Computed Tomography Aortic Valve Calcium Research Articles

Disproportionately High Aortic Valve Calcium Scores in Atrial Fibrillation: Implications for Transcatheter Aortic Valve Replacement.

Doppler mean gradient (MG) can underestimate aortic stenosis (AS) severity in patients with atrial fibrillation (AF) compared to patients in sinus rhythm (SR), potentially delaying intervention in AF. This study compared outcomes in patients with AF and SR following transcatheter aortic valve replacement (TAVR) and investigated delay in TAVR based on computed tomography aortic valve calcium score (AVCS). Patients who underwent TAVR from 2013 to 2017 for native valve severe AS were identified from an institutional database. Baseline characteristics and overall survival were compared between those in SR and AF. There were 820 patients (mean age 81 years; 41.6% female) included. AF was present in 356 patients. Patients in AF were older (82.2 vs. 80.5, p = 0.003), had lower MG compared to SR patients (42.0 vs. 44.9, p = 0.002) with similar indexed aortic valve area (0.4 vs. 0.4, p = 0.17). Median AVCS was higher in AF (males: AF 2850.0 vs. SR 2561.0, p = 0.044; females: AF 1942.0 vs. SR 1610.5, p = 0.025). Projected AVCS assuming same age of diagnosis was similar between AF and SR. Median survival post-TAVR was worse in AF compared to SR (3.2 vs 5.4 years, log rank p < 0.001). AF, lower MG, higher RVSP, dialysis, diabetes, and significant TR were associated with higher mortality (p < 0.05 for all). Older age and higher AVCS in patients with AF compared to SR suggests that AS was both underestimated and more advanced at TAVR referral.

The diagnostic accuracy of aortic valve calcium score in patients with low gradient and high gradient aortic stenosis

Abstract Funding Acknowledgements Type of funding sources: None. Introduction The gold standard imaging modality for diagnosing aortic stenosis (AS) is echocardiography (echo); the definition of severe AS is based on the transvalvular mean gradient (AMG) (&amp;gt;40 mmHg) and aortic valve area (AVA) (&amp;lt;1 cm2). However, in around one quarter of the cases echo provides discordant findings (AVA&amp;lt;1 cm2, despite of an AMG &amp;lt;40 mmHg), complicating clinical decision making. Computed tomography aortic valve calcium scoring (CT-AVC) offers an alternative diagnostic method. In cases with discordant echo measurements current guidelines recommend CT-AVC to decide on severity. Purpose Our aim was to validate the sensitivity of the recommended calcium score (CAS) thresholds within our patient population, as well as to identify any factors associated with below cut-off CAS values despite confirmed severe AS (CAS false negativity). Methods Our retrospective study included 332 consecutive patients with severe AS (AVA ≤1 cm2), who underwent CT angiography (CTA) for transcatheter aortic valve implantation (TAVI) planning. Based on the AMG the patients were classified into high gradient (HG: AMG ≥ 40 mmHg) and low gradient (LG: AMG &amp;lt;40 mmHg) groups. In the LG group AS severity was assessed by a multiparametric algorithm. To specify the predictors of CAS false negativity among patients with HG-AS, logistic regression analysis was used. The patients were followed for 50 months. Cox proportional hazard model was used to assess the risk of death from any cause. Results The HG-AS group consisted of 244 and the LG-AS cohort of 88 patients. In the HG-AS population the sensitivity of CAS to diagnose severe AS was 89%. Within the HG severe AS group, logistic regression analysis revealed an association between CAS false negativity and the AMG (OR 0.89, CI 0.83 – 0.95, p &amp;lt;0,001), whereas none of the other tested factors (age, sex, hypertension, diabetes, left ventricle function, renal function) showed a predictive value. In the LG-AS group, contrary to the HG-AS patients, the sensitivity of CAS to define severe LG AS was limited (53% in males and 67% in females). Over a median follow-up of 50 months, the prognosis of HG AS patients with low CAS (false negative group) was more favourable than that of the high CAS patient population (HR 0.41; CI 017 – 097; p = 0.04). Conclusions Our results confirmed that among patients with HG AS, the recommended CAS thresholds provide a good diagnostic sensitivity for severe AS. Nonetheless, the number of severe AS patients with low CAS is not negligible, especially within the LG-AS population, where the diagnosis is the most challenging. Our findings underline that in patients with discordant echocardiographic findings, a personalized, multiparametric diagnostic approach is needed, instead basing the final diagnosis exclusively on CAS.

