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Cited by 569Cardiac Valve Diseases and TreatmentsAortic Disease and Treatment ApproachesCardiac Imaging and Diagnostics

The Complex Nature of Discordant Severe Calcified Aortic Valve Disease Grading

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Clavel, Marie-Annick, Messika-Zeitoun, David, Pibarot, Philippe, Aggarwal, Shivani R., Malouf, Joseph, Araoz, Phillip A., Michelena, Hector I., Cueff, Caroline +4 more·2013·Journal of the American College of Cardiology
DOI 10.1016/j.jacc.2013.08.1621
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Abstract

Objectives With concomitant Doppler echocardiography and multidetector computed tomography (MDCT) measuring aortic valve calcification (AVC) load, this study aimed at defining: 1) independent physiologic/structural determinants of aortic valve area (AVA)/mean gradient (MG) relationship; 2) AVC thresholds best associated with severe aortic stenosis (AS); and 3) whether, in AS with discordant MG, severe calcified aortic valve disease is generally detected.Background Aortic stenosis with discordant markers of severity, AVA in severe range but low MG, is a conundrum, unresolved by outcome studies.Methods Patients (n = 646) with normal left ventricular ejection fraction AS underwent Doppler echocardiography and AVC measurement by MDCT. On the basis of AVA-indexed-to-body surface area (AVAi) and MG, patients were categorized as concordant severity grading (CG) with moderate AS (AVAi >0.6 cm²/m², MG <40 mm Hg), severe AS (AVAi ≤0.6 cm²/m², MG ≥ 40 mm Hg), discordant-severity-grading (DG) with low-MG (AVAi ≤0.6 cm(2)/m(2), MG <40 mm Hg), or high-MG (AVAi >0.6 cm(2)/m(2), MG ≥40 mm Hg).Results The MG (discordant in 29%) was strongly determined by AVA and flow but also independently and strongly influenced by AVC-load (p < 0.0001) and systemic arterial compliance (p < 0.0001). The AVC-load (median [interquartile range]) was similar within patients with DG (low-MG: 1,619 [965 to 2,528] arbitrary units [AU]; high-MG: 1,736 [1,209 to 2,894] AU; p = 0.49), higher than CG-moderate-AS (861 [427 to 1,519] AU; p < 0.0001) but lower than CG-severe-AS (2,931 [1,924 to 4,292] AU; p < 0.0001). The AVC-load thresholds separating severe/moderate AS were defined in CG-AS with normal flow (stroke-volume-index >35 ml/m(2)). The AVC-load, absolute or indexed, identified severe AS accurately (area under the curve ≥0.89, sensitivity ≥86%, specificity ≥79%) in men and women. Upon application of these criteria to DG-low MG, at least one-half of the patients were identified as severe calcified aortic valve disease, irrespective of flow.Conclusions Among patients with AS, MG is often discordant from AVA and is determined by multiple factors, valvular (AVC) and non-valvular (arterial compliance) independently of flow. The AVC-load by MDCT, strongly associated with AS severity, allows diagnosis of severe calcified aortic valve disease. At least one-half of the patients with discordant low gradient present with heavy AVC-load reflective of severe calcified aortic valve disease, emphasizing the clinical yield of AVC quantification by MDCT to diagnose and manage these complex patients.

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  • Studies show different cut-off values of aortic valve calcium score should be used in women (>1200 AU) versus men (>2000 AU) to identify haemodynamically severe stenosis.

    “Studies have shown that different cut-off values of aortic valve calcium score (AU) should be used in women (>1200 AU) compared with men (>2000 AU) to identify haemodynamically severe stenosis169;170.”

    From Calcific aortic stenosis (2016) · cites this paper as [169]

    The AS grading results and Table 4 report sex-specific aortic valve calcium thresholds for identifying severe stenosis. They give best cutoffs of approximately 1,275 AU for women and 2,065 AU for men, rather than the cited >1,200 and >2,000 AU; those figures are close but not the thresholds this paper reports. (LLM, conf=0.86)

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  • Lower AVC thresholds are recommended in women (≥1300 AU) than men (≥2000 AU) to confirm severe AS in patients with moderate versus severe discordant grading and predict rapid disease progression and worse clinical outcomes.

    “Hence, it is recommended to apply lower threshold values of AVC in women (≥1300 arbitrary units [AU]) versus men (≥2000 AU) to confirm severe AS in patients with moderate versus severe DG and predict rapid disease progression and worse clinical outcomes in AS. 12 , 14 , 15 , 16 , 17”

    From Grading of Aortic Valve Calcification Severity and Risk Stratification in Aortic Stenosis (2024) · cites this paper as [12]

    Table 4 and the Conclusions (page not specified in our copy) give lower AVC cutoffs for women (1,274 AU) than men (2,065 AU) to help identify severe AS, including in patients with discordant grading. The Discussion associates higher AVC load with worse outcomes, but the paper does not establish that these cutoffs predict rapid progression or clinical outcomes; its Conclusions say they need validation in longitudinal outcome studies. (LLM, conf=0.88)

    Experimental — accuracy not yet measured

  • Prior studies have demonstrated that CT-calcium scoring is a robust and reproducible imaging technique, with excellent diagnostic accuracy for identifying severe aortic stenosis.

