In this patient with combined AS and MR, therapy benefiting AS can exacerbate the severity of MR. It is best to prioritize management based on the character of the paramount symptoms. Patients with AS and MR who present with syncope or angina are best managed for their AS, whereas patients with dyspnea and pulmonary edema are best managed for their congestive heart failure symptoms. Preoperative echocardiography and ECG findings can also be used to determine the predominant lesion. It is best to maintain the patient's usual hemodynamics. Early aggressive intervention is the key to managing these combined lesions. A lower margin for error usually exists because minor hemodynamic aberrations can rapidly lead to cardiac collapse. TEE evaluation of left ventricular performance can be helpful in distinguishing pulmonary congestion secondary to left heart failure from that due to decreased diastolic left ventricular compliance from AS.

References

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