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cardio.aortic-valve.mixed-as-ar.v1PRODUCTION
cardio.aortic-valve.mixed-as-ar.v1

Mixed aortic valve disease (combined AS + AR)

cardiologychronicadult
Hard-required inputs
0 / 9
Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Confirm mixed AS+AR; grade each lesion; identify etiology; if one lesion clearly dominant route to that engine

Inputs
2
Actions
0
Advance rule
Set
Advance when

mixed-disease confirmed + etiology assigned

Patient inputs (11)

Bicuspid vs rheumatic vs degenerative — aortopathy/multi-valve/AC implications

AS component grade (Vmax/mean gradient/AVA)

AR component grade (VC/RF/EROA)

Surgical risk + SAVR vs TAVR + prosthesis choice

LV systolic dysfunction attributable to combined burden = AVR trigger

LV end-systolic dilatation from combined volume/pressure load

Symptoms occur at lesser individual severities — key AVR trigger

BP control bridge; afterload affects AR component

CT aorta/TAVR contrast + peri-op dosing

Rheumatic + AF → VKA; AF worsens hemodynamics

Bicuspid/root aortopathy drives concomitant aortic surgery

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (9)

9 need judgement
  • informationallife_threateningacute_on_chronic_ar
    Acute decompensation from dissection/IE superimposed on mixed AVD — emergency surgery — 2020 ACC/AHA VHD
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresymptomatic_mixed_avd
    Symptomatic with ≥moderate AS + ≥moderate AR — AVR indicated at a LOWER combined threshold (burden additive) — 2020 ACC/AHA VHD
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverelv_dysfunction_combined
    LVEF ≤55% or LVESD >50 mm attributable to combined burden — AVR even if neither lesion is isolated-severe — 2020 ACC/AHA VHD
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepregnancy_special_pop
    Pregnancy/planning — combined burden poorly tolerated; mWHO risk class; STOP ACEi/ARB → BB; pre-pregnancy AVR if severe; cardio-obstetric — ESC 2018 Pregnancy
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatebicuspid_aortopathy_branch
    Bicuspid mixed AVD with aortopathy — lower aortic surgical threshold (≥5.0 cm with risk features); family screening — 2022 ACC/AHA Aortic
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderaterheumatic_multivalve_branch
    Rheumatic mixed AVD — assess concomitant mitral disease; VKA (not DOAC) if AF; secondary prophylaxis — 2020 ACC/AHA VHD
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatetavr_limited_by_ar
    High surgical risk but significant AR component — TAVR anchoring/paravalvular-leak risk; SAVR or dedicated devices preferred — 2020 ACC/AHA VHD
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateckd_special_pop
    CKD — minimise contrast for CT aorta/TAVR; renal-adjust peri-op meds — KDIGO 2024
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatepost_avr_lv_dysfunction
    Persistent LV dysfunction after AVR — co-manage as HFrEF with GDMT — 2022 ACC/AHA HF
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

Mixed AVD — combined-burden intervention timing + bridge (2020 ACC/AHA VHD; 2022 ACC/AHA Aortic)
axis: mixed_avd_combined_burden_timingstep 1 - Step 1 — Asymptomatic, preserved LV, modest combined burden — SURVEILLANCE
Selected step "Step 1 — Asymptomatic, preserved LV, modest combined burden — SURVEILLANCE" — Asymptomatic, LVEF >55%, LVESD ≤50 mm, neither lesion severe, aorta below threshold

outpatient playbook — drug actions (2)

  1. 1. losartan ± amlodipine for BP/wall stress
    losartan 50–100 mg • PO • daily
    trigger: HTN with mixed AVD or aortopathy (2020 ACC/AHA VHD)
    Afterload + aortic-growth reduction
  2. 2. metoprolol if bicuspid aortopathy / AF
    25–100 mg • PO • BID
    trigger: Aortic dilatation / AF (2022 Aortic)
    Slows aortic dilatation; AF rate control

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Combined systolic ejection + early diastolic aortic murmur; Echo: combined ≥moderate AS and ≥moderate AR; Exertional dyspnea / angina / syncope at modest individual lesion severity.

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Mixed aortic valve disease (combined AS + AR)** (cardio.aortic-valve.mixed-as-ar.v1).
Phenotype framing: Balanced mixed AS+AR vs dominant-AS vs dominant-AR vs LFLG-AS
Scope: Confirm mixed AS+AR; grade each lesion; identify etiology; if one lesion clearly dominant route to that engine

No severity triggers fired against current inputs.

