Aortic Valve Calcium Score Research Articles

Catheter-Induced Postextrasystolic Potentiation in the Assessment of Severity of Low-Gradient Aortic Valve Stenosis.

Deciphering which patients with low-gradient aortic valve disease have severe stenosis can be difficult. We aimed to correlate the postextrasystolic potentiation (PESP) with dobutamine stress echocardiography and multidetector computed tomography in patients with low-gradient aortic valve stenosis. Patients with an aortic valve area ≤1 cm2 and a mean gradient <40 mm Hg were included. Aortic valve stenosis severity was assessed by a core lab with dobutamine stress echocardiography, followed by a multidetector computed tomography aortic valve score if indeterminate. A premature ventricular contraction was induced by intentional catheter contact with the myocardium within the left ventricle. PESP was calculated as a percent change of pre-to-post mean gradient. Multidetector computed tomography was used to measure the aortic valve calcification score, and subsequently, aortic valve calcification density. Twenty-eight patients (age, 77±10 years; 19 female) were included. Dobutamine stress echocardiography increased mean gradient from baseline of 25±7 mm Hg to 36±11 mm Hg; pre-premature ventricular contraction mean gradient was 25±7 mm Hg and increased to post-premature ventricular contraction mean gradient of 32±10 mm Hg, representing a PESP of 24±11%. A ≥20% in PESP resulted in 100% sensitivity, 77% specificity, 83% positive predictive value, and 100% negative predictive value for diagnosing severe aortic valve stenosis. There was a significant correlation between PESP and projected aortic valve area and aortic valve calcification density (R=-0.64, P=0.0003; R=0.057, P=0.014, respectively). In patients with low-gradient aortic valve stenosis, catheter-induced premature ventricular contractions during cardiac catheterization causing ≥20% PESP has a 100% sensitivity for severe aortic valve stenosis. Validation of this 20% cutoff in larger groups with correlation to clinical end points is required.

Supra-renal aortic atheroma extent and composition predict acute kidney injury after transcatheter aortic valve replacement: A three-dimensional computed tomography study

ObjectiveAcute kidney injury (AKI) may complicate transcatheter aortic valve replacement (TAVR) and could be linked to atheroembolization associated with catheter manipulation in the supra-renal (SR) aorta.We sought to determine the impact of SR aortic atheroma burden (SR-AAB) and composition, as well as of the aortic valve calcium score (AV-CS), measured at pre-operative multislice computed tomography (PO-MSCT), on AKI-TAVR. MethodsAll TAVR-patients 3 January-2018 to December-2020 were included. A three-dimensional analysis of PO-MSCT was performed, calculating percentage SR-AAB (%SR-AAB) as [(absolute SR-AAB volume)*100/vessel volume]. Types of plaque were defined according to Hounsfield unit (HU) intensity ranges. Calcified plaque was subcategorized into 3 strata: low- (351–700 HU), mid- (701–1000 HU), and high‑calcium (>1000 HU, termed 1 K-plaque). ResultsThe study population included 222 patients [mean age 83.3 ± 5.7 years, 95 (42.8%) males], AKI-TAVR occurred in 67/222 (30.2%). Absolute SR-AAB (41.3 ± 16.4 cm3 vs. 32.5 ± 10.7 cm3,p < 0.001) and %SR-AAB (17.6 ± 5.1% vs. 13.9 ± 4.3%,p < 0.001) were significantly higher in patients developing AKI-TAVR.Patients who developed AKI-TAVR had higher mid‑calcium (6.9 ± 3.8% vs. 4.2 ± 3.5%,p < 0.001) and 1 K-plaque (5.4 ± 3.7% vs. 2.4 ± 2.4%,p < 0.001) with no difference in AV-CS (p = 0.691).Adjusted multivariable logistic regression analysis showed that %SR-AAB [OR (x%increase): 1.12, 95%CI: 1.04–1.22,p = 0.006] and %SR-calcified plaque [OR (x%increase): 5.60, 95%CI: 2.50–13.36,p < 0.001] were associated with AKI-TAVR. Finally, 3-knots spline analyses identified %SR-AAB >15.0% and %SR-calcified plaque >7.0% as optimal thresholds to predict an increased risk of AKI-TAVR. ConclusionsSuprarenal aortic atheroma, when highly calcified, is associated with AKI-TAVR. Perioperative-MSCT assessment of aortic atherosclerosis may help in identification of patients at high-risk for AKI-TAVR, who could benefit from higher peri-operative surveillance.

Doppler Underestimates Transvalvular Gradient Measured by Catheterization in Patients With Severe Aortic Stenosis

We sought to clarify characteristics of patients with severe aortic stenosis (AS) in whom transvalvular mean pressure gradient (MPG) was underestimated with Doppler compared with catheterization. Study subjects included 127 patients with severe AS who underwent transcatheter aortic valve implantation. Between subjects with Doppler MPG underestimation ≥10mm Hg (group U) and those without (group C), we retrospectively compared echocardiographic parameters and aortic valve calcification score using the Agatston method. Despite a strong correlation (rS = 0.88) and small absolute difference (2.1 ± 10.1mm Hg) between Doppler and catheter MPG, 27 patients (21%) were in group U. Among 48 patients with catheter MPG ≥60mm Hg, 10 patients (21%) revealed Doppler MPG of 40 to 59mm Hg, suggesting they had been misclassified as having severe AS instead of very severe AS. According to the guidelines, indication of valve replacement for patients without symptoms should be considered for very severe AS but not for severe AS. Therefore, sole reliance on Doppler MPG could cause clinical misjudgments. Group U had larger relative wall thickness (median [interquartile range: 0.60 [0.50 to 0.69] vs 0.53 [0.46 to 0.60], p=0.003) and higher calcification score (3,024 [2,066 to 3,555] vs 1,790 [1,293 to 2,501]arbitrary units, p <0.001). Both calcification score (per 100 arbitrary unit increment, odds ratio 1.10, 1.04 to 1.17, p=0.002) and relative wall thickness (per 0.05 increment, odds ratio 1.29, 95% confidence interval 1.05 to 1.60, p=0.02) were independently associated with Doppler underestimation. In conclusion, Doppler might underestimate transvalvular gradient compared with catheterization in patients with severe AS who have heavy valve calcification and prominent concentric remodeling left ventricular geometry.