Effect of Denosumab or Alendronic Acid on the Progression of Aortic Stenosis: A Double-Blind Randomized Controlled Trial.

Valvular calcification is central to the pathogenesis and progression of aortic stenosis, with preclinical and observational studies suggesting that bone turnover and osteoblastic differentiation of valvular interstitial cells are important contributory mechanisms. We aimed to establish whether inhibition of these pathways with denosumab or alendronic acid could reduce disease progression in aortic stenosis. In a single-center, parallel group, double-blind randomized controlled trial, patients >50 years of age with calcific aortic stenosis (peak aortic jet velocity >2.5 m/s) were randomized 2:1:2:1 to denosumab (60 mg every 6 months), placebo injection, alendronic acid (70 mg once weekly), or placebo capsule. Participants underwent serial assessments with Doppler echocardiography, computed tomography aortic valve calcium scoring, and 18F-sodium fluoride positron emission tomography and computed tomography. The primary end point was the calculated 24-month change in aortic valve calcium score. A total of 150 patients (mean age, 72±8 years; 21% women) with calcific aortic stenosis (peak aortic jet velocity, 3.36 m/s [2.93-3.82 m/s]; aortic valve calcium score, 1152 AU [655-2065 AU]) were randomized and received the allocated trial intervention: denosumab (n=49), alendronic acid (n=51), and placebo (injection n=25, capsule n=25; pooled for analysis). Serum C-terminal telopeptide, a measure of bone turnover, halved from baseline to 6 months with denosumab (0.23 [0.18-0.33 µg/L] to 0.11 µg/L [0.08-0.17 µg/L]) and alendronic acid (0.20 [0.14-0.28 µg/L] to 0.09 µg/L [0.08-0.13 µg/L]) but was unchanged with placebo (0.23 [0.17-0.30 µg/L] to 0.26 µg/L [0.16-0.31 µg/L]). There were no differences in 24-month change in aortic valve calcium score between denosumab and placebo (343 [198-804 AU] versus 354 AU [76-675 AU]; P=0.41) or alendronic acid and placebo (326 [138-813 AU] versus 354 AU [76-675 AU]; P=0.49). Similarly, there were no differences in change in peak aortic jet velocity or 18F-sodium fluoride aortic valve uptake. Neither denosumab nor alendronic acid affected progression of aortic valve calcification in patients with calcific aortic stenosis. Alternative pathways and mechanisms need to be explored to identify disease-modifying therapies for the growing population of patients with this potentially fatal condition. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02132026.

Computed tomography aortic valve calcium scoring for the assessment of aortic stenosis progression

ObjectiveCT quantification of aortic valve calcification (CT-AVC) is useful in the assessment of aortic stenosis severity. Our objective was to assess its ability to track aortic stenosis progression compared with...

Correlates of the ratio of acceleration time to ejection time in patients with aortic stenosis: An echocardiographic and computed tomography study

