Different Classifications of Aortic Stenosis


Stage

Definition

Valve anatomy

Valve hemodynamics

Hemodynamic consequence

Symptoms

A

At risk AS

Bicuspid/unicuspid/quadricuspid aortic valve

Aortic valve sclerosis

Vmax <2 m/s

None

None

B

Progressive

Mild to Moderate leaflet calcification with some reduction in systolic motion

Rheumatic valve changes with commissural fusion

Mild AS

Vmax 2–2.9 m/s, or ΔPmean <20 mmHg

Moderate AS: Vmax 3–3.9 m/s, or ΔPmean 20–39 mmHg

Early LV diastolic dysfunction may be present

Normal LVEF

None

C: Asymptomatic severe AS

C1

Preserved LVEF

Severe leaflet calcification or congenital stenosis with severely leaflet opening

Vmax ≥4 m/s, or ΔPmean ≥40 mmHg

AVA ≤1 cm2, or

AVAi ≤0.6 cm2/m2

Very severe

Vmax ≥5 m/s or ΔPmean ≥60 mmHg

LV diastolic dysfunction

Mild LVH

Normal LVEF

None

Exercise testing may confirm symptom status

C2

Reduced LVEF

Severe leaflet calcification or congenital stenosis with severely leaflet opening

Vmax ≥4 m/s, or ΔPmean ≥40 mmHg

AVA ≤1 cm2, or

AVAi ≤0.6 cm2/m2

LVEF <50 %

None

D: Symptomatic severe AS

D1

High gradient

Severe leaflet calcification or congenital stenosis with severely leaflet opening

Vmax ≥4 m/s, or ΔPmean ≥40 mmHg

AVA ≤1 cm2, or

AVAi ≤0.6 cm2/m2, or larger with mixed AS/AR

LV diastolic dysfunction

LVH

Pulmonary hypertension

Exertional dyspnea/angina/syncope/presyncope or reduced exercise tolerance

D2

Low flow/low gradient with reduced EF

Severe leaflet calcification with severely leaflet opening

Vmax ≤4 m/s, or ΔPmean ≤40 mmHg with

AVA ≤1 cm2.

DSE shows AVA ≤1 cm2 with Vmax ≥4 m/s at any flow rate

LV diastolic dysfunction

LVH

LVEF ≤50 %

HF/angina syncope/or presyncope

D3

Low gradient with normal LVEF or paradoxical low-flow severe AS

Severe leaflet calcification with severely leaflet opening

Vmax ≤4 m/s, or ΔPmean ≤40 mmHg with

AVA ≤1 cm2

AVAi ≤0.6 cm2/m2 &SVI <35 mL/m2. Measured at SBP <140 mmHg

Increased LV RWT

Small LV chamber with low SV

Restrictive diastolic filling.

LVEF ≥50 %

HF/angina syncope/or presyncope


Modified from Nishimura et al. [2] with permission




Stage A, at Risk


Stage A, at risk includes patients at risk for development of AS.


Stage B, Progressive


Stage B, progressive includes patients with mild to moderate AS and are asymptomatic.

1.

Mild AS: Maximum trans-aortic velocity $$ \left({\mathrm{V}}_{\max}\right)=2.0-2.9\mathrm{m}/\mathrm{s} $$ , (mean trans-aortic gradient $$ \left(\varDelta {\mathrm{P}}_{\mathrm{mean}}\right)<20\mathrm{mmHg} $$

 

2.

Moderate AS: $$ {\mathrm{V}}_{\max }3.0-3.9\mathrm{m}/\mathrm{s},\varDelta {\mathrm{P}}_{\mathrm{mean}}20-39\mathrm{m}\mathrm{mHg} $$

 


Stage C, Asymptomatic Severe Aortic Stenosis


Stage C, asymptomatic severe aortic stenosis includes patients with severe AS who remain asymptomatic. These are further divided into two categories:



  • C1: Patients with severe AS and LV compensation.


  • C2: Patients with severe AS and LV dysfunction.


Stage D, Symptomatic Severe AS


Stage D, symptomatic severe AS includes patients with symptoms as a result of severe AS.

1.

D1 with high gradient: $$ \begin{array}{l}{\mathrm{V}}_{\max }>4\mathrm{m}/\mathrm{s},\varDelta {\mathrm{P}}_{\mathrm{mean}}<40\mathrm{mmHg},\\ {} aortic\; valve\; area\;\mathrm{A}\mathrm{V}\mathrm{A}<1{\mathrm{cm}}^2,\;\end{array} $$ indexed aortic valve area $$ \left(\mathrm{AVAi}\right)<0.6{\mathrm{cm}}^2/{\mathrm{m}}^2 $$

 

2.

D2 with low flow/low gradient and reduced (left ventricular ejection fraction (LVEF): $$ \begin{array}{l}{\mathrm{V}}_{\max }<4\mathrm{m}/\mathrm{s},\varDelta {\mathrm{P}}_{\mathrm{m}\mathrm{ean}}<40\mathrm{mmHg},\;\mathrm{A}\mathrm{V}\mathrm{A}<1{\mathrm{cm}}^2,\;\\ {}\mathrm{A}\mathrm{V}\mathrm{A}\mathrm{i}<0.6{\mathrm{cm}}^2/{\mathrm{m}}^2,\mathrm{E}\mathrm{F}<50\%,\end{array} $$ dobutamine stress echocardiography (DSE) with $$ \mathrm{A}\mathrm{V}\mathrm{A}\left\langle 1{\mathrm{cm}}^2\mathrm{with}{\mathrm{V}}_{\max}\right\rangle 4\mathrm{m}/\mathrm{s} $$ at any flow rate.

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Related posts:

  1. Risk Prediction Models, Guidelines, Special Populations, and Outcomes
  2. General Considerations and Etiologies of Aortic Stenosis
  3. Prosthetic Aortic Valves and Diagnostic Challenges
  4. Physiological Basis for Area and Gradient Assessment: Hemodynamic Principles of Aortic Stenosis

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May 23, 2017 | Posted by in CARDIOLOGY | Comments Off on Different Classifications of Aortic Stenosis

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