Central obesity as assessed by conicity index and a-body shape index associates with cardiovascular risk factors and mortality in kidney failure patients.

Anthropometric indices of central obesity, waist circumference (WC), conicity index (CI), and a-body shape index (ABSI), are prognostic indicators of cardiovascular (CV) risk. The association of CI and ABSI with other CV risk indices, markers of nutritional status and inflammation, and clinical outcomes in chronic kidney disease (CKD) stage 5 (CKD5) patients was investigated. In a cross-sectional study with longitudinal follow up of 203 clinically stable patients with CKD5 (median age 56 years; 68% males, 17% diabetics, 22% with CV disease, and 39% malnourished), we investigated CI and ABSI and their associations with atherogenic index of plasma (AIP), Framingham CV risk score (FRS), Agatston scoring of coronary artery calcium (CAC) and aortic valve calcium (AVC), handgrip strength (HGS), high sensitivity C-reactive protein (hsCRP) and interleukin-6 (IL-6). CV events (CVE) and all-cause mortality during up to 10-years follow up were analyzed by multivariate survival analysis of restricted mean survival time (RMST). Chronic kidney disease patients with middle and highest CI and ABSI tertiles (indicating greater abdominal fat deposition), compared to those with the lowest CI and ABSI tertiles, tended to be older, more often men and diabetic, had significantly higher levels of hsCRP, IL-6, AIP, FRS, CAC and AVC scores. CI and ABSI were positively correlated with CAC, FRS, AIP, hsCRP and IL-6. Both CI and ABSI were negatively correlated with HGS. In age-weighted survival analysis, higher CI and ABSI were associated with higher risk of CVE (Wald test = 4.92, p = 0.027; Wald test = 4.95, p = 0.026, respectively) and all-cause mortality (Wald test = 5.24, p = 0.022; Wald test = 5.19, p = 0.023, respectively). In RMST analysis, low vs. high and middle tertiles of CI and ABSI associated with prolonged CVE-free time and death-free time, and these differences between groups increased over time. Abdominal fat deposit indices, CI and ABSI, predicted CV outcomes and all-cause mortality, and were significantly associated with the inflammatory status in CKD patients.

Aortic valve and vascular calcium score in pre-TAVI CT: correlation with early post-procedural complications

PurposeThe aim of our study was to evaluate the prevalence of early complications after Transcatheter Aortic Valve Implantation (TAVI) and their correlation with the Calcium Score (CS) of the aortic valve, aorta and ilio-femoral arteries derived from pre-procedural computed tomography (CT).Materials and methodsWe retrospectively reviewed 226 patients (100 males, mean age 79.4 ± 6.7 years) undergoing 64-slice CT for pre-TAVI evaluation from January 2018 to April 2021. The population was divided into CS quartiles.ResultsOverall, 173 patients underwent TAVI procedure, of whom 61% presented paravalvular leak after the procedure, 28% presented bleeding or vascular complications, 25% presented atrioventricular block, and 8% developed acute kidney injury. The prevalence of paravalvular leak and vascular complications was higher in the upper CS quartiles for aortic valve and ilio-femoral arteries.ConclusionsAortic valve and vascular CS could help to predict post-TAVI early complications.

Aortic valve calcium score in prediction of post-TAVI complications in an Egyptian cohort

BackgroundSevere symptomatic aortic stenosis is a common disorder in the elderly and is associated with high morbidity and mortality rate. Traditionally, surgical aortic valve replacement has been considered the most effective treatment for advanced disease. Transcatheter aortic valve implantation (TAVI) has been established as a valuable alternative treatment option for inoperable and high-risk patients with symptomatic severe aortic stenosis. Pre-procedure ECG-gated CT aortography study is important in planning the procedure. The aim of the study was to correlate the aortic valve calcium score with the post-TAVI complications.ResultsThirty patients who were candidates for TAVI procedure were enrolled for ECG-gated CT aortic valve calcium score and CT aortography. The calcium score was calculated. The patients were followed up both clinically and by echocardiography every 3 months for 1 year. Those who developed complications were enrolled for another CT study. Fourteen out of 30 patients (46.7%) presented with post-TAVI complications [9 cases (30%) presented with paravalvular leak (PVL) and 5 cases (16.7%) presented with major adverse cardiac events (MACE), while 16 cases (53.3%) had no complications]. There was a strong correlation between the calcium score and post-procedure complications.ConclusionsThe degree of aortic valve calcification can be considered as a predictor of post-TAVI complications: PVL and MACE.