Acceleration time to ejection time ratio (AT/ET) prolongation is associated with increased mortality in patients with aortic stenosis (AS). To identify the factors associated with increased AT/ET. The relationships between AT/ET ratio, clinical and Doppler echocardiographic variables of interest in the setting of AS were retrospectively analyzed in 1107 patients with AS and preserved left ventricular (LV) ejection fraction (EF), with Computed Tomography–Aortic Valve Calcium (CT-AVC) score studied in a subgroup of 342 patients. In univariate analysis, AT/ET ratio did correlate with aortic peak velocity (Vmax, r = 0.57, P < 0.0001), mean pressure gradient (MPG, r = 0.60, P < 0.0001), aortic valve area (AVA, r = −0.50, P < 0.0001) and CT-AVC score ( r = 0.24, P <0.0001). An AT/ET ratio had a good accuracy to predict a Vmax ≥ 4 m/s, an MPG ≥ 40 mmHg, or an AVA ≤ 1.0 cm 2 , with an optimal cut-off value of 0.34. Multivariate linear regression analysis showed that presence of AS-related symptoms, decreased LV stroke volume index, LVEF, absence of diabetes mellitus, systolic blood pressure (SBP), increased LV mass index, relative wall thickness, and Vmax were independently associated with increased AT/ET ratio (all P < 0.05). In the subgroup of patients who underwent CT-AVC, CT-AVC score was independently associated with increased AT/ET ratio ( P < 0.05) ( Fig. 1 ). AT/ET ratio is related to echocardiographic and CT-AVC indices of AS severity. However, multiple intricate factors beyond hemodynamic and anatomic severity of AS influence AT/ET ratio including LV geometry, function and SBP. These findings should be considered when assessing AT/ET in patients with AS and preserved LVEF.

1049 High single-beat Doppler signals in low-gradient aortic stenosis are associated with higher aortic valve calcium

Abstract Funding Acknowledgements Mayo Clinic Background Variability in Doppler signals is common in patients with atrial fibrillation (AF) and AF is common in low-gradient AS (LGAS). Presence of high single beat Doppler signals (peak velocity ≥4m/s or mean gradient ≥40mmHg) is not factored into decision-making in low-gradient aortic stenosis (LGAS). Objective Determine prevalence of at least one high Doppler signal in AF LGAS and its relationship to computed tomography aortic valve calcium score (AVCS) versus sinus rhythm (SR) high-gradient aortic stenosis (HGAS). Methods Consecutive patients with aortic valve area ≤1cm2 and left ventricular ejection fraction ≥50% during echo were identified (January 1, 2012-December 31, 2016). At least three consecutive Doppler signals were averaged in sinus rhythm (SR) and five in atrial fibrillation (AF). Results Of 1,854 patients, age 76± 11 years, male 52%, 301/1,854 (16%) were in AF and LGAS was present in 122/301 (41%). At least one high Doppler signal in AF LGAS was present in 43/122 (35%). AVCS within 1 year of echo was available for 36% of patient with SR HGAS and 34% of AS LGAS. Median AVCS was not different in SR HGAS 2424 (IQR 1623, 3445) vs AF LGAS with at least one high Doppler signal 2509 [IQR1547, 3119], p =0.10 AVCS threshold for severe AS (men &amp;gt;2000 women &amp;gt;1200) was met in 80% SR HGAS vs 86% AF LGAS with high signals. Conclusions High Doppler signals in AF LGAS are associated with high AVCS more frequently exceeding thresholds for severe AS. Single-beat high Doppler signals instead of the average correlate better with AVCS and classic HGAS.

P3696Correlates of the ratio of acceleration time to ejection time in patients with aortic stenosis: an echocardiographic and computed tomography study

Abstract Background Acceleration time to ejection time ratio (AT/ET) prolongation is associated with increased mortality in patients with aortic stenosis (AS). Purpose To identify the determinants associated with increased AT/ET. Methods The relationships between AT/ET ratio, clinical and Doppler echocardiographic variables of interest in the setting of AS were studied in 1107 patients with AS and preserved left ventricular (LV) ejection fraction (EF), with Computed Tomography – Aortic Valve Calcium (CT-AVC) score studied in a subgroup of 342 patients. Results In univariate analysis, AT/ET ratio did correlate with aortic peak velocity (Vmax, r=0.57, p&lt;0.0001), mean pressure gradient (MPG, r=0.60, p&lt;0.0001), aortic valve area (AVA, r=−0.50, p&lt;0.0001) and CT-AVC score (r=0.24, p&lt;0.0001). An AT/ET ratio had a good accuracy to predict an aortic peak velocity ≥4 m/s, a MPG≥40 mmHg, or an AVA≤1.0 cm2, with an optimal cut-off value of 0.34. By multivariate linear regression analysis, presence of AS-related symptoms, decreased LV stroke volume index, LVEF, systolic blood pressure (SBP), absence of diabetes mellitus, and increased LV mass index, relative wall thickness, and Vmax were independently associated with increased AT/ET ratio (all P&lt;0.05). In the subgroup of patients who underwent CT-AVC, CT-AVC score was independently associated with increased AT/ET ratio (P&lt;0.05). Conclusion AT/ET ratio is related to echocardiographic and CT-AVC indices of AS severity. However, multiple intricate factors beyond hemodynamic and anatomic severity of AS influence AT/ET ratio including LV geometry, function and SBP. These findings should be considered when assessing AT/ET in patients with AS and preserved LVEF. Acknowledgement/Funding Local funding

