It is unknown whether aortic valve calcium volume, as measured by contrast-enhanced computed tomography angiography (angio-CT), is associated with mortality in patients undergoing transcatheter aortic valve implantation (TAVI). We aimed to confirm that contrast-enhanced aortic valve calcium correlates with noncontrast-enhanced calcium score and provides useful prognostic information in patients undergoing TAVI.

This retrospective observational study included patients from 2 high-volume TAVI centers in Germany, all of whom underwent high-quality angio-CT prior to TAVI. Calcium volume in contrast-enhanced angio-CT was calculated using 3Mensio software (Pie Medical, The Netherlands), while the calcium score from noncontrast-enhanced angio-CT was obtained using the Syngo.via (Siemens Healthineers, Germany) workstation to validate contrast-enhanced angio-CT values. Calcium volume was dichotomized using the median based on to sex-specific values from contrast-enhanced angio-CT, and the risk associated with increased calcium volume was determined using Cox proportional hazard regression analysis.

We included 3318 TAVI patients. A good correlation was observed between noncontrast-enhanced and contrast-enhanced angio-CT (r2=0.680; P<.001). The median values for sex-specific contrast-enhanced angio-CT calcium volume were 514 mm3 for women and 1025 mm3 for men. Patients with higher calcium volumes showed lower mortality at 1 year (8.8% vs 12.1%; adjusted HR, 0.86; 95%CI, 0.75-0.98; P=.02) compared with those with lower calcium volumes.

Calcium volume in contrast-enhanced angio-CT correlated well with noncontrast-enhanced angio-CT calcium score. Patients with higher calcium volume showed lower mortality at 1 year after TAVI.

This study examines the use of computed tomography (CT)-derived calcified and non-calcified aortic valve (AV) features, including radiomics-based quantitative imaging biomarkers, for predicting aortic stenosis (AS) severity and evaluating sex-specific differences.

In this retrospective, single-center study, 270 patients (50 ​% female) with severe AS and preserved left ventricular ejection fraction were assessed in the primary-cohort using both echocardiography and CT angiography. Correlation-based feature selection and Lasso regression were employed to refine the most predictive features. Logistic regression models were developed for the overall-, male-, and female-cohorts, evaluating the predictive power of calcified and non-calcified AV features for identification of peak aortic valve jet velocity (PAV) ​≥ ​4 ​m/s and mean pressure gradient (MPG) ​≥ ​40 ​mmHg.

Statistical methods reduced the initial 44 CT variables to 13 in overall-cohort models, 10 in male-cohort models, and 12 in female-cohort models. The inclusion of these additional features significantly improved model performance compared to using the AV calcium score (AVCS) alone or its indexed variants. Indexing the AVCS to anatomical features resulted in modest improvements, with ROC-AUC values increasing from 0.71 (non-indexed Agatston) to 0.78 (indexed to sinus-of-Valsalva (SOV) volume) for PAV prediction in overall-cohort models. However, incorporating the full set of selected features further enhanced predictive accuracy, raising the ROC-AUC to 0.80. Similar trends were observed for MPG, with the best-performing models achieving a ROC-AUC of 0.84 compared to 0.73 using the non-indexed AVCS score alone. The male- and female-cohort models demonstrated similar improvements, with sex-specific feature sets significantly enhancing performance beyond indexed AVCSs.

Indexing the AVCS to SOV volume and aortic annulus area enhances the predictive power of AS severity models, though incorporating a broader set of calcified and non-calcified CT features provides the greatest improvement. These findings underscore the importance of considering anatomical and sex-specific differences in the assessment of AS.