149 QUANTIFICATION OF FIBROCALCIFIC VOLUME IN AORTIC VALVE STENOSIS BY A NOVEL CONTRAST COMPUTED TOMOGRAPHY METHOD BASED ON A GAUSSIAN MIXTURE MODEL

Abstract Background Discordant echocardiographic measurements are observed in up to one third of patients with aortic stenosis (AS), in whom computed tomography (CT) derived aortic valve calcium scoring is now recommended. Nonetheless, CT calcium scoring only evaluates calcific valve thickening and is unable to assess non-calcific fibrotic thickening, which could be a relevant contributor of AS. Aim of the present study was to generate a quick and robust contrast-CT method based on a gaussian mixture model (GMM) for the assessment of fibro-calcific aortic valve thickening in AS patients, and to investigate its reproducibility and associations with echocardiographic parameters of AS severity and disease progression. Methods A post-hoc analysis of 136 patients with calcific AS (24 with severe, 81 moderate and 31 mild AS) enrolled in the SALTIRE2 trial (Study Investigating the Effects of Drugs used to Treat Osteoporosis on the Progression of Aortic Stenosis) (NCT-02132026) was performed. Aortic valve fibrocalcific volume was calculated using a GMM applied on contrast-CT at baseline and at 1-year follow up. The software estimated the Hounsfield Units (HU) distribution of 3 compartments (blood pool, non-calcific and calcific tissue) within the aortic valve volume of interest, automatically generating thresholds for non-calcific and calcific volumes, respectively computed as the lower 99.7 and the upper 99.7 percentile of the blood pool HU distribution (Figure). Thus, Fibrocalcific volume was measured as the sum of non-calcific and calcific volumes, indexed for CT annulus area and compared to echo parameters of AS severity. Scan-rescan reproducibility and analysis of AS progression were also assessed. Results Image analysis took 5.8 ± 1.0 minutes per scan and showed excellent scan-rescan reproducibility (mean difference -1%, limits of agreement -9% to 7%). Indexed-fibrocalcific volume correlated well with echocardiographic aortic peak velocity (rho=0.70, p&amp;lt;0.0001), better than non-calcific and calcific volumes alone (rho=0.30 and rho=0.61 respectively, both p&amp;lt;0.0001) and Agatston calcium score (rho=0.63, p&amp;lt;0.0001). Baseline indexed-fibrocalcific volume was also the strongest predictor of subsequent AS progression in terms of change in aortic valve peak velocity (rho=0.29, p=0.006) and mean gradient (rho=0.39, p&amp;lt;0.0001). Progression-to-noise ratio for fibrocalcific volume was favourable (Cohen's statistic d=0.62), indicating that groups sizes of 21, 46 and 170 participants would be required to demonstrate 30%, 20% and 10% reductions in fibro-calcific volume progression with a novel drug respectively (alpha=0.05, power=80%). Conclusions This contrast CT-based approach based on a GMM is able to provide robust and relatively rapid assessment of fibrocalcific thickening in patients with AS. Fibrocalcific volume measured using this method, correlates well with other markers of AS severity, predicts disease progression and holds promise in tracking disease progression and response to novel therapies.

The diagnostic role of "acceleration time" measurement in patients with classical low flow low gradient aortic stenosis with reduced left ventricular ejection fraction.

In our study, we aimed to assess the role of acceleration time (AT), ejection time (ET), and AT/ET ratio to distinguish between true and pseudo severe AS in patients with classical low flow-low gradient (LF-LG) aortic stenosis (AS) with reduced left ventricular ejection fraction (LVEF). Sixty-seven classical LF-LG AS with reduced LVEF patients who underwent dobutamine stress echocardiography (DSE) were included in the study. According to DSE results, all patients were divided into two groups; true AS and pseudo severe AS. Aortic valve calcium score was measured in patients with inconclusive DSE results. AT and other ejection dynamics (ET and AT/ET) were calculated by taking baseline echocardiographic records into account for all patients. The predictive power of AT and other ejection dynamics were evaluated to estimate true and pseudo severe AS. According to DSE results, out of 67 patients, 44 (65.7%) was diagnosed as true severe AS. There was a statistically significant relation between baseline AT and true AS [adjusted OR 4.47 (95% CI 1.93-10.4), p = 0.001]. The best cutoff value of AT was measured as 100 msec according to the Youden index. This value had a sensitivity value of 77%, specificity value of 87%, positive predictive value of 92%, and a negative predictive value of 67%. The measurement of AT can predict the DSE outcome and can be used for diagnostic purposes to distinguish between true and pseudo severe AS in classical LF-LG AS patients with reduced LVEF.

Abstract 15231: Relationship Between Severe Aortic Stenosis, Chronic Kidney Disease, and Clinical Outcomes in Patients With Aortic Stenosis

Introduction: Patients with chronic kidney disease (CKD) often have cardiovascular calcification with a higher prevalence of AV disease. Aortic valve calcium (AVC) scores are often used to assess the severity of aortic stenosis (AS). Methods: We retrospectively studied 361 patients with AS who underwent a CTA at our institute from Nov 2018 to Mar 2022. GFR values closest to the CTA, but at most three months prior, along with the occurrence of the following outcomes: TAVR, SAVR, and all-cause mortality were recorded. An AVC score &gt; 2000 for men and 1200 for women was defined as severe AS. Also, GFR values were split into 3 groups: &gt;=60 (Group 1), 30-59 (Group 2), and &lt;30 (Group 3). An interaction term (CKD x AS) was also used to evaluate the differential impact of severe AS on outcomes within the CKD groups. Results: There was no significant difference in AVC scores among the CKD groups (p = 0.21) using a Kruskal-Wallis test. However, severe AS was associated with a higher occurrence of outcomes (OR = 6.84 [1.67 - 27.96], p = 0.008*), along with a non-significant interaction term (OR = 0.63 [0.26 - 1.52], p = 0.3) using a logistic regression with severe AS, CKD groups, and the interaction term as independent variables. Moreover, using a cox proportional-hazards model with the same variables, severe AS had a significant association with the outcomes (HR = 2.51, p = 0.009*), with a non-significant interaction term (HR = 0.85, p = 0.43). Conclusions: There was no significant difference in AVC scores among the CKD groups. But irrespective of kidney function, severe AS was associated with worse outcomes. Therefore, similar thresholds of AVC scores can be used to define severe AS in patients with and without CKD.

