MioAtlas
G1: Left-sided valves

Calcific aortic stenosis

Degenerative aortic valve stenosis of the elderly characterized by progressive fibroatheromatous calcification of the three aortic cusps that begins at the bases and advances toward the free edges without commissural fusion.

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Definition

Degenerative aortic valve stenosis of the elderly characterized by progressive fibroatheromatous calcification of the three aortic cusps that begins at the bases and advances toward the free edges without commissural fusion, restricting systolic valve opening and increasing left ventricular afterload [V1] [V4].

Severity criteria

  • Mild (L): Peak transaortic velocity (Vmax) 2.6–2.9 m/s; Mean transaortic gradient < 20 mmHg; Aortic valve area (AVA) > 1.5 cm²; Velocity ratio (Vratio) > 0.50 [V1] [V4].
  • Moderate (M): Vmax 3.0–3.9 m/s; Mean gradient 20–39 mmHg; AVA 1.0–1.5 cm²; Vratio 0.25–0.50 [V1] [V4].
  • Severe (G): Vmax ≥ 4.0 m/s; Mean gradient ≥ 40 mmHg; AVA < 1.0 cm² (or indexed AVA < 0.6 cm²/m²); Vratio < 0.25 [V1] [V4].

Findings by layer

Hemodynamics

  • Aortic mean gradient: L < 20 mmHg, M 20–39 mmHg, G ≥ 40 mmHg [V1] [V4].
  • Peak aortic velocity: L 2.6–2.9 m/s, M 3.0–3.9 m/s, G ≥ 4.0 m/s [V1] [V4].
  • Systemic arterial pressure: In severe stages, narrow pulse pressure with delayed systolic rise [B4] [V1].

Rhythm

  • Normal sinus rhythm [V1].
  • In advanced stages or calcification extending to the AV node: possible atrial fibrillation or conduction disturbances [E2] [V1].

ECG

  • Concentric left ventricular hypertrophy due to systolic pressure overload (left ventricular hypertrophy voltage criteria, positive Sokolow-Lyon / Cornell criteria with ST depression and asymmetric T-wave inversion in lateral leads) [E1] [V1].

Heart sounds and murmurs

  • Systolic murmur: Rough, harsh ejection mesosystolic murmur (crescendo-decrescendo) at the 2nd right intercostal space (aortic area), classically radiating to the carotid arteries [G1-14] [V4].
  • Gallavardin phenomenon: Acoustic dissociation in the elderly where the high-frequency component of the murmur is auscultated as musical and pure at the cardiac apex, mimicking mitral regurgitation [G1-14].
  • Second heart sound (S2): Aortic component (A2) decreased, soft, or absent in severe forms due to extreme calcific cusp rigidity; possible paradoxical splitting of S2 [G1-11] [V4].
  • Fourth heart sound (S4): Frequent in sinus rhythm due to atrial contraction against a non-compliant hypertrophied ventricle [G1-13].

Arterial pulse

  • In severe forms: Slow-rising pulse with delayed peak (pulsus parvus et tardus / anacrotic pulse) [B4] [V1].

Jugular venous pulse

  • Generally normal; prominent 'a' wave in the presence of septal hypertrophy reducing RV compliance (Bernheim effect) [B3].

Maneuvers

  • Valsalva maneuver (strain phase): Markedly decreases murmur intensity [B1].
  • Squatting: Increases murmur intensity due to increased venous return and stroke volume [B1].
  • Abrupt standing: Decreases the murmur by reducing preload [B1].
  • Isometric handgrip: Maintains or slightly decreases murmur intensity [B1].

Simulator severity grades

Simulator severity grades: Mild, Moderate, Severe
Baseline rhythm: Normal Sinus Rhythm

Also known as: Senile aortic stenosis · Degenerative aortic stenosis · Calcific aortic stenosis · Aortic valve stenosis · AS

Other pathologies in this group

Related clinical comparisons

Sources

  1. [B1] Bedside diagnosis of systolic murmurs . N Engl J Med (1988) . DOI: 10.1056/NEJM198806163182404 PubMed: 2897627
  2. [B3] The jugular venous pressure revisited . Cleve Clin J Med (2013) . DOI: 10.3949/ccjm.80a.13039 PubMed: 24085809
  3. [B4] The Carotid Pulse . Clinical Methods: The History, Physical, and Laboratory Examinations (1990) . PubMed: 21250154
  4. [E1] AHA/ACCF/HRS recommendations for the standardization and interpretation of the electrocardiogram: part V: electrocardiogram changes associated with cardiac chamber hypertrophy: a scientific statement from the American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; the American College of Cardiology Foundation; and the Heart Rhythm Society: endorsed by the International Society for Computerized Electrocardiology . Circulation (2009) . DOI: 10.1161/CIRCULATIONAHA.108.191097 PubMed: 19228820
  5. [E2] AHA/ACCF/HRS recommendations for the standardization and interpretation of the electrocardiogram: part III: intraventricular conduction disturbances: a scientific statement from the American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; the American College of Cardiology Foundation; and the Heart Rhythm Society: endorsed by the International Society for Computerized Electrocardiology . Circulation (2009) . DOI: 10.1161/CIRCULATIONAHA.108.191095 PubMed: 19228822
  6. [G1-01] Echocardiographic assessment of valve stenosis: EAE/ASE recommendations for clinical practice . J Am Soc Echocardiogr (2009) . DOI: 10.1016/j.echo.2008.11.029 PubMed: 19130998
  7. [G1-11] The Second Heart Sound . Clinical Methods: The History, Physical, and Laboratory Examinations (1990) . PubMed: 21250183
  8. [G1-13] The Fourth Heart Sound . Clinical Methods: The History, Physical, and Laboratory Examinations (1990) . PubMed: 21250185
  9. [G1-14] Systolic Murmurs . Clinical Methods: The History, Physical, and Laboratory Examinations (1990) . PubMed: 21250186
  10. [V1] 2025 ESC/EACTS Guidelines for the management of valvular heart disease . Eur Heart J (2025) . DOI: 10.1093/eurheartj/ehaf194 PubMed: 40878295
  11. [V2] 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines . Circulation (2021) . DOI: 10.1161/CIR.0000000000000923 PubMed: 33332150
  12. [V4] Recommendations on the echocardiographic assessment of aortic valve stenosis: a focused update from the European Association of Cardiovascular Imaging and the American Society of Echocardiography . Eur Heart J Cardiovasc Imaging (2017) . DOI: 10.1093/ehjci/jew335 PubMed: 28363204