JACC Cardiovasc Imaging. 2026 Jun 10:S1936-878X(26)00259-7. doi: 10.1016/j.jcmg.2026.04.015. Online ahead of print.
ABSTRACT
BACKGROUND: Patients with moderate aortic stenosis (AS) and concomitant mitral regurgitation (MR) often present with symptoms despite neither lesion individually reaching intervention thresholds. The clinical impact of this dual valvular disease remains a knowledge gap.
OBJECTIVES: The aims of this study were to evaluate the effect of concomitant MR on cardiac remodeling and clinical outcomes in patients with moderate AS using cardiac magnetic resonance (CMR) and to compare with isolated moderate and severe AS.
METHODS: A total of 742 patients with at least moderate AS on CMR (422 with moderate AS, 320 with severe AS) were studied. Patients were stratified by AS severity and MR burden. Remodeling parameters, symptoms, and outcomes, including cardiovascular death and heart failure hospitalization, were analyzed. Multivariable Cox models identified covariates associated with outcomes.
RESULTS: Among 422 patients with moderate AS, 76 had moderate or greater MR. Compared with isolated moderate AS, combined AS and MR was associated with higher symptom burden (80.3% in NYHA functional classes II-IV), more pronounced remodeling (larger indexed left ventricular volumes, lower left ventricular ejection fractions), and reduced aortic forward flow. Over a median 1.8 years, coexisting moderate or greater MR was independently associated with cardiovascular death or heart failure hospitalization (adjusted HR: 1.86; 95% CI: 1.31-2.65; P < 0.001). This risk was more apparent in the low-flow subgroup (stroke volume index ≤35 mL/m2), whereas in normal-flow patients, there was a trend toward increased risk that did not reach statistical significance. Outcomes in moderate AS with moderate or greater MR were worse than in isolated severe AS and comparable with severe AS populations meeting criteria for intervention.
CONCLUSIONS: Patients with moderate AS and MR constitute a high-risk subgroup with high symptom burden, adverse cardiac remodeling, and poor clinical outcomes. Risk appears more pronounced in the setting of reduced forward flow (stroke volume index ≤35 mL/m2). CMR enables the quantitative assessment of dual valvular burden and may improve risk stratification. These findings highlight a therapeutic gap and support studies of earlier intervention in this high-risk subgroup.
PMID:42274428 | DOI:10.1016/j.jcmg.2026.04.015