Abstract 14964: Photon Counting Computed Tomography for Aortic Valve Calcium Scoring in Contrast Enhanced Datasets of the Heart

Introduction: The prognostic value of aortic valve calcification prior to transcatheter aortic valve replacement (TAVR) is well established. Its reliable quantification requires a non-contrast computed tomography (CT) of the heart (‘true non contrast’, TNC) which in this cohort is not regularly performed at all centers. Photon Counting Detector CT (PCD-CT) permits the routine derivation of ‘virtual non-contrast’ (VNC) and ‘virtual non-iodine’ (VNI) series from CT Angiography (CTA) acquisitions due to its intrinsic spectral sensitivity. These might render separate non-contrast acquisitions unnecessary. Hypothesis: We hypothetized that quantification of aortic valve calcification of VNC/ VNI series derived from CTA scans is feasable and correlates with calcium scores of TNC series. Methods: 45 consecutive patients underwent pre TAVR CT on a novel PCD-CT (NAEOTOM Alpha, Siemens Healthineers, Erlangen, Germany) comprising a non-contrast CT of the heart, followed by a CTA of the heart, aorta, and iliac arteries. VNC series were derived from CTA acquisitions and two readers independently quantified aortic valve calcium scores (Agaston score) and calcium volumes on VNC-, VNI- and TNC-series. Results: A total of 41 patients (41.46% female) were included in the study. In comparison with aortic valve calcium scores and volume scores derived from TNC series (i.e., 2800[2075-3681] vs. 2206[1645-2894] mm3), those derived from VNC (i.e., 752[390-1357] vs. 653.3[319.5-1052.3] mm3) and VNI (i.e., 1986[1270-3278] vs. 1515[971-2480] mm3) series were consistently lower but correlation was excellent for both, i.e., calcium and volume score, respectively (r’s: 0.96 and 0.96 for VNC; r’s: 0.92 and 0.91 for VNI, p&lt; 0.05). Conclusions: Our initial patient experience with TAVR planning CT on a novel PCD-CT showed signficant correlation of aortic valve calcium scores and volumes derived from VNC and VNI series, as compared with those derived from TNC series, thus rendering non-contrast acquisitions for TAVR planning redundant.

Predictive Role of Aortic Valve Calcium score on post-procedural outcomes and mortality after Transcatheter aortic valve replacement

Abstract Introduction Extent of aortic valve (AV) calcium increases as degenerative aortic valve stenosis progresses. Initial studies postulated AV calcium (AVC) score to be a predictor of complications such as need for pacemaker implantation, paravalvular regurgitation and mortality after Trans-catheter Aortic valve Replacement (TAVR). However, evidence regarding the impact of AVC score as a predictor of post-procedural complications and mortality has been conflicting. Objective This study aimed to determine the prognostic impact of AVC as predictor of post-procedural outcomes and mortality in patients with severe aortic stenosis (AS) who underwent TAVR. Methods We retrospectively abstracted the records of 497 patients with severe AS who underwent TAVR between January 2016 and July 2019 at our institution. All patients underwent a non-contrast cardiac CT scan on a Siemens Somatom Definition Flash 128 slice scanner. AVC score using the Agatston method was obtained retrospectively. Patients were divided into two groups: 1) Non-severe AVC score group [women &amp;lt;1200 Agatston unit (AU) and men &amp;lt;2000 AU]; 2) Severe AV Calcium Score group [women &amp;gt;1200 AU and men &amp;gt;2000 AU]. Primary outcome was 1-year mortality. Results Among 466 patients included in the analysis, 352 patients were included severe AVC group while 114 patients were in the non-severe AVC group. Patients in the severe AVC group were older (81±8 vs 79±8 years), were predominantly males (79% vs 71%), and had less diabetes mellitus (31% vs 42%, p=0.02). Post-TAVR AV dimensionless index (0.58±0.13 vs 0.58±0.12, p=0.8) and AV mean gradient (9.5±4.9 vs 9.2±5.4 mmHg) were not statistically different between both groups. There was no statistical difference in the need for PPM (12% vs 7%, p=0.16), post-TAVR stroke (1.5% vs 0%), post-TAVR major complications (17.4% vs 10%, p=0.07), 30 day (3.7% vs 4.4%), and 1-year mortality (13.6 vs 11.4, p=0.6) between both groups. Conclusion Our study report that the severity of AVC score does not have a prognostic impact on major post-procedural outcomes and mortality after TAVR. Funding Acknowledgement Type of funding sources: None.

