In a prospective case series, event rates were high and unrelated to baseline severity of disease, but aortic jet velocity was a reliable predictor of outcome.

Lacking evidence-based management strategies in patients with both aortic stenosis (AS) and aortic regurgitation (AR), clinicians often follow guideline recommendations for the more-severe disorder. However, this approach has not been validated. To find out more, investigators prospectively studied disease progression and outcomes in 71 consecutive asymptomatic patients (mean age, 52; 30% women) with mixed AS and AR of at least moderate severity.

About half of the patients had bicuspid valves. At baseline, mean peak aortic jet velocity (AV-Vel) was 4.31 m/sec, and mean aortic valve area was 0.98 cm². During long-term follow-up (mean, 8.9 years), 50 patients (71%) developed indications for aortic-valve replacement, including symptoms, progression of AS, and aortic aneurysm. Event-free survival was 82% at 1 year, 33% at 4 years, and 19% at 6 years. AV-Vel was an independent predictor of event-free survival; patients with an AV-Vel between 3.0 and 3.9 m/sec had a low event rate, but progression to a higher-velocity group (associated with a higher event rate) was common. In the 43 patients who underwent surgery, only one perioperative death and no postoperative deaths occurred.

Comment: This is among the first studies to examine the natural history of combined stenotic and regurgitant aortic valve disease. The findings suggest that asymptomatic patients can be safely followed until surgical criteria for aortic stenosis, aortic regurgitation, or aortic lesions are met; and that aortic jet velocity can be used for risk stratification. Nonetheless, as the editorialists point out, most of these patients were relatively young, the proportion of bicuspid disease was high, and the prognosis even with a low AV-Vel (3.0–3.9 m/sec) was worse than in patients with moderate AS alone. This condition warrants very close surveillance.

  Source: Journal Watch Cardiology