Aortic valve calcification is subject to aortic stenosis severity and the underlying flow pattern
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ORIGINAL ARTICLE
Aortic valve calcification is subject to aortic stenosis severity and the underlying flow pattern Verena Veulemans1 · Kerstin Piayda1 · Oliver Maier1 · Georg Bosbach1 · Amin Polzin1 · Katharina Hellhammer1 · Shazia Afzal1 · Kathrin Klein1 · Lisa Dannenberg1 · Saif Zako1 · Christian Jung1 · Ralf Westenfeld1 · Malte Kelm1,2 · Tobias Zeus1 Received: 9 March 2020 / Accepted: 28 August 2020 © The Author(s) 2020
Abstract Sex- and flow-related aortic valve calcification (AVC) studies are still limited in number, and data on the exact calcium quantity and distribution are scarce. Therefore, we aimed to (1) re-define the best threshold of AVC load to distinguish severe from moderate aortic stenosis (AS) in common AS entities and to (2) evaluate differences in the aortic annulus and left ventricular outflow tract (LVOT) calcium load. Nine hundred and thirty-eight patients with contrast-enhanced cardiac MSCT and moderate-to-severe aortic stenosis (AS) were retrospectively enrolled. Patients with severe AS ≤ 1.0 cm2 (n = 841) were further separated into three AS entities: high gradient (HGAS, n = 370, 44.0%), paradoxical low gradient (pLGAS, n = 333, 39.6%), and classical low gradient (LGAS, n = 138, 16.4%). AVC, leaflet, and LVOT calcification were quantified. Aortic valve calcification scores were highest in severe HGAS, and lower in severe pLGAS and classical LGAS. In all severity and AS entities, the non-coronary cusp (NCC) was the most calcified one. LVOT calcification was consistently comparable between gender and AS entities. Accuracy of logistic regression was the highest in HGAS (male vs. female: AVC > 2156 Agatston units (AU), c-index 0.76; vs. AVC > 1292 AU, c-index 0.85; or AVC density > 406 AU/cm2, c-index 0.82; vs. > 259 AU/cm2, c-index 0.86; each p 1274 AU in women and 2065 AU in men or with AVC density (indexed to annulus cross-sectional area) > 292 AU/cm2 in women and > 476 AU/cm2 in men are set to be the cut-off to distinguish between moderate and severe AS [4]. Those findings entered current guideline recommendations on the management of patients with valvular heart disease to improve clinical decision-making in patients with inconsistent diagnostic findings. However, the definition of AS entities is subject to continuous modifications, and the existing sex- and flow-related AVC studies are limited to the number of studies in this context, and detailed information about calcium distribution and severity in patients with altered flow patterns are still missing. Therefore, we aimed to (1) re-define the best threshold of AVC load to distinguish severe from moderate AS in several AS entities and to (2) evaluate differences in the calcium load of the aortic annulus and left-ventricular outflow tract (LVOT).
Methods Study population We retrospectively enrolled 938 consecutive patients with moderate-to-severe tricuspid AS, who underwent diagnostic work-up for transcatheter aortic valve replacement between 2011 and 2019 at our heart center. Patients with moderateto-severe AS underwent MSCT if
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