Impact of Aortic Valve Calcification, as Measured by MDCT, on Survival in Patients With Aortic Stenosis
Open accessAbstract
Background Aortic valve calcification (AVC) load measures lesion severity in aortic stenosis (AS) and is useful for diagnostic purposes. Whether AVC predicts survival after diagnosis, independent of clinical and Doppler echocardiographic AS characteristics, has not been studied.Objectives This study evaluated the impact of AVC load, absolute and relative to aortic annulus size (AVCdensity), on overall mortality in patients with AS under conservative treatment and without regard to treatment.Methods In 3 academic centers, we enrolled 794 patients (mean age, 73 ± 12 years; 274 women) diagnosed with AS by Doppler echocardiography who underwent multidetector computed tomography (MDCT) within the same episode of care. Absolute AVC load and AVCdensity (ratio of absolute AVC to cross-sectional area of aortic annulus) were measured, and severe AVC was separately defined in men and women.Results During follow-up, there were 440 aortic valve implantations (AVIs) and 194 deaths (115 under medical treatment). Univariate analysis showed strong association of absolute AVC and AVCdensity with survival (both, p < 0.0001) with a spline curve analysis pattern of threshold and plateau of risk. After adjustment for age, sex, coronary artery disease, diabetes, symptoms, AS severity on hemodynamic assessment, and LV ejection fraction, severe absolute AVC (adjusted hazard ratio [HR]: 1.75; 95% confidence interval [CI]: 1.04 to 2.92; p = 0.03) or severe AVCdensity (adjusted HR: 2.44; 95% CI: 1.37 to 4.37; p = 0.002) independently predicted mortality under medical treatment, with additive model predictive value (all, p ≤ 0.04) and a net reclassification index of 12.5% (p = 0.04). Severe absolute AVC (adjusted HR: 1.71; 95% CI: 1.12 to 2.62; p = 0.01) and severe AVCdensity (adjusted HR: 2.22; 95% CI: 1.40 to 3.52; p = 0.001) also independently predicted overall mortality, even with adjustment for time-dependent AVI.Conclusions This large-scale, multicenter outcomes study of quantitative Doppler echocardiographic and MDCT assessment of AS shows that measuring AVC load provides incremental prognostic value for survival beyond clinical and Doppler echocardiographic assessment. Severe AVC independently predicts excess mortality after AS diagnosis, which is greatly alleviated by AVI. Thus, measurement of AVC by MDCT should be considered for not only diagnostic but also risk-stratification purposes in patients with AS.
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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 [170]
The Methods (MDCT Measurements; page unavailable) and Discussion (AVC in AS; page unavailable) support sex-specific calcium thresholds for identifying severe haemodynamic aortic stenosis. They give ≥1,274 AU for women and ≥2,065 AU for men, however, not the cited >1,200 and >2,000 AU cut-offs. (LLM, conf=0.87)
Experimental — accuracy not yet measuredSymptomatic patients with classical low-flow, low-gradient aortic stenosis and reduced LVEF below 50% are reasonable candidates for aortic valve replacement if anatomic or haemodynamic evidence shows the stenosis is truly severe.
“Symptomatic patients with classical low-flow, low-gradient and reduced LVEF (<50%) are reasonable candidates for AVR (Class IIa indication, Box 1) provided there is anatomic evidence (MDCT calcium score) or haemodynamic evidence (peak aortic jet velocity ≥4 m per sec or mean gradient ≥40 mmHg with dobutamine stress echocardiography) that the AS is truly severe3;4;170.”
From Calcific aortic stenosis (2016) · cites this paper as [170]
The Discussion (‘AVC and AS Management’; page not provided) says dobutamine echocardiography helps distinguish pseudosevere stenosis in patients with low ejection fraction and that MDCT-measured valve calcification can inform decisions about valve implantation. The paper also says implantation is indicated for severe symptomatic stenosis. It does not establish the specific Class IIa recommendation, LVEF cutoff below 50%, or dobutamine velocity and gradient thresholds in the citing sentence. (LLM, conf=0.84)
Experimental — accuracy not yet measuredThere was a steeper slope in the hazard increase for death with increasing aortic valve calcification score in women, although this difference did not reach statistical significance.