Recently, a cardiac damage staging system has been proposed in patients with severe AS to improve risk stratification, but there is still paucity of data in women. Accordingly, we aimed to characterize the change in cardiac damage after transcatheter aortic valve implantation (TAVI), and to assess the prognostic value of cardiac damage staging in women. A total of 334 women (mean age 81 ± 7 years) with severe AS undergoing TAVI were included and retrospectively analyzed. Echocardiography was performed before and 6 months after TAVI. Patients were classified according to the following stages of cardiac damage: 0 = no damage; 1 = left ventricular damage; 2 = left atrial or mitral valve damage; 3 = pulmonary vasculature or tricuspid valve damage; and 4 = right ventricular damage. The primary endpoint was all-cause mortality. Most patients presented with advanced heart failure symptoms (62% in NYHA III-IV). TAVI consistently improved cardiac damage of at least one stage in 43% of patients at 6-month follow-up. During a median follow-up of 48 months, 79 patients (24%) died. Each increment of both baseline (HR per 1-stage increment 1.537, P = 0.001) and follow-up (HR per 1-stage increment 1.714, P = 0.01) cardiac damage stage were independently associated with all-cause death. Moreover, the re-assessment of cardiac damage at 6-month follow-up provided incremental prognostic value over baseline assessment (Chi-square change = 6.885; P = 0.009). TAVI has a beneficial effect on cardiac function and remodeling in women. Cardiac damage assessed before and 6 months after TAVI showed to be consistently and independently associated with prognosis.

Aortic valve calcium score (AVCa) measured on noncontrast computed tomography (CT) is well-established for grading aortic stenosis (AS) severity. However, thresholds for AVCa measured on contrast CT remain uncertain. We evaluated correlations, associated factors, and severity thresholds of AVCa measured on contrast CT against transthoracic echocardiography (TTE) measures of AS.

Patients with native AS undergoing transcatheter aortic valve replacement evaluation from 2019 to 2020 who underwent TTE and contrast-enhanced CT were retrospectively studied (n=1035, age 79±9 years, 429 (41.5%) women, 906 (87.5%) severe and 129 (12.5%) moderate AS by TTE). AVCa was measured using the modified Agatston method with the minimum threshold of 4 SD above the mean ascending aorta blood pool Hounsfield units. Receiver-operating characteristics analysis and Youden index were used to define sex-specific optimal AVCa thresholds for identifying severe AS defined by TTE (aortic valve area by continuity equation ≤1.0 cm2) in the derivation cohort and assessed when applied to the validation cohort.

Mean aortic valve area on TTE was 0.79±0.21 cm2, while mean AVCa score, volume, and mass were 2152±1102 modified AU, 1853±1592 mm3, and 673±485 mg, respectively. Multivariable linear regression identified women to be associated with lower AVCa (β-coefficient, -358), while chronic kidney disease was associated with a higher AVCa (β-coefficient, 171). Optimal severe AS thresholds of ≥1840 modified AU for men and ≥1430 modified AU for women were determined, with area under curve (95% CIs) and sensitivities/specificities of 0.809 (0.749-0.869, 71.3%, 82.2%) for men and 0.822 (0.751-0.892), 73.4%/78.9% for women in the derivation cohort, and 0.830 (0.786-0.875), 75.9%/87.5% for men and 0.780 (0.670-0.890), 77.5%/71.4% for women in the validation cohort.

AVCa by contrast CT is a useful tool for identifying severe AS by TTE, with sex-specific thresholds for severe AS identified. Further studies are necessary to externally validate our findings and evaluate their prognostic significance.

Aortic stenosis (AS) involves calcific and fibrotic degeneration of the valve tissue. The only noninvasive method for evaluating both processes is contrast-enhanced computed tomography angiography. We aimed to explore the differences in aortic valve (AV) tissue composition across sex, race/ethnicity, and AS hemodynamic phenotype in US patients referred for transcatheter AV replacement planning.

We retrospectively analyzed symptomatic patients with AS who underwent computed tomography angiography for transcatheter AV replacement planning between 2015 and 2022. Using semi-automated software, we quantified the AV tissue composition by fibrotic, calcific, and fibro-calcific volumes, and the fibro-calcific ratio (fibrotic/calcific volume) as a measure of valve phenotype.

