Aortic insufficiency stages

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

Overview

According to the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease, aortic insufficiency has 4 stages based on the valve's anatomy, hemodynamics and the patients symptoms.

Stages

Shown below is a table summarizing the stages of aortic regurgitation (AR) according to the 2014 AHA/ACC guidelines for the management of patients with valvular heart disease.

Abbreviations: AR: aortic regurgitation; HF: heart failure; IE: infective endocarditis; LV: left ventricular; LVEF: left ventricular ejection fraction; LVESD: left ventricular end-systolic dimension; LVOT: left ventricular outflow tract; Jet/LVOT : jet width and LVOT ratio

STAGE	DEFINITION	VALVE ANATOMY	VALVE HEMODYNAMICS	HEMODYNAMIC CONSEQUENCES	SYMPTOMS
A	At risk of AR	❑ Bicuspid valve ❑ Valve sclerosis ❑ History of rheumatic fever ❑ Infective endocarditis	❑ None	❑ None	❑ None
B	Progressive AR	❑ Mild-to-moderate calcification ❑ Rheumatic valve changes ❑ Dilatation of aortic sinuses ❑ Infective endocarditis	❑ Mild AR: ❑ Jet/LVOT <25% ❑ Vena contracta <0.3 cm ❑ Regurgitant volume <30 mL/beat ❑ Regurgitant fraction <30% ❑ Effective regurgitant orifice <0.10 cm² ❑ Angiography grade 1+ ❑ Moderate AR: ❑ Jet/LVOT: 25%–64% ❑ Vena contracta 0.3–0.6 cm ❑ Regurgitant volume 30–59 mL/beat ❑ Regurgitant fraction 30%–49% ❑ Effective regurgitant orifice 0.10–0.29 cm² ❑ Angiography grade 2+	❑ Normal LV systolic function ❑ Normal LV volume or mild LV dilation	❑ None
C	Asymptomatic severe AR	❑ Calcific aortic valve disease ❑ Rheumatic valve changes ❑ Bicuspid valve ❑ Dilated aortic sinuses ❑ Infective endocarditis with abnormal leaflet closure	❑ Severe AR ❑ Jet/LVOT ≥65% ❑ Vena contracta >0.6 cm; ❑ Holodiastolic flow reversal in the proximal abdominal aorta ❑ Regurgitant volume ≥60 mL/beat; ❑ Regurgitant fraction ≥50%; ❑ Effective regurgitant orifice ≥0.3 cm2; ❑ Angiography grade 3+ to 4+;	❑ C1: Normal LVEF and mild to moderate LV dilatation ❑ C2: abnormal LV systolic function with decreased LVEF or severe LV dilatation	❑ None ❑ Exercise testing to confirm symptom status
D	Symptomatic severe AR	❑ Calcific aortic valve disease ❑ Rheumatic valve changes ❑ Dilated aortic sinuses ❑ Infective endocarditis with abnormal leaflet closure	❑ Severe AR ❑ Jet/LVOT ≥65% ❑ Vena contracta >0.6 cm; ❑ Holodiastolic flow reversal in the proximal abdominal aorta ❑ Regurgitant volume ≥60 mL/beat; ❑ Regurgitant fraction ≥50%; ❑ Effective regurgitant orifice ≥0.3 cm2; ❑ Angiography grade 3+ to 4+;	❑ May occur with normal systolic function or decreased function ❑ Presence of moderate to severe LV dilatation	❑ Exertional dyspnea ❑ Exertional angina ❑ HF symptoms