# Severe mitral stenosis as a cause of paradoxical low-flow, low-gradient severe aortic stenosis: an explorative study on hemodynamics and outcomes

## TL;DR

This study finds that combined aortic and mitral stenosis is relatively common and linked to worse survival, but does not increase paradoxical low-flow aortic stenosis.

## Contribution

The study explores the hemodynamics and outcomes of combined aortic and mitral stenosis, revealing its prevalence and clinical impact.

## Key findings

- Combined AS-MS was found in 11% of patients with significant aortic stenosis.
- Patients with combined AS-MS had worse 5-year survival compared to those with isolated AS.
- Concomitant mitral stenosis did not increase the prevalence of paradoxical low-flow, low-gradient aortic stenosis.

## Abstract

Aortic stenosis (AS) and mitral stenosis (MS) are valvular heart diseases that may present concomitantly, particularly in regions where rheumatic heart disease remains prevalent. While each condition has been extensively studied in isolation, there is limited data on the clinical characteristics of patients with combined AS-MS.

We retrospectively identified patients with significant AS and concomitant significant MS from the echocardiography database between 2003 and 2018. Exclusion criteria included left ventricular ejection fraction <50%, other significant valvular lesions, prior cardiac surgery, and associated congenital heart disease. Patients with isolated AS were compared to patients with combined AS-MS.

Of 1470 patients with severe AS, a total of 353 patients were included: 41 with combined AS-MS and 312 with isolated AS. The prevalence of combined AS-MS was 11% among patients with significant AS. Compared to patients with isolated AS, patients with combined AS-MS were significantly younger (50 vs. 63 years, p < 0.001), had a lower prevalence of hypertension (44% vs. 64%, P = 0.017) and diabetes (22% v. 42%, p = 0.013), and a greater prevalence of atrial fibrillation (17% vs. 5%, p = 0.003). Patients with combined AS-MS had a significantly larger left atrial size (4.79 ± 0.70 cm vs. 3.93 ± 0.73 cm, p < 0.001), higher peak tricuspid velocities (3.14 ± 0.59 m/s vs. 2.72 ± 0.45 m/s, p < 0.001), and greater prevalence of moderate or severe tricuspid regurgitation (15% vs. 1%, p < 0.001). Echocardiographic parameters assessing transvalvular flow rate did not differ significantly between the two groups. After multivariate adjustment for age and gender combined AS-MS was associated with worse 5-year overall survival (HR 2.672, 95% CI 1.060–6.732, p = 0.037).

Combined mitral and aortic stenosis is not uncommon (11%) but linked to worse outcomes than isolated AS. Despite expectations, concomitant significant MS did not increase prevalence of paradoxical low-flow, low-gradient AS.