Expert proposal to analyze the combination of aortic and mitral regurgitation in multiple valvular heart disease by comprehensive echocardiography.

The assessment of valvular pathologies in multiple valvular heart disease by echocardiography remains challenging. Data on echocardiographic assessment-especially in patients with combined aortic and mitral regurgitation-are rare in the literature. The proposed integrative approach using semi-quantitative parameters to grade the severity of regurgitation often yields inconsistent findings and results in misinterpretation. Therefore, this proposal aims to focus on a practical systematic echocardiographic analysis to understand the pathophysiology and hemodynamics in patients with combined aortic and mitral regurgitation. The quantitative approach of grading the regurgitant severity of each compound might be helpful in elucidating the scenario in combined aortic and mitral regurgitation. To this end, both the individual regurgitant fraction of each valve and the total regurgitant fraction of both valves must be determined. This work also outlines the methodological issues and limitations of the quantitative approach by echocardiography. Finally, we present a proposal that enables verifiable assessment of regurgitant fractions. The overall interpretation of echocardiographic results includes the symptomatology of patients with combined aortic and mitral regurgitation and the individual treatment options with respect to their individual risk. In summary, a reproducible, verifiable, and transparent in-depth echocardiographic investigation might ensure consistent hemodynamic plausibility of the quantitative results in patients with combined aortic and mitral regurgitation. The quantitative approach to assess LV volumes in combined AR and MR patients: explanation and algorithm of how to determine the relevant target parameters. LVSV eff -effective left ventricular (LV) stroke volume, LVSV forward -forward LV stroke volume through the aortic valve (AV), LVSV tot -total LV stroke volume, RegVol AR -regurgitant volume through the AV, RegVol MR -regurgitant volume through the mitral valve (MV), LV filling volume  = LV MV -Inflow - transmitral LV inflow, LVOT-left ventricular outflow tract, RF AR -regurgitant fraction of aortic regurgitation (AR), RF MR -regurgitant fraction of mitral regurgitation (MR), RVSV eff  -effective right ventricular (RV) stroke volume, RVSV forward -forward RV stroke volume through the pulmonary valve, RVSV tot -total RV stroke volume.