Synopsis Mixed valve disease is either 1) stenosis and regurgita- tion of a single valve or 2) stenosis or regurgitation of 2 separate valves. Mixed valve disease presents a special diagnostic challenge to the clinician in assessing the im- pact of the lesions on cardiac remodeling, ventricular function, and timing of intervention.1 5 For many pa- tients with mixed valve disease, there is a predominant valve lesion (ie, stenosis versus regurgitation; mitral versus aortic), and symptoms and pathophysiology re- semble those of a pure dominant lesion. When pres- sure overload predominates, there is usually concentric hypertrophy, whereas volume overloads cause chamber dilation and eccentric hypertrophy; management should follow the guidelines for the predominant lesion. How- ever, in other cases, patients present with a more bal- anced picture, with the mixed pathophysiology making patient management difficult. It may be that neither lesion by itself reaches Stage C as described in previ- ous sections for pure lesions, yet the lesions may be, in combination, severe enough to impact outcome. Mixed valve disease was primarily attributable to rheumatic disease in the past, but it is now more frequently seen with degenerative disease or after prior chest radiation.5 Decision-making for patients with mixed valve disease is frequently complex and may require referral to or con- sultation with a Comprehensive Valve Center. Recommendation-Specific Supportive Text 1. The complex nature of mixed valve disease requires a comprehensive imaging approach that involves assessing each lesion separately and then collectively judging how the lesions affect the patient s overall presentation. TTE is the standard modality for measuring jet velocities, valve areas, regurgitant flow, and regurgitant orifice areas. TTE establishes the baseline for pathoanatomy and pathophysiology from which comparison is made as the lesions progress over time. 