Aortic Valve / Q000000981:diagnostic imaging; D001022:Aortic Valve Insufficiency / Q000401:mortality* / Q000601:surgery*; D001024:Aortic Valve Stenosis / Q000401:mortality* / Q000601:surgery*; D058070:Asymptomatic Diseases; D016022:Case-Control Studies; D003645:Death, Sudden; D005260:Female; D005500:Follow-Up Studies; D006333:Heart Failure / Q000401:mortality; D019918:Heart Valve Prosthesis Implantation; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000401:mortality; D012189:Retrospective Studies; D012720:Severity of Illness Index; D013318:Stroke Volume
keywords: adverse events; aortic regurgitation; aortic stenosis; aortic valve replacement