Significance and distribution of aortic valve calcium score before TAVI

Abstract Introduction Aortic valve calcium scoring by multislice computed tomography (MSCT) is an alternative load independent assessment of aortic stenosis severity. Recent studies have further demonstrated that aortic valve calcification load is related to adverse outcomes during and after transcatheter aortic valve implantation (TAVI), however reference values in this population are uncertain. This study aimed to assess aortic valve calcium in P referred for TAVI. Methods Retrospective analysis of consecutive patients (P) submitted to TAVI between 2014 and 2020 in a tertiary care centre. Clinical and echocardiographic characteristics, along with MSCT-derived aortic valve calcium score were collected. Results A total of 467 P were included, 57% female, median age 83 (9) years (minimum 45 and maximum 95 years-old). The prevalence of hypertension, dyslipidemia and diabetes was 83%, 69% and 36%, respectively. Chronic renal failure was present in 51%, atrial fibrillation in 34% and peripheral artery disease in 14%. Considering the 346 P with aortic valve calcification quantified by MSCT, median calcium score was 2161 (1761) AU. Age did not correlate with valvular calcification (r=0.043, p=0.422). Male gender showed significantly higher calcium score (2800 (2093) vs 1850 (1584), p&amp;lt;0.001) (Figs. 1 and 2). 11P had bicuspid aortic valve disease, with this population being younger (75 (16) vs 83 (8) years, p=0.001), nonetheless displaying higher aortic valve calcium load (2800 (2599) vs 2112 (1788), p=0.025). A weak but statistically significant correlation between calcium score and maximum (r=0.366, p&amp;lt;0.001) and mean gradients (r=0.387, p&amp;lt;0.001) and aortic valve area (r=−0.120, p=0.047) was demonstrated. Valvular calcification was not significantly different in P with reduced ejection fraction (&amp;lt;50%) (p=0.388). Conclusion There are significant differences in aortic valve calcium score between men and women referred for TAVI. Higher maximum and mean gradients were associated with increasing valvular calcification. Age and left ventricle ejection fraction were not related. P with bicuspid aortic valve have distinct calcification characteristics. As calcification burden may influence preprocedural planning, this parameter should be incorporated in the general work-up and reference values in this population should be known. Funding Acknowledgement Type of funding sources: None.

Aortic valve calcium score: does it correlate with mean transaortic gradient?

Abstract Introduction Aortic valvular calcium score (AVCS) is useful in patients with aortic stenosis for whom echocardiography was not conclusive in grading its severity. Transcatheter aortic valve implantation (TAVI) is an established procedure of treatment in symptomatic severe AS. The burden of aortic valve calcification has been associated with some TAVI related complications (as perivalvular leaks), but at the same time it is well accepted that some degree of calcification is needed to ensure stable anchoring of the prosthesis to the aortic annulus. Purpose To assess if there is a correlation between aortic valve calcium score and mean transvalvular gradient 6 months after TAVI – is a higher AVCS correlated with lower mean transaortic gradient after TAVI? Methods We performed a single-center, retrospective cohort study including patients who underwent TAVI with a preoperative standardized contrast enhanced MSCT with AVCS available. Clinical and echocardiographic data were collected previously to TAVI (pre-TAVI) and at 6 months follow up (6M-FUP). Results A total of 187 patients were included, with 54% female and a mean age of 79.4±9.0 years old. Most patients had tricuspid aortic valve (95.7%); 5 patients had aortic bicuspidy and 3 had aortic valve bioprothesis. Concerning the valve type, 73.3% had new generation prosthesis and the main valve used was the CoreValve Evolut Pro (33.7%). Also, 38,5% needed balloon pre-dilation before TAVI. The mean pre-TAVI aortic transvalvular maximum and mean gradients were 76.5±23.2 mmHg and 48.3±15.5 mmHg, respectively; mean aortic valve area was 0.75±0.16 cm2. The mean AVCS was 2851±1524 AU (Agaston Units); 81.2% of women had AVCS&amp;gt;1300 AU and 74.4% men had AVCS &amp;gt;2000 AU. Comparing transvalvular aortic gradients previously and 6M-FUP after TAVI, there was an average differential of maximum gradient of 61±22 mmHg and of mean gradient of 40±15 mmHg. A negative and weak correlation was found between the AVCS and the maximum gradient (pearson coefficient of −0.181, p=0.02) and between mean gradient at 6M-FUP (pearson coefficient of −0.191, p=0.014). Discussion and conclusion AVCS is a significant predictor for death, stroke and perivalvular leaks after TAVI. On the other hand, high AVCS is associated with better seating in the native annulus during deployment. Nevertheless, high AVCS did not strongly correlated with mean transaortic gradient 6 months after TAVI. Funding Acknowledgement Type of funding sources: None.

Sex-based differences of the impact of aortic valve calcium score on mortality and post-procedural outcomes after trans-catheter aortic valve replacement