Correlates of the ratio of acceleration time to ejection time in patients with aortic stenosis: An echocardiographic and computed tomography study

An increased acceleration time to ejection time (AT/ET) ratio is associated with increased mortality in patients with aortic stenosis (AS). To identify the factors associated with an increased AT/ET ratio. The relationships between the AT/ET ratio and clinical and Doppler echocardiographic variables of interest in the setting of AS were analysed retrospectively in 1107 patients with AS and preserved left ventricular (LV) ejection fraction (LVEF). The computed tomography aortic valve calcium (CT-AVC) score was studied in a subgroup of 342 patients. In the univariate analysis, the AT/ET ratio was found to correlate with peak aortic jet velocity (r=0.57; P<0.0001), mean pressure gradient (r=0.60; P<0.0001), aortic valve area (r=-0.50; P<0.0001) and CT-AVC score (r=0.24; P<0.0001). The AT/ET ratio had good accuracy in predicting a peak aortic jet velocity≥4m/s, a mean pressure gradient≥40mmHg and an aortic valve area≤1.0cm2, with an optimal cut-off value of 0.34. Multivariable linear regression analysis showed that presence of AS-related symptoms, decreased LV stroke volume index, LVEF, absence of diabetes mellitus, systolic blood pressure, increased LV mass index, relative wall thickness and peak aortic jet velocity were independently associated with an increased AT/ET ratio (all P<0.05). In the subgroup of patients who underwent CT-AVC scoring, the CT-AVC score was independently associated with an increased AT/ET ratio (P<0.05). The AT/ET ratio is related to echocardiographic and CT-AVC indices of AS severity. However, multiple intricate factors beyond the haemodynamic and anatomical severity of AS influence the AT/ET ratio, including LV geometry, function and systolic blood pressure. These findings should be considered when assessing the AT/ET ratio in patients with AS and preserved LVEF.

Factors associated with the ratio of acceleration time to ejection time in patients with aortic stenosis: An echocardiographic and computed tomography study

Acceleration time to ejection time ratio (AT/ET) prolongation is associated with increased mortality in patients with aortic stenosis (AS). We aimed at evaluating the determinants associated with increased AT/ET. The relationships between AT/ET ratio, clinical and Doppler echocardiographic variables of interest in the setting of AS were studied in 1107 patients with AS and preserved left ventricular (LV) ejection fraction (EF), with Computed Tomography–Aortic Valve Calcium (CT-AVC) score studied in a subgroup of 342 patients. In univariate analysis, AT/ET ratio did correlate with aortic peak velocity (Vmax, r = 0.57, P < 0.0001), mean pressure gradient (MPG, r = 0.60, P < 0.0001), aortic valve area (AVA, r = −0.50, P < 0.0001) and CT-AVC score ( r = 0.24, P <0.0001). An AT/ET ratio had a good accuracy to predict a Vmax ≥ 4 m/s, a MPG ≥ 40 mmHg, or an AVA ≤ 1.0 cm 2 , with an optimal cut-off value of 0.34. Multivariate linear regression analysis showed that presence of AS-related symptoms, decreased LV stroke volume index, LVEF, absence of diabetes mellitus, systolic blood pressure (SBP), increased LV mass index, relative wall thickness, and Vmax were independently associated with increased AT/ET ratio (all P < 0.05). In the subgroup of patients who underwent CT-AVC, CT-AVC score was independently associated with increased AT/ET ratio ( P < 0.05). AT/ET ratio is related to echocardiographic and CT-AVC indices of AS severity. However, multiple intricate factors beyond hemodynamic and anatomic severity of AS influence AT/ET ratio including LV geometry, function and SBP. These findings should be considered when assessing AT/ET in patients with AS and preserved LVEF.

