| A | At risk of AS | - Bicuspid aortic valve (or other congenital valve anomaly)
- Aortic valve sclerosis
| | | |
| B | Progressive AS | - Mild to moderate leaflet calcification of a bicuspid or trileaflet valve with some reduction in systolic motion or
- Rheumatic valve changes with commissural fusion
| - Mild AS: Aortic Vmax 2.0 to 2.9 m/s or mean ΔP <20 mmHg
- Moderate AS: Aortic Vmax 3.0 to 3.9 m/s or mean ΔP 20 to 39 mmHg
| - Early LV diastolic dysfunction may be present
- Normal LVEF
| |
| 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 is an 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 symptom status
|
| 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)
| | |
| D1 | Symptomatic severe high-gradient 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 or 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%
| - HF
- Angina
- Syncope or presyncope
|
| D3 | Symptomatic severe low-gradient AS with normal LVEF or paradoxical low-flow severe AS | - Severe leaflet calcification with severely reduced leaflet motion
| - AVA ≤1.0 cm2 with aortic Vmax <4 m/s or mean ΔP <40 mmHg
- Indexed AVA ≤0.6 cm2/m2
- Stroke volume index <35 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%
| - HF
- Angina
- Syncope or presyncope
|