Abstract Introduction Sex based differences exist in the presentation, outcomes, and management of cardiovascular diseases. Although aortic valve calcium (AVC) score has been postulated to be associated with post-procedural outcomes after transcatheter aortic valve replacement (TAVR), data on the impact of AVC score on procedural outcomes after TAVR based on sex have been scarce. Objective The aim of the present study was to elucidate sex related differences in the prognostic impact of AVC score as a predictor of post-procedural outcomes and mortality in patients with severe aortic stenosis (AS) who underwent TAVR. Methods We retrospectively abstracted the records of 497 patients with severe AS who underwent TAVR between January 2016 and July 2019 at our institution. All patients underwent a non-contrast cardiac CT scan on a Siemens Somatom Definition Flash 128 slice scanner. AVC score using the Agatston method was calculated retrospectively. Primary outcome was 1-year mortality. Patients were divided into two groups: 1) Non-severe AVC score group [women &amp;lt;1200 Agatston unit (AU) and men &amp;lt;2000 AU]; 2) Severe AVC Score group [women &amp;gt;1200 AU and men &amp;gt;2000 AU]. Cox-regression model was used to predict effect of variables on 1-year mortality in male and female patients. Results Among 466 patients included, 268 patients were male and 198 were female (57.5% vs 42.5%). When compared with males, female patients had significantly lower AVC score (p&amp;lt;0.001), aortic valve area (AVA) (p&amp;lt;0.001), obstructive CAD (p&amp;lt;0.001), and history of previous PCI (p&amp;lt;0.004), and CABG (&amp;lt;0.001) but had a significantly higher STS score (6.7±3.2 vs 5.8±3.3 P=0.01). There was no difference between need for permanent pacemaker (PPM) implantation (11% vs 9.6%, p=0.4), major complications (16% vs 15%, p=0.9), stroke (0.8% vs 1.6%, p=0.7), 30-day (3.7% vs 4%, p=0.9), and 1-year mortality (14% vs 12%, p=0.6) between males and females, respectively. Female patients required smaller bio-prosthetic valves compared with males (26±3.2 vs 30±3, p&amp;lt;0.001). Cox regression analysis for female patients showed BMI, hemoglobin level, and AVA independently predicted 1-year mortality, while there was no impact of severe AVC score (&amp;gt;1200 AU) on 1-year mortality in females. Similarly, Cox regression analysis for male patients showed there was no impact of severe AVC score (&amp;gt;2000 AU) on 1-year mortality in males. When males in the severe AVC group were compared with female patients in the severe AVC group, there was no difference in 30 day (4.3% vs 3.3%, p=0.82) and 1-year mortality (14.2% vs 13.3%, p=0.77). Similarly, in the severe AVC group there was no difference between need for PPM implantation (12.8% vs 12.1%, p=0.9), major complications (19.7% vs 15.8%, p=0.4), and stroke (2.2% vs 1%, p=0.6) between males and females, respectively. Conclusion There were no sex differences in the impact of AVC score on mortality and post-procedural outcomes after TAVR. Funding Acknowledgement Type of funding sources: None.

High JAK2V617F allele burden is associated with an increased burden of coronary artery calcification in MPNs

Abstract Background Patients with the haematological cancers Philadelphia-negative Myeloproliferative Neoplasms (MPNs), have an increased risk of coronary artery and aortic valve calcification, and an increased risk of myocardial infarctions. The most common acquired mutation in MPNs, the JAK2V617F mutation, has been linked to increased risk of thrombosis. Aims To exam the association between the JAK2V617F mutation, its allele burden, and coronary artery and aortic valve calcification. Methods One hundred and sixty one patients with MPN disease from one specialized haematological outpatient clinic where included. Information on demographics, smoking, alcohol habits and co-morbidities were registered. Blood samples were drawn for determination of the JAK2V617 mutation and allele burden. Patients were examined by cardiac computer tomography in order to determine their coronary artery calcium score (CACS) and aortic valve calcification (AVC) score. The association between the JAK2V617F mutation, its allele burden and coronary artery and aortic calcification was investigated with univariate and multivariate logistic regression analysis, adjusting for age, sex, ischemic heart disease (IHD), stroke, smoking, obesity, hypertension, hypercholesterolemia, diabetes mellitus, and family history of IHD or stroke in the multivariate analysis. Results Of the 161 patients (52% male, mean age 65.5±10.5 years), 137 (85%) were JAK2V617F positives, and the JAK2V617F allele burden was quantified in 120. The median JAK2V617F allele burden was 12% (IQR range 6–33%). There were 42 (26%) patients with a CACS &amp;gt;400, and 93 (58%) patients AVC. Among the JAK2V617F positive patients, 38 (24%) had a CACS &amp;gt;400 and 81 (59%) had AVC. In the 32 patients with a JAK2V617F allele burden&amp;gt;33%, 19 (59%) had a CACS &amp;gt;400 and 26 (81%) had AVC. In the univariate logistic regression analysis the presence of JAK2V617F mutation was not associated with a CACS &amp;gt;400 (Odds Ratio (OR) 1.92, 95% confidence interval (CI) 0.62–5.98, p=0.26). Similar result was found for the analysis on AVC (OR 1.45, 95% CI 0.61–3.45, p=0.41). In contrast, a JAK2V617F allele burden &amp;gt;33% was significantly associated with a CACS &amp;gt;400 (OR 5.31, 95% CI 2.23–12.66, p=0.0002), and similarly with AVC (OR 4.14, 95% CI 1.55–11.05, p=0.0045). In the multivariate adjusted analysis, a JAK2V617F allele burden &amp;gt;33% was significantly associated with a CACS &amp;gt;400 (OR 2.08, 95% CI 0.43–10.10, p=0.36), but not with AVC (OR 0.90, 95% CI 0.27–3.03, p=0.86). In the adjusted analysis the association between a JAK2V617F allele burden &amp;gt;33% and CACS &amp;gt;400 was significant (OR3.86, 95% CI 1.14–13.09, p=0.031), but the analysis on AVC was not (OR 1.59, 95% CI 0.42–6.04, p=0.50). Conclusion There is a significant association between a JAK2V617F allele burden &amp;gt;33% and the burden of coronary calcification in MPNs, measured as a CACS &amp;gt;400. The association remains significant after adjustment for cardiovascular risk factors. Funding Acknowledgement Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Region Sjællands Sundhedsvidenskabelige ForskningsfondTømrermester Jørgen Holm og hustru Elisa F. Hansens Mindelegat

Novel contrast-computed tomography method based on a Gaussian Mixture Model for assessment of fibrocalcific volume in aortic valve stenosis

