SENILE CALCIFIC AORTIC VALVE DISEASE WITH MULTIPLE VALVE INVOLVEMENT

In contrast to aortic stenosis caused by rheumatic disease in which associated mitral valve disease is common, senile calcific aortic stenosis usually presents as an isolated lesion. Although the combination of mitral valve disease and senile calcific aortic stenosis is uncommon, senile aortic calcification is a frequent cause of aortic valve stenosis. [79 ] The incidence of senile calcific aortic disease has steadily increased in the last 20 years. Therefore, although mitral valve disease associated with calcific aortic stenosis is rare, as the incidence of calcific aortic stenosis increases, so does the likelihood of encountering patients with disease of both valves.

Patterns of Multiple Valve Involvement with Calcific Aortic Stenosis [92 ]

Stenotic aortic valves are frequently sites of infective endocarditis. As discussed in the section on endocarditis, the mitral valve may become involved with infective endocarditis by common abscess, by verrucous extension, or from a jet lesion, and infection may cause mitral valve aneurysm, perforation, and chordae disruption. [92 ] Management of these patients usually requires aortic valve replacement and assessment of the mitral valve at the time of operation. Vegetations of the mitral valve can sometimes be removed and perforations patched if the remaining tissue is sturdy and appears healthy.

Senile calcification of the aortic valve may lead to mixed stenosis and regurgitation, [79 ] and the volume load from regurgitation may lead to left ventricular dilatation and secondary mitral regurgitation of an otherwise normal mitral valve. [79 ] Mitral regurgitation secondary to aortic valvular disease is discussed in the section on Pathophysiology of Multiple Valve Disease.

Degenerative calcification is an age-related process usually affecting the aortic and mitral valves. In a study of patients over 75 years of age, one-third had degenerative aortic or mitral calcification. [77 ] About 25–50 percent of patients with calcific aortic stenosis have calcification of the mitral valve annulus. Generally, patients with associated mitral annular calcification are older, have more severe aortic stenosis, and are more often female when compared with patients with aortic stenosis without mitral annular calcification. [85 ] Mills reported 17 patients undergoing mitral valve replacement for valvular disease related to severe annular calcification. Four of these patients also had concomitant aortic valve replacement. [93 ] Patients with mitral annular calcification have increased incidence of conduction defects [94 ] and aortic outflow murmurs, and annular calcification may exist in combination with rheumatic or myxomatous disease. [95 ]

Auscultatory findings in aortic stenosis and mitral regurgitation consist of two systolic murmurs that can be distinguished by location of maximum intensity and radiation. Characteristically, aortic stenosis produces a crescendo-decrescendo murmur at the base, and mitral regurgitation produces a holosystolic murmur at the apex. Occasionally, a prolonged ejection murmur of aortic stenosis may simulate a holosystolic murmur at the apex, and the murmur of severe mitral regurgitation may radiate toward the base and may take on a crescendo-decrescendo pattern simulating an ejection murmur. [49 ] , [52 ]

Atrial fibrillation is uncommon in isolated aortic stenosis, and its presence is a clue to associated mitral valve disease. [49 ] Both aortic stenosis and mitral regurgitation produce left ventricular hypertrophy and left atrial enlargement.