The ESC Textbook of Cardiovascular Medicine (3 edn)
Cite
This chapter provides the background information and detailed discussion of the data for the following current ESC Guidelines on: 
Management of Valvular Heart Disease - https://dbpia.nl.go.kr/eurheartj/article/38/36/2739/4965046#115331514
This section was reviewed and edited by The Task Force for the Management of Valvular Heart Disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS) Authors/Task Force Members: Helmut Baumgartner (ESC Chairperson) (Germany), Volkmar Falk (EACTS Chairperson) (Germany), Jeroen J. Bax (The Netherlands), Michele De Bonis (Italy), Christian Hamm (Germany), Per Johan Holm (Sweden), Bernard Iung (France), Patrizio Lancellotti (Belgium), Emmanuel Lansac (France), Daniel Rodriguez Muñoz (Spain), Raphael Rosenhek (Austria), Johan Sjögren (Sweden), Pilar Tornos Mas (Spain), Alec Vahanian (France), Thomas Walther (Germany), Olaf Wendler (UK), Stephan Windecker (Switzerland), Jose Luis Zamorano (Spain)
Summary
Management of multiple valve disease is dictated by the pathology of the valve which is predominantly involved. As a general rule, in combined lesions, valvular heart disease is considered severe even if both stenosis and regurgitation are only of moderate severity, and pressure gradients become of major importance for assessment. However more data on the natural history and the impact of intervention on outcome are required to better define the indications for intervention.
Significant stenosis and regurgitation can be found on the same valve. Disease of multiple valves may be encountered in several conditions, but particularly in rheumatic heart disease and, less frequently, in degenerative valve disease. There is a lack of data on mixed and multiple valve diseases. This does not allow for evidence-based recommendations.1
The general principles for the management of mixed or multiple valve disease are as follows:
When either stenosis or regurgitation is predominant, management follows the recommendations concerning the predominant valvular heart disease (VHD). When the severity of both stenosis and regurgitation is balanced, indications for interventions should be based upon symptoms and objective consequences, rather than the indices of severity of stenosis or regurgitation.
Besides the separate assessment of each valve lesion, it is necessary to take into account the interaction between the different valve lesions. As an illustration, associated mitral regurgitation may lead to underestimation of the severity of aortic stenosis, since decreased stroke volume due to mitral regurgitation lowers the flow across the aortic valve and, hence, the aortic gradient. This underlines the need to combine different measurements, including assessment of valve areas, if possible using methods that are less dependent on loading conditions, such as planimetry.
Indications for intervention are based on global assessment of the consequences of the different valve lesions, that is, symptoms or presence of left ventricular dilatation or dysfunction. Intervention can be considered for non-severe multiple lesions associated with symptoms or leading to left ventricular impairment.
The decision to intervene on multiple valves should take into account the extra surgical risk of combined procedures.
The choice of surgical technique should take into account the presence of the other VHD; repair remains the ideal option.
The management of specific associations of VHD is detailed in other chapters in Section 35.
Reference
1. Unger P, Rosenhek R, Dedobbeleer C, Berrebi A, Lancellotti P.
Further reading
Unger P, Rosenhek R, Dedobbeleer C, Berrebi A, Lancellotti P.