Abstract Background Discordant echocardiography is observed in up to one third of patients with aortic stenosis (AS), in whom computed tomography (CT) derived aortic valve calcium scoring is now recommended. However, CT calcium scoring only assesses calcific valve thickening and ignores non-calcific fibrotic thickening, which could be an important contributor of AS. Purpose To generate a quick and robust contrast-CT method based on a gaussian mixture model (GMM) for assessment of fibro-calcific aortic valve thickening in patients with AS, and to investigate its reproducibility and associations with echo parameters of AS severity and disease progression. Methods A post-hoc analysis of 136 patients with calcific AS (24 with severe, 81 moderate and 31 mild AS) enrolled in the SALTIRE2 trial (NCT-02132026) was performed. Aortic valve fibrocalcific volume was calculated using a GMM applied on contrast-CT at baseline and at 1-year follow up. The software estimated the Hounsfield Units (HU) distribution of 3 compartments (blood pool, non-calcific and calcific tissue) within the aortic valve volume of interest, automatically generating thresholds for non-calcific and calcific tissue, respectively computed as the lower 99.7 and the upper 99.7 percentile of the blood pool HU distribution (Figure 1). Fibrocalcific volume was measured as the sum of calcific and non-calcific volumes, indexed for CT annulus area and compared to echo parameters of AS severity. Evaluation of scan-rescan reproducibility and AS progression were also assessed. Results Image analysis took 5.8±1.0 minutes per scan and showed excellent scan-rescan reproducibility (mean difference −1%, limits of agreement −9% to 7%). Indexed-fibrocalcific volume correlated well with echocardiographic aortic peak velocity (rho=0.70, p&amp;lt;0.0001), better than non-calcific and calcific volumes alone (rho=0.30 and rho=0.61 respectively, both p&amp;lt;0.0001) and Agatston calcium score (rho=0.63, p&amp;lt;0.0001). Baseline indexed-fibrocalcific volume was also the strongest predictor of subsequent AS progression in terms of change in aortic valve peak velocity (rho=0.29, p=0.006) and mean gradient (rho=0.39, p&amp;lt;0.0001). Progression-to-noise ratio for fibrocalcific volume was favourable (Cohen's statistic d=0.62), indicating that groups sizes of 21, 46 and 170 participants would be required to demonstrate 30%, 20% and 10% reductions in fibro-calcific volume progression with a novel drug respectively (alpha=0.05, power=80%). Conclusions This novel contrast CT-based approach can provide robust and rapid assessment of fibrocalcific thickening in AS patients. Fibrocalcific volume measured using this technique, correlates well with other markers of AS severity, predicts disease progression and holds promise in tracking disease progression and response to novel therapies. Funding Acknowledgement Type of funding sources: None.

Aortic valve calcium volume as measured by native versus contrast-enhanced computer tomography and the implications for the diagnosis of severe aortic stenosis in TAVR patients with low-gradient aortic stenosis

BackgroundMost of TAVR centers evaluate the calcium score in contrast-enhanced (ce) CT. We compared in this study between different methodologies to measure calcium score. We studied also the difference between patients with low-gradient (LG) and high-gradient (HG) severe aortic stenosis (AS) as regard the burden of aortic valve calcium (AVC).ResultsWe measured the calcium volume and score using Agatston methodology in non-contrast (nc) CT and with modified and fixed 850 Hounsfield unit (HU) thresholds in ce CT. The calcium score and volume in ceCT using even with modified thresholds is significantly lower than the assessed score and volume in ncCT. The median (IQR) of calcium score in nc CT and in cc CT were 1288 AU (750–1815) versus 947 HU (384–2202). The median (IQR) of calcium volume in nc CT and in cc CT with modified thresholds were 701 mm3 (239–1632) versus 197 mm3 (139–532). Agatston score and calcium volume were lower in patients with LG AS than HG AS; 2069 AU (899–2477) versus 928AU (572–1284) and 1537 mm3 (644–1860) versus 286 mm3 (160–700), respectively. Only 20% of patients with LGAS had Agatston score higher than the previously supposed AVC score threshold for the diagnosis of severe AS (> 2000AU in men and > 1200 in women).ConclusionsThe diagnosis of severe LGAS should not depend on a single parameter as calcium score. In these patients, calcium score should be measured in nc CT and not in ce CT.

Optimal threshold score of aortic valve calcification for identification of significant aortic stenosis on non-electrocardiographic-gated computed tomography.

This study evaluated the association between aortic valve calcification (AVC) and aortic stenosis (AS) by scoring the AVC to determine the threshold scores for significant AS on non-electrocardiographic (ECG)-gated computed tomography (CT). We retrospectively analyzed the AVC scores of 5385 patients on non-contrast non-ECG-gated CT, who underwent transthoracic echocardiography (TTE) from March 1, 2013, to December 26, 2019, at our institution. Multivariable logistic regression models were used to identify potential risk factors for significant AS. The thresholds for significant AS were computed using receiver operator characteristic (ROC) curves, based on the AVC scores after propensity score matching. A significant association was found between AS and age (p < 0.001; odds ratio [OR], 1.04; 95% confidence interval [CI], 1.02-1.06), female sex (p < 0.001; OR, 4.5; 95% CI, 2.75-7.36), bicuspid aortic valve (p < 0.001; OR, 23.2; 95% CI, 7.35-72.9), and AVC score (AVC score/100) (p < 0.001; OR, 1.82; 95% CI, 1.71-1.95). All sex-specific AVC thresholds for significant AS (moderate and over AS severity, moderate and over AS severity without discordance, discordant severe AS, and concordant severe AS) showed high sensitivity and specificity (AUC, 0.939-0.968; sensitivity, 84.6-96%; specificity, 84.2-97.1%). We determined the optimal AVC threshold scores for significant AS, which may aid in diagnosing significant asymptomatic AS on incidental detection of AVC through non-ECG-gated CT for non-cardiac indications. • Increased frequency of non-electrocardiographic (ECG)-gated computed tomography (CT) for non-cardiac indications has led to the increased incidental identification of aortic valve calcification (AVC). • It is important to identify patients with significant aortic stenosis (AS) who require additional echocardiographic assessment on incidental detection of AVC via non-ECG-gated CT. • We determined the AVC thresholds with high sensitivity and specificity to identify significant AS on non-ECG-gated CT, which could lead to early diagnosis of asymptomatic significant AS and improved prognosis.

