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Otto et al 2020 ACC/AHA Guideline for the Management of Valvular Heart Disease

Circulation. 2021;143:e72–e227. DOI: 10.1161/CIR.0000000000000923 February 2, 2021 e91 CLINICAL STATEMENTS AND GUIDELINES

results in a lower forward stroke volume and lower transaortic pressure gradient than when the patient is normotensive. Thus, Doppler velocity data and invasive pressure measurements ideally are recorded when the patient is normotensive. If results indicate only moderate stenosis but were recorded when the patient was hypertensive, repeat measurements when the blood pressure is better controlled ensure that a diagnosis of severe AS is not missed. 3.	 Patients with severe AS and LVEF <50% present with an aortic valve area <1.0 cm2 but a low transvalvular velocity and pressure gradient (ie, velocity <4 m/s or mean gradient <40 mm Hg) at rest. In these patients, severe AS with LV systolic dysfunction attributable to afterload

Table 13.  Stages of AS

Stage Definition Valve Anatomy Valve Hemodynamics Hemodynamic Consequences Symptoms A At risk of AS BAV (or other congenital valve anomaly)

Aortic valve sclerosis Aortic Vmax <2 m/s with normal leaflet motion None None

B Progressive AS Mild to moderate leaflet calcification/fibrosis of a bicuspid or trileaflet valve with some reduction in systolic motion or

Rheumatic valve changes with commissural fusion Mild AS: aortic Vmax 2.0–2.9 m/s or mean ∆P <20 mm Hg

Moderate AS: aortic Vmax 3.0–3.9 m/s or mean ∆P 20–39 mm Hg Early LV diastolic dysfunction may be present

Normal LVEF None

C: Asymptomatic severe AS C1 Asymptomatic severe AS Severe leaflet calcification/ fibrosis or congenital stenosis with severely reduced leaflet opening Aortic Vmax ≥4 m/s or mean ∆P ≥40 mm Hg

AVA typically is ≤1.0 cm2 (or AVAi 0.6 cm2/m2) but not required to define severe AS Very severe AS is an aortic Vmax ≥5 m/s or mean P ≥60 mm Hg LV diastolic dysfunction

Mild LV hypertrophy Normal LVEF None

Exercise testing is reasonable to confirm symptom status

C2 Asymptomatic severe AS with LV systolic dysfunction Severe leaflet calcification/ fibrosis or congenital stenosis with severely reduced leaflet opening Aortic Vmax ≥4 m/s or mean ∆P ≥40 mm Hg

AVA typically ≤1.0 cm2 (or AVAi 0.6 cm2/m2) but not required to define severe AS LVEF <50% None

D: Symptomatic severe AS D1 Symptomatic severe high-gradient AS Severe leaflet calcification/ fibrosis or congenital stenosis with severely reduced leaflet opening Aortic Vmax ≥4 m/s or mean ∆P ≥40 mm Hg

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, decreased exercise tolerance, or HF

Exertional angina Exertional syncope or presyncope

D2 Symptomatic severe low-flow, low-gradient AS with reduced LVEF Severe leaflet calcification/ fibrosis with severely reduced leaflet motion AVA ≤1.0 cm2 with resting aortic Vmax <4 m/s or mean ∆P <40 mm Hg

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/ fibrosis with severely reduced leaflet motion AVA ≤1.0 cm2 (indexed AVA ≤0.6 cm2/m2) with an aortic Vmax <4 m/s or mean ∆P <40 mm Hg

AND Stroke volume index <35 mL/m2 Measured when patient is normotensive (systolic blood pressure <140 mm Hg) Increased LV relative wall thickness

Small LV chamber with low stroke volume Restrictive diastolic filling LVEF ≥50% HF

Angina Syncope or presyncope

AR indicates aortic regurgitation; AS, aortic stenosis; AVA, aortic valve area circulation; AVAi, AVA indexed to body surface area; BAV, bicuspid aortic valve; ΔP, pressure gradient between the LV and aorta HF, heart failure; LV, left ventricular; LVEF, left ventricular ejection fraction; and Vmax, maximum velocity.

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