대동맥판막 협착증, 수술 적응증

Stages of valvular aortic stenosis

Stage	Definition	Valve anatomy	Valve hemodynamics	Hemodynamic consequences	Symptoms
A	At risk of AS	Bicuspid aortic valve (or other congenital valve anomaly) 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 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	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 cm(or AVAi ≤0.6 ㎠/㎡) 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 ㎠ (or AVAi ≤0.6 ㎠/㎡)	LVEF <50%	None
D: Symptomatic severe AS
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 ㎠ (or AVAi ≤0.6 ㎠/㎡) 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 ㎠ with resting aortic Vmax <4 m/s or mean ΔP <40 mmHg Dobutamine stress echocardiography shows AVA ≤1.0 ㎠ 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 ㎠ with aortic Vmax <4 m/s or mean ΔP <40 mmHg Indexed AVA ≤0.6 ㎠/㎡ 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

AS: aortic stenosis; Vmax: maximum aortic velocity; ΔP: pressure gradient; LV: left ventricular; LVEF: left ventricular ejection fraction; AVA: aortic valve area; AVAi: aortic valve area indexed to body surface area; AR: aortic regurgitation; HF: heart failure; BP: blood pressure.

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• Severe aysmptomatic AS인 거의 모든 환자에서 (aortic velocity is ≥4.0 m/s 또는 mean pressure gradient is ≥40 mm Hg) 2-5년 이내에 증상 발생이 시작한다.
• 다른 판막 이외 수술 시 AVR를 시행하는 것은 5년 이내 AVR을 따로 수술하는 것보다 위험이 더 적다.
• Mean Pressure gradient가 AVR 수술 후 outcome의 강력한 예견 인자이다. Gradient가 클수록 outcome이 더 좋다.
• Exercise testing은 severe AS 환자에서 증상을 분명히 하는데 도움이 된다. 증상이 운동 검사로 유발된다면 증상이 있는 것으로 간주되고 AVR에 대한 COR1 권고를 만족한다. 환자 스스로 증상이 있다고 하던지 운동 검사로 유발되던지 모두 증상은 증상인 것이다.
• Aortic velocity가 ≥2 m/s에 도달하면 거의 모든 무증상 AS 환자들에서 궁극적으로 증상 발생을 초래하는 혈역학적 진행이 일어난다. Hemodynamic progression은 aortic velocity : 0.3 m/s per year 증가, mean gradient :7 - 8 mm Hg per year 증가, valve area : 0.15 cm2 per year 감소이다.
• LVEF의 점진적인 감소는 AS가 severe가 되기 전에 LVEF < 60% 사람에서 잘 일어난다. 약물 치료에 반응하지 않고 다른 원인 원인 LVEF가 점진적으로 감소한다면 AVR에 대한 고려가 필요하다.

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