The study included 651 patients (mean age 84 years; 55% women) with 38% non-Hispanic (NH)-White, 27% Hispanic, and 13% NH-Black. Women had lower fibro-calcific (230 versus 293 mm³/cm²; P<0.001) and calcific volumes (85 versus 149 mm³/cm²; P<0.001), and higher fibro-calcific ratio (1.47 versus 0.83; P<0.001). No differences were observed in the fibrotic volumes (P=0.805). NH-White women had higher fibro-calcific (256 mm³/cm², P=0.002) and fibrotic volumes (145 mm³/cm²; P<0.001), and fibro-calcific ratio (1.57; P=0.01) compared with Hispanic and NH-Black women. No differences were found among men. High-gradient AS had higher fibro-calcific (295 versus 219 mm3/cm2; P<0.001) and calcific volumes (148 versus 88 mm3/cm2; P<0.001), and a lower fibro-calcific ratio (0.90 versus 1.45; P<0.001), although no difference in fibrotic volume (P=0.099) compared with low-gradient AS.

Phenotypic differences in computed tomography angiography valve tissue composition exist in AS patients referred for transcatheter AV replacement, with females and low-gradient AS showing a proportionally more fibrotic phenotype. NH-White women have the highest fibrotic tissue composition, and no differences are evident among men.

Degenerative aortic valve disease is the third most common cause of heart disease in the developed world. Calcific deposits accrue in the valve endothelium causing progressive stenosis of the orifice. Increasingly, transcatheter aortic valve implantation is being used in place of surgery as treatment for aortic stenosis, particularly for patients who are considered high surgical risk. Although echocardiography remains the gold standard for the diagnosis and grading of aortic valve stenosis, there is an increasing interest in the role that aortic valve calcification scoring may play in these areas. In this review, the authors evaluate the current evidence for aortic valve calcium scoring as an adjunct to echocardiography in grading, and as a prognostic marker in challenging cases. They also explore the ability of calcium scoring to predict outcomes following transcatheter aortic valve implantation.

Valvular heart disease (VHD) is a common condition that poses several challenges from the standpoints of diagnosis and therapeutic management. While several studies have explored the role of blood biomarkers in assessing the severity and risk of progression of VHD, as well as in evaluating related cardiac damage and predicting the occurrence of adverse events, blood biomarkers are generally not considered criteria to trigger valve intervention in the latest European and American guidelines for VHD management. This review article provides an up-to-date overview of the utility of blood biomarkers to (i) assess the presence, severity, and progression of left-sided VHD; (ii) establish the presence and extent of cardiovascular damage; (iii) predict clinical outcomes before and after valve interventions; and (iv) identify patients at risk for early structural valve deterioration, valve thrombosis, and paravalvular leak.

The aortic-valve Agatston score (AVAS) is valuable for evaluating severe aortic stenosis (AS). While visual assessment of AS using chest computed tomography (CT) during lung cancer screening facilitates qualitative evaluation, it remains unclear whether AVAS derived from body CT that are neither electrocardiography (ECG)-triggered nor ECG-gated can quantitatively evaluate severe AS. This study aims to investigate the quantitative feasibility of AVAS derived from the 5 ​mm-thick noncontrast body CT for evaluating severe AS.

In this retrospective study, data were collected from participants who underwent both cardiac CT scans that were either ECG-gated or ECG-triggered and noncontrast body CT scans that were neither ECG-triggered nor ECG-gated prior to AS treatment. We quantified AVAS from the body CT scan with a slice thickness of 5 ​mm (body CT AVAS) and AVAS from the cardiac CT scan with a slice thickness of 3 ​mm (cardiac CT AVAS). Regression analysis was performed between body CT AVAS and cardiac CT AVAS. Receiver-operating characteristic (ROC) curve analysis of body CT AVAS was conducted to detect cardiac CT AVAS of ≥2000 and ​≥1300.

