Intervention for Mixed AS and AR Recommendations for Timing of Intervention for Mixed AS and AR Referenced studies that support the recommendations are summarized in Online Data Supplement 33. COR LOE Recommendations In symptomatic patients with combined AS and AR and a peak transvalvular jet velocity of at least 4.0 m/s or a mean transvalvular gradient of at least 40 mmHg, AVR is In asymptomatic patients with combined AS and AR who have a jet velocity of 4.0 m/s with an LVEF <50%, SAVR is recommended.1,2 Synopsis The indications for AVR in patients with combined AS and AR and a peak transvalvular jet velocity of 4.0 m/s are the same as for patients with severe isolated AS. Recommendation-Specific Supportive Text 1. Currently, isolated moderate AS or moderate AR is placed in Stage B, progressive disease for which no therapeutic action is indicated. However, some patients with moderate mixed disease develop symptoms that stem from their valve disease. Formerly, the argument was raised that if there were no AR, the aortic jet velocity and gradient would be correspondingly lower and would not meet the definitions for severe AS, and obvi- ously there would be only moderate AR by defi- nition. Therefore, no action was recommended. However, recent data suggest that the natural his- tory of moderate mixed disease behaves similarly to that of pure severe AS1,2 and that moderate mixed disease has a mortality risk similar to that of pure severe AS. Thus, valve replacement is war- ranted for the symptomatic patient if the patient s data fulfill any of the criteria for severe AS. The decision about whether to proceed with TAVI ver- sus SAVR is discussed in Section 3.2.4.2. 2. 