Computed Tomography Aortic Valve Calcium Scoring in Patients With Aortic Stenosis.

Computed tomography aortic valve calcium scoring (CT-AVC) holds promise for the assessment of patients with aortic stenosis (AS). We sought to establish the clinical utility of CT-AVC in an international multicenter cohort of patients. Patients with AS who underwent ECG-gated CT-AVC within 3 months of echocardiography were entered into an international, multicenter, observational registry. Optimal CT-AVC thresholds for diagnosing severe AS were determined in patients with concordant echocardiographic assessments, before being used to arbitrate disease severity in those with discordant measurements. In patients with long-term follow-up, we assessed whether CT-AVC thresholds predicted aortic valve replacement and death. In 918 patients from 8 centers (age, 77±10 years; 60% men; peak velocity, 3.88±0.90 m/s), 708 (77%) patients had concordant echocardiographic assessments, in whom CT-AVC provided excellent discrimination for severe AS (C statistic: women 0.92, men 0.89). Our optimal sex-specific CT-AVC thresholds (women 1377 Agatston unit and men 2062 Agatston unit) were nearly identical to those previously reported (women 1274 Agatston unit and men 2065 Agatston unit). Clinical outcomes were available in 215 patients (follow-up 1029 [126-2251] days). Sex-specific CT-AVC thresholds independently predicted aortic valve replacement and death (hazard ratio, 3.90 [95% confidence interval, 2.19-6.78]; P<0.001) after adjustment for age, sex, peak velocity, and aortic valve area. Among 210 (23%) patients with discordant echocardiographic assessments, there was considerable heterogeneity in CT-AVC scores, which again were an independent predictor of clinical outcomes (hazard ratio, 3.67 [95% confidence interval, 1.39-9.73]; P=0.010). Sex-specific CT-AVC thresholds accurately identify severe AS and provide powerful prognostic information. These findings support their integration into routine clinical practice. URL: http://www.clinicaltrials.gov. Unique identifiers: NCT01358513, NCT02132026, NCT00338676, NCT00647088, NCT01679431.

P183Clinical application of computed tomography aortic valve calcium scoring

P183Clinical application of computed tomography aortic valve calcium scoring

Sex-related differences in calcific aortic stenosis: correlating clinical and echocardiographic characteristics and computed tomography aortic valve calcium score to excised aortic valve weight

Calcific aortic valve stenosis (AS) is purportedly associated with less calcium burden in women than in men. We sought to examine sex-related differences and correlates of surgically excised aortic valve weight (AVW) in pure AS. Clinical and echocardiographic characteristics of 888 consecutive patients who underwent aortic valve replacement for severe AS were correlated to AVW, and in 126 patients, AVW was also correlated to computed tomography aortic valve calcium (AVC) score. Women and men had similar indexed valve area (0.42 ± 0.09 vs. 0.42 ± 0.07 cm (2)/m(2), P = 0.95) and mean systolic gradient (53 ± 15 vs. 52 ± 13 mmHg, P = 0.11), but women had higher New York Heart Association class (2.63 ± 0.70 vs. 2.50 ± 0.70, P = 0.01) and less prevalent coronary artery disease (38 vs. 52%, P < 0.0001). Aortic valve weight was lower in women (1.94 ± 0.88 vs. 3.08 ± 1.32 g, P < 0.0001) even when indexed to body surface area (1.09 ± 0.48 vs. 1.48 ± 0.62 g/m(2), P < 0.0001) or left ventricular outflow tract (LVOT) area (0.54 ± 0.23 vs. 0.71 ± 0.29 g/cm(2), P < 0.0001). Using multivariate analysis, male sex (P < 0.0001), bicuspid valve (P < 0.0001), and larger LVOT area (P < 0.0001) were the major determinants of increased AVW, along with current cigarette smoking (P = 0.007). Diabetes (P = 0.004) and hypertension (P = 0.03) were independently associated with lower AVW. Aortic valve calcium correlated well with AVW (r = 0.81, P < 0.0001) and was lower in women than in men (2520 ± 1199 vs. 3606 ± 1632 arbitrary units, P < 0.0001). Despite the same degree of AS severity, women have less AVC and lower AVW compared with men, irrespective of valve morphology. Aortic valve calcium is correlated to excised AVW. Hypertension, diabetes, and current cigarette smoking were independently associated with AVW.

