Usefulness of Extra-Valvular Cardiac Damage Staging in Aortic Valve Stenosis

Bicuspid Aortic Valve Stenosis With CT Imaging
Bicuspid Aortic Valve Stenosis With CT Imaging
Extra-valvular cardiac damage staging may be useful to improve the management of patients with aortic valve stenosis.

Extra-valvular cardiac damage staging may be useful to improve the management of patients with aortic valve stenosis (AS), aortic valve regurgitation (AR), or mixed aortic valve disease (MAVD), according to a review published in the Canadian Journal of Cardiology.

As aortic valve diseases may alter other cardiovascular structures, a novel approach for their management involving severity grading t combined with staging of extra-valvular damage was proposed. Current guidelines for aortic valve diseases do not specify timing and preferred treatment plans for valve replacement. This grading approach may help the decision-making process and was validated in patients with moderate or severe AS.

Severity of all aortic valve diseases should be assessed by transthoracic echocardiography, according to the 2017 European Association for Cardiovascular Imaging and the American Society of Echocardiography guidelines. AR monitoring should include cardiac magnetic resonance, and AS and MAVD, multi-slice computed tomography assessments.

The proposed staging of aortic valve diseases is as follows: stage 0 (no cardiac damage); stage 1 (left ventricular damage); stage 2 (left atrial or mitral valve damage); stage 3 (pulmonary or tricuspid valve damage); and stage 4 (right ventricular or subclinical heart failure). All disease states are determined by transthoracic echocardiography. AS also requires serum assessment of N-terminal pro-B-type natriuretic peptide and cardiac magnetic resonance imaging to determine the presence of myocardial fibrosis.

Timing of aortic valve replacement surgery remains a controversial topic. Earlier replacement may allow for better symptom management but could expose patients to increased risk for mortality or long-term complications.

The benefit of this novel staging system would be to assist physicians in more accurately determining timing of valve replacement. Patients who have more advanced disease staging and increased cardiac damage were found to have higher risk for adverse outcomes. For this reason, patients with stage ³2 should be candidates for earlier interventions and patients with stage <2, conservative management.

Staging may also aid in optimizing valve type. For instance, patients with stage ³3 should be candidates for less invasive transfemoral transcatheter aortic valve replacement. Patients with more deteriorated right ventricular systolic function are likely poorer candidates for surgical valve replacement.

Additional studies examining this novel staging approach are needed to assess patients who have already undergone aortic valve replacement as well as the longitudinal trajectory of those with progressive disease, to optimize specific thresholds distinguishing the stages, and to confirm the usefulness of staging in patients with AS or MAVD.

“The initially proposed staging schemes were primarily based on echocardiographic parameters and criteria. However, other diagnostic modalities may be used to perform or complement these schemes including cardiac catheterization, CMR, and blood biomarkers,” concluded the study authors.

Disclosure: Multiple authors declared affiliations with industry. Please refer to the original article for a full list of disclosures.


Tastet L, Généreux P, Bernard J, et al. The Role of Extra-valvular Cardiac Damage Staging in Aortic Valve Disease Management. Can J Cardiol. 2021;S0828-282X(21)00065-9. doi:10.1016/j.cjca.2021.01.020