Aortic stenosis classification

Resident Survival Guide

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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 2020 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 2020 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)

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 <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%	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.