Multivalvular disease (MVD) is a prevalent form of valvular heart disease; rheumatic heart disease is the predominant aetiology in developing countries, whereas degenerative aetiologies are increasingly common in developed countries
Haemodynamic interactions between valve lesions can promote, exacerbate, or, by contrast, blunt the clinical expression of each singular lesion
Several diagnostic tools used for the assessment of valve stenosis or regurgitation have been validated in patients with single-valve disease, but such tools might not be valid for MVD
Therapeutic decisions should be made by a heart valve team, considering the severity of MVD, the patient's life expectancy and comorbidities, and the risks of multiple prostheses and eventual reoperation
The introduction of transcatheter valve therapies is changing the therapeutic paradigm, but further studies are needed to guide therapeutic decision-making
Multivalvular disease (MVD) is common among patients with valvular disease, and has a complex pathophysiology dependent on the specific combination of valve lesions. Diagnosis is challenging because several echocardiographic methods commonly used for the assessment of stenosis or regurgitation have been validated only in patients with single-valve disease. Decisions about the timing and type of treatment should be made by a multidisciplinary heart valve team, on a case-by-case basis. Several factors should be considered, including the severity and consequences of the MVD, the patient's life expectancy and comorbidities, the surgical risk associated with combined valve procedures, the long-term risk of morbidity and mortality associated with multiple valve prostheses, and the likelihood and risk of reoperation. The introduction of transcatheter valve therapies into clinical practice has provided new treatment options for patients with MVD, and decision-making algorithms on how to combine surgical and percutaneous treatment options are evolving rapidly. In this Review, we discuss the pathophysiology, diagnosis, and treatment of MVD, focusing on the combinations of valve pathologies that are most often encountered in clinical practice.
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B.R.L. is supported by NIH K23 HL116660. P.P. holds the Canada Research Chair in Valvular Heart Disease, and his research programme is funded by the Canadian Institutes of Health Research (grant numbers FDN-143225, MOP 126072, MOP 114997 and MOP 102737) (Ottawa, Ontario, Canada).
B.R.L. has received research support from, and served on the scientific advisory board for, Roche Diagnostics. P.P. has Core Lab contracts with Edwards Lifesciences, for which he receives no direct compensation, and has received research grants from Ionis. The other authors declare no competing interests.
Moderate-to-severe mitral regurgitation in a patient with severe aortic stenosis. (MOV 1222 kb)
Transcather aortic valve implantation is performed in a patient with severe aortic stenosis and moderate-to-severe mitral regurgitation and, 6 months after the procedure, only mild mitral regurgitation remains. (MOV 1794 kb)
Typical features of the combination of rheumatic aortic and mitral stenosis. (MOV 1443 kb)
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Unger, P., Clavel, MA., Lindman, B. et al. Pathophysiology and management of multivalvular disease. Nat Rev Cardiol 13, 429–440 (2016). https://doi.org/10.1038/nrcardio.2016.57
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