The Heart Valve Society

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Aortic Valve Calcification in Patients with Aortic Stenosis and Discordant Echocardiographic Measures
Tania A. Pawade, MD1, Marie-Annick Clavel, DVM, PhD2, Christophe Tribouilloy, MD, PhD3, Julien Dreyfus, MD, PhD4, Lionel Tastet, Msc5, Cedric Renard, MD6, Mesut Gun, MSc7, Laurent Macron, MD4, Jacob W. Sechrist, MD8, Joan Lacomis, MD8, Virginia Nguyen, MD9, Tiffany Mathieu, MD9, Laura G. Gay, MD10, Hug C. Calabria, MD, PhD10, Ioannis Ntalas, MD11, William S.A Jenkins, MD1, Anoop Shah, MD, PhD1, Timothy R.G Cartlidge, MD1, David E. Newby, Md, PhD1, Bernard Prendergast, DM, PhD11, Ronak Rajani, MD11, Arturo Evangelista, MD, PhD10, Joao L. Cavalcante, MD12, Philippe Pibarot, DVM, PhD13, David Messika-Zeitoun, MD, PhD14, Marc R. Dweck, MD, PhD1.
1University of Edinburgh, Edinbrugh, United Kingdom, 2Institut Universitaire de Cardiology et de Pneumologie de Québec (Quebec Heart and Lung Institute), Laval University, Quebed, QC, Canada, 3Department of Cardiology. Centre Hospitalier Universitaire d'Amiens, Picardie, Amiens, France, 4Centre Cardiologique du Nord,, Saint-Denis, France, 5. Institut Universitaire de Cardiology et de Pneumologie de Québec (Quebec Heart and Lung Institute), Laval University,, Quebec City, QC, Canada, 6Department of Cardiology, University Hospital Amiens, Amiens, France, 7Department of Radiology, University Hospital Amiens, Amiens, France, 8Department of Radiology, Division of Cardiothoracic Imaging, University of Pittsburgh/UPMC, Pittsburgh, PA, USA, 9Bichat Hospital, Paris, France, 10Department of Cardiology. Hospital Universitari Vall d'Hebron, Barcelona, Spain, 11Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom, 12Department of Medicine, Division of Cardiology,, University of Pittsburgh/UPMC, PA, USA, 13Institut Universitaire de Cardiology et de Pneumologie de Québec (Quebec Heart and Lung Institute), Laval University, Quebec City, QC, Canada, 14Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust,, London, United Kingdom.

Objective
CT aortic valve calcium (AVC) scoring may provide an alternative method for assessing disease severity in aortic stenosis (AS). We sought to validate the recently proposed sex-specific thresholds for severe disease (men: 2065 AU, women: 1274 AU) in an international multicentre cohort of patients.
Methods
Patients with AS who had undergone ECG-gated CT calcium scoring within 3 months of echocardiography (peak aortic jet velocity [Vmax]>2.5 m/s) were entered into an international multicentre registry. Vmax and aortic valve area (AVA) were used to categorise patients into 4 groups of stenosis severity: concordant-severe (Vmax≥4 m/s AVA<1 cm2), discordant with high Vmax (≥4 m/s AVA ≥1 cm2), discordant with low Vmax (<4m/s AVA<1 cm2) and concordant non-severe (CNS; <4m/s AVA>1 cm2). In patients with concordant disease we determined the sensitivity and specificity of the previously proposed AVC thresholds and also determined our own optimum thresholds using receiver operator curves. In patients with discordant echocardiographic measurements we used CT AVC as an umpire test to arbitrate disease severity
Results
918 patients were recruited from 8 international centers (age 77±10, 60% male). 436 had concordant-severe and 272 had concordant non-severe AS in whom the thresholds for severe AVC on CT calcium scoring performed well (men: sensitivity 80%, specificity 82%; women: sensitivity 88%, specificity 81%). Our own optimum AVC thresholds were similar (men 2072 women 1321 AU).
210 patients (23%) had discordant echocardiographic assessments. Those with a high Vmax (n=35) had AVC scores similar to the concordant-severe group with 74% having severe AVC. Patients with discordant values and low Vmax (n=175) were more heterogeneous: 45% had AVC in the severe range, 55% had AVC in the non-severe range. 51 patients had a low indexed stroke-volume <35ml/m2, 29 of whom had severe AVC.
Conclusions
We have validated the proposed AVC thresholds for defining severe AS confirming their diagnostic accuracy in a large independent cohort of patients. They should be considered for clinical use particularly in patients with discordant echocardiographic measures.


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