Mixed Valve Disease

• Identify the predominant lesion
• Predominant lesion will have clinical signs associated with severity of that lesion
• Aortic stenosis
  • Low-volume pulse
  • Slow-rising pulse
  • Narrow pulse pressure
  • Heaving apex beat (left ventricular hypertrophy)
  • Thrill over the aortic area
  • Soft S2
  • S4
  • Late-peaking ejection systolic murmur
  • Signs of left ventricular failure
  • Signs of pulmonary hypertension
• Aortic regurgitation
  • Collapsing pulse
  • Wide pulse pressure
  • Displaced apex beat
  • S3
  • Austin-Flint murmur
  • Very short (rapid equalization of aortic and ventricular pressures) or very long murmur
  • Signs of left ventricular failure
  • Signs of pulmonary hypertension
• Mitral stenosis
  • Early opening snap
  • Long diastolic murmur
  • Graham-Steele murmur of pulmonary regurgitation
  • Signs of pulmonary hypertension
• Mitral regurgitation
  • Displaced apex beat
  • Palpable thrill over mitral area
  • Soft S1
  • Widely-split S2 (large regurgitant volume, resulting in earlier aortic valve closure)
  • Diastolic murmur (increased flow across the mitral valve)
  • Signs of pulmonary hypertension
  • Signs of left heart failure

Causes of mixed valve disease

• Rheumatic heart disease
• Infective endocarditis
• Bicuspid aortic valve (mixed aortic valve disease only)
• Mitral stenosis with mitral valvotomy complicated by mitral regurgitation (mixed mitral valve disease only)