    “Prior studies have demonstrated that CT‐calcium scoring is a robust and reproducible imaging technique, with excellent diagnostic accuracy for identifying severe AS. 10 , 11 , 12 , 14 , 25 , 26”

    From Grading of Aortic Valve Calcification Severity and Risk Stratification in Aortic Stenosis (2024) · cites this paper as [12]

    Table 4 reports high diagnostic accuracy for CT aortic-valve calcium scoring in 451 patients with preserved ejection fraction, normal flow, and concordant echocardiographic grading (AUC 0.90–0.93). The Methods describe standardized measurement across three centers, but the paper does not report a reproducibility result; its discussion says inter-observer variability was addressed by training and an investigator visit. Thus, the diagnostic-accuracy claim is supported, while the claim of demonstrated reproducibility is not established by this paper. (LLM, conf=0.83)

    Experimental — accuracy not yet measured

  • By applying sex-specific aortic valve calcification thresholds for identifying moderate aortic stenosis to previously reported and validated thresholds for severe aortic valve calcification, the authors established a new classification system that distinguishes aortic valve calcification severity into 3 grades, from mild to severe.

    “By applying the sex‐specific AVC thresholds for identifying moderate AS to the previously reported and validated thresholds for severe AVC, we established a new classification system that distinguishes AVC severity into 3 grades, from mild to severe.”

    From Grading of Aortic Valve Calcification Severity and Risk Stratification in Aortic Stenosis (2024) · cites this paper as [12]

    Split into 2 atoms — 1 confirmed, 1 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.

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  • 34% of patients with concordant moderate aortic stenosis presented severe calcification load based on validated aortic valve calcification thresholds.

    “Another important finding was that 34% of patients with concordant moderate AS presented severe calcification load based on the validated AVC thresholds. 12 , 14”

    From Grading of Aortic Valve Calcification Severity and Risk Stratification in Aortic Stenosis (2024) · cites this paper as [12]

    Table 5 (indexed under Conclusions; page not supplied) reports that some patients with concordant moderate aortic stenosis exceeded the study’s severe-calcification thresholds. It gives 16% or 32% for absolute AVC and 19% or 30% for indexed AVCd, depending on the cutoff—not the claimed 34%. (LLM, conf=0.87)

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Research works printed but not linked: 1

  1. [24]24. Messika-Zeitoun D, Bielak LF, Peyser PA, et al. Aortic valve calcifi- cation: determinants and progression in the population. Arterioscler Thromb Vasc Biol 2007;27:642-8.

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Authors
Clavel, M.-A., Messika-Zeitoun, D., Pibarot, P., Aggarwal, S. R., Malouf, J., Araoz, P. A., Michelena, H. I., Cueff, C., Larose, E., Capoulade, R., Vahanian, A., & Enriquez-Sarano, M.
Affiliations
  • Mayo Clinic (US)
  • Assistance Publique – Hôpitaux de Paris (FR)
  • Institut universitaire de cardiologie et de pneumologie de Québec (CA)
  • Inserm (FR)
Corresponding author
Enriquez-Sarano, Maurice
ORCID
Venue
Journal of the American College of Cardiology
Publisher
Elsevier BV
Published
2013-12
Volume
62
Issue
24
Pages
2329-2338
ISSN
0735-1097 (ISSN-L)
DOI
10.1016/j.jacc.2013.08.1621
OpenAlex
W68457931
Cited by
569
References
44
Citations by year
2026: 42 · 2025: 46 · 2024: 48 · 2023: 40 · 2022: 54 · 2021: 46 · 2020: 60 · 2019: 51 · 2018: 34 · 2017: 48 · 2016: 43 · 2015: 34 · 2014: 19 · 2013: 4
FWCI
22.64
Type
journal article
Language
en
Open access
Licence
Locations
  • Journal of the American College of Cardiology (publishedVersion)
  • PubMed (publishedVersion)
  • Corpus Université Laval (Université Laval) (submittedVersion)
Funders
  • Assistance Publique–Hopitaux de Paris
  • Canadian Institutes of Health Research, Ottawa, Ontario, Canada
  • International Chair of Cardiometabolic Risk
Topics
  • Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac Valve Diseases and Treatments
  • Health Sciences › Medicine › Pulmonary and Respiratory Medicine › Aortic Disease and Treatment Approaches
  • Health Sciences › Medicine › Radiology, Nuclear Medicine and Imaging › Cardiac Imaging and Diagnostics
Keywords
aortic stenosis, aortic valve calcification, calcific aortic valve disease, aortic valve area, mean gradient, systemic arterial compliance, Doppler echocardiography, multidetector computed tomography, aortic valve replacement, transcatheter aortic valve implantation
MeSH terms
Aged, Analysis of Variance, Aortic Valve, Aortic Valve Stenosis, Blood Flow Velocity, Female, Humans, Male, Prospective Studies, Sensitivity and Specificity, Severity of Illness Index, Echocardiography, Doppler, Multivariate Analysis, Vascular Calcification, Multidetector Computed Tomography

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