Aortic insufficiency stages

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Alejandro Lemor, M.D. [2]; Usama Talib, BSc, MD [3]

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Overview

According to the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease, aortic insufficiency is classified into 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 Guideline for the Management of Patients With Valvular Heart Disease.[1]

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 SYMPTOMS VALVE ANATOMY VALVE HEMODYNAMICS HEMODYNAMIC CONSEQUENCES
A At risk of AR • None • Bicuspid valve
• Valve sclerosis
• History of rheumatic fever
Infective endocarditis
No regurgitation • None
B Progressive AR • None • Mild-to-moderate calcification
• Rheumatic valve changes
• Dilatation of aortic sinuses
Infective endocarditis
Mild regurgitation:
• 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 regurgitation:

• 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
C Asymptomatic severe • None
• Exercise testing to confirm symptom status
• Calcific aortic valve disease
• Rheumatic valve changes
• Bicuspid valve
• Dilated aortic sinuses
Infective endocarditis with abnormal leaflet closure
Severe regurgitation
• 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: LV systolic dysfunction with decreased LVEF or severe LV dilatation

D Symptomatic severe • Exertional dyspnea
• Exertional angina
HF symptoms
• Calcific aortic valve disease
• Rheumatic valve changes
• Dilated aortic sinuses
Infective endocarditis with abnormal leaflet closure
Severe regurgitation
• 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+;
• Normal or decreased systolic function
• Moderate to severe LV dilatation


References

  1. Nishimura, R. A.; Otto, C. M.; Bonow, R. O.; Carabello, B. A.; Erwin, J. P.; Guyton, R. A.; O'Gara, P. T.; Ruiz, C. E.; Skubas, N. J.; Sorajja, P.; Sundt, T. M.; Thomas, J. D. (2014). "2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines". Circulation. doi:10.1161/CIR.0000000000000031. ISSN 0009-7322.


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