Each of these stages is defined by valve anatomy, valve hemodynamics, se- verity of LV dilation, and LV systolic function, as well as by patient symptoms. CLINICAL STATEMENTS AND GUIDELINES Table 15. Stages of Chronic AR Stage Definition Valve Anatomy Valve Hemodynamics Hemodynamic Consequences Symptoms A At risk of AR BAV (or other congenital valve anomaly) Aortic valve sclerosis Diseases of the aortic sinuses or ascending aorta History of rheumatic fever or known rheumatic heart disease IE AR severity: none or trace None None B Progressive AR Mild to moderate calcification of a trileaflet valve BAV (or other congenital valve anomaly) Dilated aortic sinuses Rheumatic valve changes Previous IE Mild AR: Jet width <25% of LVOT Vena contracta <0.3 cm Regurgitant volume <30 mL/ beat Regurgitant fraction <30% Angiography grade 1 Moderate AR: Jet width 25% 64% of LVOT Vena contracta 0.3 0.6 cm Regurgitant volume 30 59 mL/ beat Regurgitant fraction 30% to Angiography grade 2 Normal LV systolic function Normal LV volume or mild LV dilation None C Asymptomatic severe AR Calcific aortic valve disease Bicuspid valve (or other congenital abnormality) Dilated aortic sinuses or ascending aorta Rheumatic valve changes IE with abnormal leaflet closure or perforation Severe AR: Jet width 65% of LVOT Vena contracta >0.6 cm Holodiastolic flow reversal in the proximal abdominal aorta Regurgitant volume 60 mL/ beat Regurgitant fraction 50% Angiography grade 3 to 4 In addition, diagnosis of chronic severe AR requires evidence of LV dilation and mild to moderate LV dilation (LVESD <50 mm) C2: Abnormal LV systolic function with depressed LVEF ( 55%) or severe LV dilation (LVESD >50 mm or ) None; exercise testing is reasonable to confirm symptom status D Symptomatic severe AR Calcific valve disease Bicuspid valve (or other congenital abnormality) Dilated aortic sinuses or ascending aorta Rheumatic valve changes Previous IE with abnormal leaflet closure or perforation Severe AR: Doppler jet width 65% of LVOT Vena contracta >0.6 cm Holodiastolic flow reversal in the proximal abdominal aorta Regurgitant volume 60 mL/ beat Regurgitant fraction 50% Angiography grade 3 to 4 In addition, diagnosis of chronic severe AR requires evidence of LV dilation Symptomatic severe AR may occur with normal systolic function (LVEF >55%), mild to moderate LV dysfunction (LVEF 40% to 55%), or severe LV dysfunction (LVEF Moderate to severe LV dilation is present Exertional dyspnea or angina or more severe HF symptoms AR indicates aortic regurgitation; BAV, bicuspid aortic valve; ERO, effective regurgitant orifice; HF, heart failure; IE, infective endocarditis; LV, left ventricular; LVEF, left ventricular ejection fraction; LVESD, left ventricular end-systolic dimension; and LVOT, left ventricular outflow tract. 