Plan

Regimen axis: **Mixed AVD — combined-burden intervention timing + bridge (2020 ACC/AHA VHD; 2022 ACC/AHA Aortic)** — step "Step 1 — Asymptomatic, preserved LV, modest combined burden — SURVEILLANCE".

Setting playbook (outpatient) — Grade combined burden, refer for AVR at the lower mixed-disease threshold, manage aortopathy, screen family (2020 ACC/AHA VHD; 2022 Aortic)
1. losartan ± amlodipine for BP/wall stress losartan 50–100 mg PO daily — HTN with mixed AVD or aortopathy (2020 ACC/AHA VHD) (Afterload + aortic-growth reduction)
2. metoprolol if bicuspid aortopathy / AF 25–100 mg PO BID — Aortic dilatation / AF (2022 Aortic) (Slows aortic dilatation; AF rate control)

Non-pharmacologic actions:
- Heart-team referral for AVR at lower combined-burden threshold — 2020 ACC/AHA VHD
- First-degree family echo screening for bicuspid valve/aortopathy — 2022 Aortic
- Endocarditis prophylaxis only if prior IE / prosthetic material — 2020 ACC/AHA VHD

AVOID / contraindication checks:
- Lower intervention threshold in mixed AVD burden is additive — 2020 ACC/AHA VHD
- TAVR less ideal when AR component significant — 2020 ACC/AHA VHD
- No medical therapy delays needed AVR in symptomatic mixed AVD — 2020 ACC/AHA VHD
- DOAC contraindicated rheumatic valve AF and mechanical valves — 2020 ACC/AHA VHD
- Lower aortic surgical threshold in bicuspid aortopathy — 2022 ACC/AHA Aortic

Monitoring

Regimen monitoring:
- TTE each lesion plus combined burden q6-12mo if severe — 2020 ACC/AHA VHD
- aortic imaging by root size if bicuspid — 2022 ACC/AHA Aortic
- serial LVEF LVESD for combined threshold — 2020 ACC/AHA VHD
- post-AVR TTE baseline then annually — 2020 ACC/AHA VHD
- INR if VKA — 2020 ACC/AHA VHD

Setting (outpatient) monitoring:
- Serial TTE (each lesion + combined) + aorta — 2020 ACC/AHA VHD; 2022 Aortic
- Symptom + BP review each visit — 2020 ACC/AHA VHD

Follow-up plan: Family screening (bicuspid); route to HFrEF engine if LV dysfunction
- Close-out criterion: follow-up + screening + escalation triggers documented

Monitoring phase: Serial TTE + aorta by combined severity and LV metrics

Disposition

Current setting: outpatient — Grade combined burden, refer for AVR at the lower mixed-disease threshold, manage aortopathy, screen family (2020 ACC/AHA VHD; 2022 Aortic)

Disposition criteria:
- Asymptomatic, modest combined burden, normal aorta → surveillance
- Combined threshold met → AVR (± aortic surgery) referral
- High surgical risk + AR not dominant → TAVR evaluation

Escalation triggers (move to higher acuity):
- Symptoms OR LV dysfunction/dilatation at modest individual severity → AVR referral now — 2020 ACC/AHA VHD
- Aortic root/ascending at threshold → aortic surgery — 2022 Aortic
- Acute-on-chronic AR (dissection/IE) → ED + emergency route — 2020 ACC/AHA VHD

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Acute decompensation from dissection/IE superimposed on mixed AVD — emergency surgery — 2020 ACC/AHA VHD
- [SEVERE] Symptomatic with ≥moderate AS + ≥moderate AR — AVR indicated at a LOWER combined threshold (burden additive) — 2020 ACC/AHA VHD
- [SEVERE] LVEF ≤55% or LVESD >50 mm attributable to combined burden — AVR even if neither lesion is isolated-severe — 2020 ACC/AHA VHD

Citations

- 2020 ACC/AHA VHD Guideline + 2022 ACC/AHA Aortic Disease Guideline + 2021 ESC/EACTS VHD Guideline [PMID:33332149](https://pubmed.ncbi.nlm.nih.gov/33332149/)
- Cited evidence (PMID 36322642) [PMID:36322642](https://pubmed.ncbi.nlm.nih.gov/36322642/)
- Cited evidence (PMID 34453165) [PMID:34453165](https://pubmed.ncbi.nlm.nih.gov/34453165/)
- Cited evidence (PMID 27040324) [PMID:27040324](https://pubmed.ncbi.nlm.nih.gov/27040324/)
- Cited evidence (PMID 30883058) [PMID:30883058](https://pubmed.ncbi.nlm.nih.gov/30883058/)

Last reconciled with current guidelines: 2026-05-16.
References