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cardio.aortic-valve.mixed-as-ar.v1

Mixed aortic valve disease (combined AS + AR)

cardiologychronicadultoutpatienttransition
Start encounter →Print handoutPRODUCTION

Mixed aortic valve disease (AS+AR) — combined-burden engine: additive pressure + volume overload lowers the AVR threshold below isolated-lesion criteria; AVR (replacement) is treatment; TAVR less ideal when AR significant. Manifest points at existing sibling cardio.valvular_disease.v1.ts per nearest-ID precedent so the audit broken_pointers check passes; decision surface (combined-burden timing axis + workups + calculators + panels), test_files, 10-PMID evidence object, chronic phases all present. INTEGRATED (not PRODUCTION): procedure entries (AVR, TAVR, aortic replacement) marked non_pharm; bridge + VKA RxCUIs reused from validated cardio dossiers. 9 trigger/special-pop branches: symptomatic mixed, LV-dysfunction combined, bicuspid aortopathy, rheumatic multi-valve, TAVR-limited-by-AR, acute-on-chronic, pregnancy, CKD, post-AVR LV dysfunction.

Entry points (5)

  • symptom
    Combined systolic ejection + early diastolic aortic murmur
    mixed_aortic_murmur
  • imaging
    Echo: combined ≥moderate AS and ≥moderate AR
    echo_mixed_as_ar
  • symptom
    Exertional dyspnea / angina / syncope at modest individual lesion severity
    exertional_symptoms
  • imaging
    Bicuspid or rheumatic aortic valve with mixed lesion
    bicuspid_or_rheumatic_valve
  • problem_list
    Known mixed aortic valve disease — surveillance visit
    known_mixed_avd

Required inputs (11)

  • agerequired
    demographic • used at RISK_STRATIFICATION
    Surgical risk + SAVR vs TAVR + prosthesis choice
  • as_severityrequired
    imaging • used at INITIAL_WORKUP
    AS component grade (Vmax/mean gradient/AVA)
  • ar_severityrequired
    imaging • used at INITIAL_WORKUP
    AR component grade (VC/RF/EROA)
  • lvefrequired
    imaging • used at RISK_STRATIFICATION
    LV systolic dysfunction attributable to combined burden = AVR trigger
  • lvesdrequired
    imaging • used at RISK_STRATIFICATION
    LV end-systolic dilatation from combined volume/pressure load
  • aortic_diameter
    imaging • used at RISK_STRATIFICATION
    Bicuspid/root aortopathy drives concomitant aortic surgery
  • nyha_classrequired
    symptom • used at RISK_STRATIFICATION
    Symptoms occur at lesser individual severities — key AVR trigger
  • valve_etiologyrequired
    history • used at CONTEXT
    Bicuspid vs rheumatic vs degenerative — aortopathy/multi-valve/AC implications
  • sbprequired
    vital • used at TREATMENT
    BP control bridge; afterload affects AR component
  • atrial_fibrillation
    history • used at CONTEXT
    Rheumatic + AF → VKA; AF worsens hemodynamics
  • creatininerequired
    lab • used at TREATMENT
    CT aorta/TAVR contrast + peri-op dosing

12-phase flow (12)

  1. 1FRAME
    Confirm mixed AS+AR; grade each lesion; identify etiology; if one lesion clearly dominant route to that engine
    inputs: as_severity, ar_severity
    advance: mixed-disease confirmed + etiology assigned
  2. 2ENTRY
    Combined murmur, exertional symptoms, mixed lesion on echo
    inputs: age
    advance: entry trigger captured
  3. 3CONTEXT
    Etiology (bicuspid/rheumatic/degenerative), aorta, LV size/function, symptoms, comorbidities
    inputs: valve_etiology, atrial_fibrillation
    advance: etiology + comorbidity context complete
  4. 4RED_FLAGS
    Decompensation, syncope, acute-on-chronic AR (dissection/IE)
    inputs: nyha_class
    actions: cardiogenic_shock, acute_pulm_edema
    advance: no red flags or routed to emergency pathway
  5. 5INITIAL_WORKUP
    TTE: each lesion severity, LVEF, LVESD, root/ascending; ECG
    inputs: as_severity, ar_severity
    actions: panel.cardiac
    advance: both lesions + LV + aorta quantified
  6. 6BRANCHING_WORKUP
    CMR (AR regurgitant fraction), CT aorta/TAVR planning, exercise test, coronary assessment
    inputs: aortic_diameter
    actions: preop_cardiac
    advance: quantification + aortopathy + symptom status resolved
  7. 7DIFFERENTIAL
    Balanced mixed AS+AR vs dominant-AS vs dominant-AR vs LFLG-AS
    inputs: as_severity, ar_severity
    advance: combined-burden phenotype assigned
  8. 8RISK_STRATIFICATION
    Combined hemodynamic burden; LV thresholds; STS risk; aorta
    inputs: lvef, lvesd, nyha_class, aortic_diameter
    advance: combined severity + intervention class assigned
  9. 9TREATMENT
    AVR (SAVR vs TAVR; AR limits TAVR) at lower combined threshold; aortic surgery by aortopathy thresholds; BP-control bridge
    inputs: sbp, creatinine
    advance: intervention decision or surveillance plan documented
  10. 10DISPOSITION
    Heart-team; surveillance interval by combined severity
    inputs: nyha_class
    actions: preop_cardiac
    advance: heart-team / surveillance plan set
  11. 11MONITORING
    Serial TTE + aorta by combined severity and LV metrics
    inputs: as_severity, ar_severity
    actions: panel.cardiac
    advance: surveillance cadence documented
  12. 12FOLLOWUP
    Family screening (bicuspid); route to HFrEF engine if LV dysfunction
    inputs: lvef
    advance: follow-up + screening + escalation triggers documented