However, if symptoms attributable to mixed mitral disease occur, they are likely because of increased LA pressure from combined increased LA inflow from MR and obstruction to outflow from the LA. An en- larged LA, a high transmitral gradient, or direct mea- surement of a high LA or pulmonary artery wedge pres- sure suggest a valvular basis for the patient s symptoms. In such cases, mitral valve replacement may be neces- sary if therapy with diuretics do not relieve symptoms, but it should be performed only in patients who have severe limiting symptoms 10.2.4. Intervention for Mixed MS and AR Combined MS and AR usually result from rheumatic heart disease. When they occur concomitantly, MS is usually the more severe lesion. However, because MS limits LV filling, it may reduce the stroke volume pre- sented to the aortic valve, in turn reducing the apparent severity of AR.1,2 Furthermore, MS reduces the LV cav- ity size for any degree of AR, causing further potential underestimation of AR severity. In this regard, contrast aortography visualizes AR flow, instead of the echo- cardiographic visualization of AR velocity of flow, and may be helpful, as is precise assessment of AR regur- gitant fraction. In patients who have continued severe symptoms not responsive to diuretics, intervention with valve surgery should be pursued. If mitral anatomy is favorable, options are PMBC to treat the MS, followed by AVR or SAVR and open mitral commissurotomy. In this way, the increased mortality risk of double valve replacement is avoided.3 10.2.5. Intervention for Mixed MS and AS Almost always the product of rheumatic heart disease, the combination of MS and AS can be very confusing to the clinician. 