Comparison of the Quantity of Calcium in the Aortic Valve and the Coronary Arteries in Men Versus Women Who Underwent Transcatheter Aortic Valve Implantation

Several studies have shown an association between aortic stenosis (AS) and coronary atherosclerosis. This study aimed to evaluate the gender differences in aortic valve calcium (AVC) and coronary artery calcium (CAC) and the association between CAC and all-cause mortality in patients with severe AS. A total of 260 patients (80 ± 7years, 39% men) with severe AS who were scheduled for transcatheter aortic valve implantation (TAVI) were included. AVC and CAC before TAVI were assessed by noncontrast cardiac computed tomography. Patients with coronary intervention or aortic valve replacement before cardiac computed tomography were excluded. Standard reference values of CAC score were used to classify the percentile groups and the distribution of AVC was assessed. The primary end point was all-cause mortality. In men, the AVC score was 3,911Hounsfield units (HUs) (interquartile range [IQR] 2,525 to 5,259) and in women, 2,409HU (IQR 1,588 to 3,359) (p &lt;0.001). CAC score in men was 824HU (IQR 328 to 1,855) and in women, 478HU (IQR 136 to 962) (p &lt;0.001). In men, the AVC score increased along with the CAC score, whereas in women, the AVC score was similar across the CAC percentile groups. During a median follow-up of 1,095days, 59 patients (23%) died. No significant gender-difference was seen in all-cause mortality for CAC score (p=0.187). Men with severe AS show higher AVC and CAC scores than women. Although the pattern of CAC distribution was similar between men and women, the AVC score increased along with the CAC score in men; whereas, in women, the AVC score remained similar across the various percentiles. CAC score was not associated with cumulative mortality in patients with severe AS who underwent TAVI.

Cardiac valves calcification and HDL-C in patients with aortic valve sclerosis

Background and Aims : Growing evidence has demonstrated the influence of many atherosclerotic risk factors on cardiac valve calcification (CVC), which is correlated with higher cardiovascular and all-cause mortality risk. The aim of this study was to investigate the effect of high-density lipoprotein cholesterol (HDL-C) on both mitral and aortic valve calcification (AVC) in individuals with AVC.Methods: Sixty-four patients with AVC, prior the intervention, were prospectively enrolled and underwent blood sampling for biochemical analysis and multi-slice computed tomography (MSCT) without contrast. Primary end points were the quantification of (1) mitral annulus calcification (MAC) and AVC, calculated by the median MAC and AVC scores (both were defined by Agatston units (AU) according to MSCT findings) and (2) the HDL-C level (defined by a direct enzymatic method). The study took place between 3 tertiary hospitals in Greece from October 2019 to November 2020.Results: The median age of all participants was 75.3 years (IR=7.4). The median HDL-C, MAC and AVC score was 46.9 mg/dl (IR 12.4) and 737.4 AU (IR=1218.5), respectively. According to the bivariate analysis results, a statistically significant correlation was found between HDL-C levels and the MAC and AVC score, with increased levels of HDL-C being related to decreased levels of CVC (r=-0.318, p=0.014).Conclusions: A significant inverse correlation between the HLD-C and CVC was confirmed in individuals with AVC. The above findings raise great interest for further research on pathophysiological mechanisms of valvular calcification and suggest that HDL-C may be an important treatment target to attenuate the development and progress of CVC. Background and Aims : Growing evidence has demonstrated the influence of many atherosclerotic risk factors on cardiac valve calcification (CVC), which is correlated with higher cardiovascular and all-cause mortality risk. The aim of this study was to investigate the effect of high-density lipoprotein cholesterol (HDL-C) on both mitral and aortic valve calcification (AVC) in individuals with AVC. Methods: Sixty-four patients with AVC, prior the intervention, were prospectively enrolled and underwent blood sampling for biochemical analysis and multi-slice computed tomography (MSCT) without contrast. Primary end points were the quantification of (1) mitral annulus calcification (MAC) and AVC, calculated by the median MAC and AVC scores (both were defined by Agatston units (AU) according to MSCT findings) and (2) the HDL-C level (defined by a direct enzymatic method). The study took place between 3 tertiary hospitals in Greece from October 2019 to November 2020. Results: The median age of all participants was 75.3 years (IR=7.4). The median HDL-C, MAC and AVC score was 46.9 mg/dl (IR 12.4) and 737.4 AU (IR=1218.5), respectively. According to the bivariate analysis results, a statistically significant correlation was found between HDL-C levels and the MAC and AVC score, with increased levels of HDL-C being related to decreased levels of CVC (r=-0.318, p=0.014). Conclusions: A significant inverse correlation between the HLD-C and CVC was confirmed in individuals with AVC. The above findings raise great interest for further research on pathophysiological mechanisms of valvular calcification and suggest that HDL-C may be an important treatment target to attenuate the development and progress of CVC.