“However, there was a steeper slope in the hazard increase for death with the increase AVC score in women, although this difference did not reach statistical significance. 16”
From Grading of Aortic Valve Calcification Severity and Risk Stratification in Aortic Stenosis (2024) · cites this paper as [16]
The Results section ('Pattern of Mortality According to AVC Load'; page unavailable) reports that higher AVC predicted mortality in both sexes and that the risk threshold was lower in women. It does not report a steeper hazard slope in women or a statistical test showing that a sex difference in slopes was nonsignificant. The reported nonsignificant p-values compare mortality thresholds with previously defined hemodynamic thresholds, not women with men. (LLM, conf=0.84)
Experimental — accuracy not yet measuredSeveral studies have reported that aortic valve calcification is a powerful predictor of rapid disease progression and adverse outcomes in aortic stenosis.
“Furthermore, several studies have reported that AVC is a powerful predictor of rapid disease progression and adverse outcomes in AS. 14 , 16 , 17 , 27”
From Grading of Aortic Valve Calcification Severity and Risk Stratification in Aortic Stenosis (2024) · cites this paper as [16]
The authors previously demonstrated a nonlinear association between aortic valve calcification and the risk of mortality in aortic stenosis, evident both in women and men.
“We previously demonstrated a nonlinear association between AVC and the risk of mortality in AS, evident both in women and men. 16”
From Grading of Aortic Valve Calcification Severity and Risk Stratification in Aortic Stenosis (2024) · cites this paper as [16]
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- Authors
- Clavel, M.-A., Pibarot, P., Messika-Zeitoun, D., Capoulade, R., Malouf, J., Aggarwal, S. R., Araoz, P. A., Michelena, H. I., Cueff, C., Larose, E., Miller, J. D., Vahanian, A., & Enriquez-Sarano, M.
- Affiliations
- Mayo Clinic (US)
- Institut universitaire de cardiologie et de pneumologie de Québec (CA)
- Assistance Publique – Hôpitaux de Paris (FR)
- Inserm (FR)
- Corresponding author
- Enriquez-Sarano, Maurice
- ORCID
- Venue
- Journal of the American College of Cardiology
- Publisher
- Elsevier BV
- Published
- 2014-09
- Volume
- 64
- Issue
- 12
- Pages
- 1202-1213
- ISSN
- 0735-1097 (ISSN-L)
- PMC
- PMC4391203
- OpenAlex
- W33235005
- Cited by
- 480
- References
- 39
- Citations by year
- 2026: 29 · 2025: 43 · 2024: 40 · 2023: 39 · 2022: 38 · 2021: 54 · 2020: 60 · 2019: 45 · 2018: 31 · 2017: 39 · 2016: 41 · 2015: 19 · 2014: 1 · 2013: 1
- FWCI
- 22.69
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Licence
- Locations
- Journal of the American College of Cardiology (publishedVersion)
- PubMed (publishedVersion)
- PubMed Central (acceptedVersion)
- Corpus Université Laval (Université Laval) (submittedVersion)
- Funders
- National Institutes of Health (UH2TR000954)
- Canadian Institutes of Health Research (114997)
- National Heart, Lung, and Blood Institute (R01HL111121)
- National Center for Advancing Translational Sciences
- 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 valve calcification, aortic stenosis, aortic annulus, mortality prediction, survival, aortic valve replacement, conservative treatment, risk stratification, net reclassification improvement, multidetector computed tomography, Doppler echocardiography, sex differences
- MeSH terms
- Aged, Aged, 80 and over, Aortic Valve, Aortic Valve Stenosis, Calcinosis, Female, Follow-Up Studies, Humans, Male, Middle Aged, Prospective Studies, Registries, Survival Rate, Internationality, Multidetector Computed Tomography
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
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