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The Complex Nature of Discordant Severe Calcified Aortic Valve Disease Grading
Open accessAbstract
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 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]
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“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]
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“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]
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“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]
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“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]
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“Interestingly, in their foundational study, Clavel et al. 12 reported that up to 20% of patients with concordant moderate AS had severe AVC.”
From Grading of Aortic Valve Calcification Severity and Risk Stratification in Aortic Stenosis (2024) · cites this paper as [12]
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“Although the AVC thresholds for anatomically moderate AS showed excellent accuracy, we observed slightly lower AUCs compared with the thresholds previously reported for severe AVC. 12 , 14 , 28”
From Grading of Aortic Valve Calcification Severity and Risk Stratification in Aortic Stenosis (2024) · cites this paper as [12]
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“In such cases, assessing aortic valve calcification using a calcium score derived from non-contrast computed tomography (CT) has proven to be valuable4–6.”
From Characterization of Aortic Valve Stenosis by CT Angiography in a Diverse US Cohort (2025) · cites this paper as [4]
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“From the landmark studies of AV calcium score using non-contrast CT4,10, we know that women present with lower calcium volumes than men for the same hemodynamic severity of AS.”
From Characterization of Aortic Valve Stenosis by CT Angiography in a Diverse US Cohort (2025) · cites this paper as [4]
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Metadata
- 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)
- 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
- bronze
- doi.org
- 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 › Cardiology and Cardiovascular 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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