Aortic stenosis classification

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mandana Chitsazan, M.D. [2]

Overview

According to the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease, there are 4 stages of aortic stenosis based on the valve anatomy, valve hemodynamics, the left ventricular and vascular consequences of aortic obstruction, and the symptoms. The stages include at risk of AS, progressive hemodynamic obstruction, severe asymptomatic AS, and symptomatic AS.

Classification

According to the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease, there are 4 stages of aortic stenosis based on the valve anatomy, valve hemodynamics, the left ventricular and vascular consequences of aortic obstruction, and the symptoms of the patient:

  • A: Patient at risk of AS
  • B: Progressive hemodynamic obstruction
  • C: Severe asymptomatic AS
  • D: Symptomatic AS

Hemodynamic severity is assessed by transaortic maximum velocity or mean pressure gradient in the presence of a normal transaortic flow rate. However, some patients with AS have a low transaortic flow rate due to:

  • LV systolic dysfunction with a reduced LV ejection fraction (designated as D2)
  • Small hypertrophied LV with a low stroke volume (designated as D3) [1]


Stage Definition Valve Anatomy Valve Hemodynamics Hemodynamic Consequences Symptoms
A At risk of AS
  • Bicuspid aortic valve (or other congenital valvular anomalies)
  • Aortic valve sclerosis
  • Aortic Vmax <2 m/s
  • None
  • None
B Progressive AS
  • Mild to moderate leaflet calcification of a bicuspid or trileaflet valve with some reduction in systolic motion or
  • Rhematic valve changes with commissural fusion
  • Mild AS: Aortic Vmax 2.0-2.9 m/s or mean ΔP <20 mmHg
  • Moderate AS: Aortic Vmax 3.0-3.9 m/s or mean ΔP 20-39 mmHg
  • Early LV diastolic dysfunction may be present
  • Normal LVEF
  • None
C: Asymptomatic severe AS
C1 Asymptomatic severe AS
  • Severe leaflet calcification or congenital stenosis with severely reduced leaflet opening
  • Aortic Vmax ≥ 4 m/s or mean ΔP ≥40 mmHg
  • AVA typically ≤ 1.0 cm2 (or AVAi ≤ 0.6 cm2/m2)
  • Very severe AS: Aortic Vmax ≥ 5 m/s or mean ΔP ≥60 mmHg
  • LV diastolic dysfunction
  • Mild LV hypertrophy
  • Normal LVEF
  • None (Exercise testing is reasonable to confirm)
C2 Asymptomatic severe AS with LV dysfunction
  • Severe leaflet calcification or congenital stenosis with severely reduced leaflet opening
  • Aortic Vmax ≥ 4 m/s or mean ΔP ≥40 mmHg
  • AVA typically ≤ 1.0 cm2 (or AVAi ≤ 0.6 cm2/m2)
  • LVEF <50%
  • None
D: Symptomatic severe AS
D1 Symptomatic severe high-grade AS
  • Severe leaflet calcification or congenital stenosis with severely reduced leaflet opening
  • Aortic Vmax ≥ 4 m/s or mean ΔP ≥40 mmHg
  • AVA typically ≤ 1.0 cm2 (or AVAi ≤ 0.6 cm2/m2) but may be larger with mixed AS/AR
  • LV diastolic dysfunction
  • LV hypertrophy
  • Pulmonary hypertension may be present
  • Exertional dyspnea or decreased exercise tolerance
  • Exertional angina
  • Exertional syncope/presyncope
D2 Symptomatic severe low-flow/low-gradient AS with reduced LVEF
  • Severe leaflet calcification with severely reduced leaflet motion
  • AVA ≤1.0 cm2 with resting aortic Vmax <4 m/s or mean ΔP <40 mmHg
  • Dobutamine stress echocardiography shows AVA ≤ 1.0 cm2 with Vmax ≥4 m/s at any flow rate
  • LV diastolic dysfunction
  • LV hypertrophy
  • LVEF <50%
  • Heart failure
  • Angina
  • Syncope/presyncope
D3 Symptomatic severe low-gradient AS with normal LVEF or paradoxical low-flow severe AS
  • Severe leaflet calcification with severely reduced leaftlet motion
  • AVA ≤1.0 cm2 with aortic Vmax <4 m/s or mean ΔP <40 mmHg
  • AVAi ≤0.6 cm2/m2 and
  • Stroke volume index <25 ml/m2
  • Measured when patient is normotensive (systolic BP <140 mmHg)
  • Increased LV relative wall thickness
  • Small LV chamber with low stroke volume
  • Restrictive diastolic filling
  • LVEF ≥50%
  • Heart failure
  • Angina
  • Syncope/presyncope

Adapted from the 2014 AHA/ACCF guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines[1].

References

  1. 1.0 1.1 Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA; et al. (2014). "2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines". J Thorac Cardiovasc Surg. 148 (1): e1–e132. doi:10.1016/j.jtcvs.2014.05.014. PMID 24939033.


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