Influence of cusp morphology and sex on quantitative valve composition in severe aortic stenosis
Open accessAbstract
Aims: Aortic stenosis is characterized by fibrosis and calcification of the valve, with a higher proportion of fibrosis observed in women. Stenotic bicuspid aortic valves progress more rapidly than tricuspid valves, which may also influence the relative composition of the valve. We aimed to investigate the influence of cusp morphology on quantitative aortic valve composition quantified from contrast-enhanced computed tomography angiography in severe aortic stenosis. Methods and results: Patients undergoing transcatheter aortic valve implantation with bicuspid and tricuspid valves were propensity matched 1:1 by age, sex, and comorbidities. Computed tomography angiograms were analysed using semi-automated software to quantify the fibrotic and calcific scores (volume/valve annular area) and the fibro-calcific ratio (fibrotic score/calcific score). The study population (n = 140) was elderly (76 ± 10 years, 62% male) and had a peak aortic jet velocity of 4.1 ± 0.7 m/s. Compared with those with tricuspid valves (n = 70), patients with bicuspid valves (n = 70) had higher fibrotic scores [204 (interquartile range 118–267) vs. 144 (99–208) mm3/cm2, P = 0.006] with similar calcific scores (P = 0.614). Women had greater fibrotic scores than men in bicuspid [224 (181–307) vs. 169 (109–247) mm3/cm2, P = 0.042] but not tricuspid valves (P = 0.232). Men had greater calcific scores than women in both bicuspid [203 (124–355) vs. 130 (70–182) mm3/cm2, P = 0.008] and tricuspid [177 (136–249) vs. 100 (62–150) mm3/cm2, P = 0.004] valves. Among both valve types, women had a greater fibro-calcific ratio compared with men [tricuspid 1.86 (0.94–2.56) vs. 0.86 (0.54–1.24), P = 0.001 and bicuspid 1.78 (1.21–2.90) vs. 0.74 (0.44–1.53), P = 0.001]. Conclusions: In severe aortic stenosis, bicuspid valves have proportionately more fibrosis than tricuspid valves, especially in women.
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Initial investigations using CTA-based approach have identified varied patterns of AV fibro-calcific remodeling attributed to age, sex, valve morphology, and hemodynamic phenotype.
“Initial investigations using this CTA-based approach have identified varied patterns of AV fibro-calcific remodeling, attributed to a complex interplay of factors including age, sex, valve morphology (tricuspid vs bicuspid), and hemodynamic phenotype (high versus low gradient-AS)13–15.”
From Characterization of Aortic Valve Stenosis by CT Angiography in a Diverse US Cohort (2025) · cites this paper as [15]
The Discussion reports CTA-derived differences in fibro-calcific valve composition by bicuspid versus tricuspid morphology and by sex. The study matched patients by age and does not report composition patterns by age or high- versus low-gradient aortic stenosis, so those parts of the attributed claim are not supported by this paper. (LLM, conf=0.86)
Experimental — accuracy not yet measuredThe ability to quantify AV leaflet fibrosis using dedicated valve segmentation software is feasible and provides important information beyond AV calcium score, especially in women, bicuspid AV, and LG-AS.
“The ability to quantify AV leaflet fibrosis using dedicated valve segmentation software, which cannot be done with non-contrast CT, has recently been shown feasible and provides important information beyond AV calcium score, especially in women, bicuspid AV, and LG-AS11,14,15,18.”
From Characterization of Aortic Valve Stenosis by CT Angiography in a Diverse US Cohort (2025) · cites this paper as [15]
The CT angiography image analysis section (page unavailable) describes software-based quantification of valve fibrosis, and the Discussion (page unavailable) reports findings particularly relevant to women and bicuspid valves. The paper does not establish added diagnostic value over calcium scoring for bicuspid valves—it says that requires further study—and the available passages do not report a finding specific to low-gradient aortic stenosis. (LLM, conf=0.86)
Experimental — accuracy not yet measuredThe intra- and interobserver reproducibility of the semiautomated AV tissue quantification has been demonstrated previously.
“The detailed process has been described previously, and the intra and interobserver reproducibility has been demonstrated14,15,18.”
From Characterization of Aortic Valve Stenosis by CT Angiography in a Diverse US Cohort (2025) · cites this paper as [15]
The Results (page unavailable) demonstrate excellent interobserver repeatability for semiautomated valve tissue measurements, and CT angiography image analysis says a previous study demonstrated excellent reproducibility. Our copy does not specify or report intraobserver reproducibility, so it supports only part of the attributed claim. (LLM, conf=0.87)
Experimental — accuracy not yet measured
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Self-citationCharacterization of Aortic Valve Stenosis by CT Angiography in a Diverse US Cohort
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Self-citation
- Authors
- Patel, K. P., Lin, A., Kumar, N., Esposito, G., Grodecki, K., Lloyd, G., Mathur, A., Baumbach, A., Mullen, M. J., Williams, M. C., Newby, D. E., Treibel, T. A., Dweck, M. R., & Dey, D.
- Affiliations
- Barts Health NHS Trust (GB)
- Cedars-Sinai Medical Center (US)
- Queen Mary University of London (GB)
- British Heart Foundation Centre for Cardiovascular Science (GB)
- Corresponding author
- Dey, Damini
- ORCID
- Venue
- European Heart Journal - Cardiovascular Imaging
- Publisher
- Oxford University Press (OUP)
- Published
- 2023-06-20
- Volume
- 24
- Issue
- 12
- Pages
- 1653-1660
- ISSN
- 2047-2404 (ISSN-L)
- 2047-2412
- OpenAlex
- W4381328801
- Cited by
- 21
- References
- 25
- Citations by year
- 2026: 7 · 2025: 10 · 2024: 4
- FWCI
- 4.17
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- European Heart Journal - Cardiovascular Imaging (publishedVersion)
- PubMed (publishedVersion)
- Edinburgh Research Explorer (University of Edinburgh) (publishedVersion, cc-by)
- UCL Discovery (University College London) (submittedVersion)
- Queen Mary Research Online (Queen Mary University of London) (submittedVersion)
- Funders
- British Heart Foundation (CH/09/002/26360, FS/ICRF/20/26002, FS/14/78/31020, FS/19/35/34374)
- 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
- severe aortic stenosis, bicuspid aortic valve, tricuspid aortic valve, valve fibrosis, valve calcification, sex differences, transcatheter aortic valve implantation, contrast-enhanced CT angiography, aortic jet velocity, aortic annulus
- MeSH terms
- Bicuspid Aortic Valve Disease, Aged, Aortic Valve, Aortic Valve Stenosis, Female, Fibrosis, Humans, Male, Transcatheter Aortic Valve Replacement
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