130 Valvular 18F-Fluorodeoxyglucose Uptake Predicts Disease Progression and Clinical Outcome in Patients with Aortic Stenosis

Background Inflammation is a key process in the pathogenesis of Aortic valve disease. 18F-Fluorodeoxyglucose (18F-FDG) is an established positron emission tomography (PET) radiotracer that has become recognised as a marker of inflammatory activity in the vasculature and aortic valve. We sought to assess its ability to predict disease progression and clinical outcome in patients with aortic stenosis. Methods and results PET and computed tomography (CT) using 18F-FDG (200 MBq) was performed in 121 volunteers (72 ± 8 years, 68% men) with and without aortic valve disease (20 controls; 20 aortic sclerosis; 25 mild, 33 moderate, and 23 severe aortic stenosis). Disease progression was assessed at 1 and 2 years using CT aortic valve calcium score and echocardiography. The primary clinical outcome endpoint was a composite of cardiovascular death and aortic valve replacement (AVR). Aortic valve calcium score increased by 61 (5–226) AU/year and aortic valve mean gradient increased by 0.7 (-0.2–2.9) mmHg/year. Baseline valvular 18F-FDG uptake (corrected for blood pool activity and valve area) correlated with the rate of progression in aortic valve calcium score (r = 0.43, p = 0.001). Modest correlations were observed between 18F-FDG valvular uptake and echocardiographic measures of disease progression (mean aortic valve gradient, r = 0.30, p = 0.002; peak aortic jet velocity, r = 0.28, p = 0.005). After a median of 1,232 (IQR 1148–1322) days, 23 patients had undergone AVR whilst 5 had died from a cardiovascular cause. After age and sex-adjustment, valvular 18F-FDG uptake was an independent predictor of clinical outcome (HR 1.59 (1.21–2.09), p = 0.002). Conclusion Valvular 18F-FDG uptake predicts progression in aortic valve calcification and stenosis, and is associated with an adverse clinical outcome.

Aortic Valve Calcification on Computed Tomography Predicts the Severity of Aortic Stenosis

AIM: Incidental aortic valve calcification is often detected during computed tomography. The aim was to compare the severity of valvular stenosis and calcification in patients with aortic stenosis. MATERIALS AND METHODS: One hundred and fifty-seven patients aged 68±11 years (range: 34–85) with aortic valve stenosis underwent multislice helical computed tomography and Doppler echocardiography performed by independent, blinded observers. The aortic valve calcium score was determined using automated computer software calibrated with a phantom. RESULTS: Doppler echocardiography demonstrated a post-valve velocity of 3.45±0.66 m/s and a peak gradient of 49±11 mmHg. Computed tomography showed excellent reproducibility and the median aortic valve calcium score was 5858 AU (interquartile range, 1555–14,596). The computed tomography aortic valve calcium score positively correlated with the Doppler post-valve velocity and peak gradient ( r=0.54, p<0.0001 for both) of the aortic valve. All patients with severe aortic stenosis had a calcium score of >3700 AU. CONCLUSION: Calcification of the aortic valve is closely associated with the severity of aortic stenosis, and heavy calcification suggests the presence of severe aortic stenosis that requires urgent cardiological assessment. Patients with lesser degrees of aortic valve calcification should be screened for aortic stenosis and monitored for disease progression.