A total of 265 participants (90 males; median age, 84 years [interquartile range, 80-88 years]) were analyzed. Regression analysis between body CT AVAS and cardiac CT AVAS yielded an R2 of 0.92. Body CT AVAS of 2540 and 1440 corresponded to cardiac CT AVAS of 2000 and 1300, respectively. The areas under the ROC curves were 0.99 and 0.98, respectively.

Five mm-thick noncontrast body CT AVAS is a quantitatively feasible tool for evaluating severe AS.

Identifying severe aortic stenosis can be difficult especially among patients with low-flow states compared to normal flow. Non-invasive modalities can aid in the diagnosis for timely treatment.

In this retrospective, single-center study of patients with aortic stenosis who underwent transcatheter aortic valve replacement (TAVR), we calculated stroke volume using CT blood pool based (CT-blp) analysis, echocardiogram and right heart catheterization (cath) performed before TAVR. We compared the performance of each modality in predicting 30-day and 1-year outcomes.

Three-hundred and forty-five patients were included with a median age of 84 (79-88) years and 52.8% females. CT-blp correlated more strongly (r = 0.60) with cath-derived stroke volume than echo (r = 0.37). After stratifying patients into groups based on flow and gradient using echo or CT-blp, there was no difference in mortality with either modality among the groups. However, the composite of mortality and hospital readmission was significantly higher in the low-flow low-gradient group (CT-blp 30-day OR 2.6, 95% CI 1.3-5.3, p < 0.01; 1-year OR 1.9, 95% CI 1.0-3.6; p = 0.04) compared to patients with normal flow high gradients when grouping was performed with CT-blp or echo.

Using the CT performed on patients pre-TAVR, CT-blp can provide an estimation of stroke volume that correlates well with invasive evaluation. The stroke volume may be used to stratify patient populations being evaluated for TAVR into flow gradient groups when echo is limited and avoid invasive catheterization to help identify patients with low-flow, low-gradient aortic stenosis. Further studies with larger cohorts are required to confirm our findings.

Tricuspid valve disorder (TVD), a critical aspect of valvular heart disease (VHD), significantly impacts cardiovascular health, yet its mortality trends are not well understood. This study aimed to investigate demographic and geographic disparities in TVD-related mortality across the United States from 1999 to 2023. Using data from the CDC WONDER database, death certificates were analyzed to identify TVD-related fatalities, and age-adjusted mortality rates (AAMRs) were calculated per 1,000,000 individuals. Joinpoint regression analysis was conducted to assess annual percent changes (APCs) in mortality rates. A total of 72,805 deaths were attributed to TVD. An initial steep increase in mortality rate from 1999 to 2003 (APC: 7.9%; 95% CI: 3.9 to 14.1) followed by a stable period from 2003 to 2014 (APC: 0.1%; 95% CI: -2.7 to 1.0) and a sharp increase in AAMR from 2014 to 2023 (APC: 6.5%; 95% CI: 5.2 to 8.4). Females consistently had higher mortality rates than males, with a sharper increase after 2012. Racial and ethnic disparities were evident, with American Indian and white populations experiencing higher mortality rates than black populations. Geographic disparities were also noted, with states like Oregon, Minnesota, and Vermont, as well as the West census region, showing significantly higher mortality rates. Rural areas had higher mortality rates compared to urban areas. TVD-related mortality trends have followed a complex trajectory, with marked disparities across demographic and geographic factors. Further research is required to fully understand the factors driving these trends and their public health implications.

The objective is to determinate the association between the degree of aortic valve calcification and the presence of paravalvular leakage (PVL) in Mexican patients who underwent transcatheter aortic valve replacement (TAVR).

We conducted a retrospective, analytic, cohort. Pooled data were retrospectively analyzed from the patient's files from January 2014 to July 2022. With a median follow-up of 6 months.

We included 83 patients. 31 (37.3%) developed residual PVL. Several factors as male gender (men 58.1% versus women 41.9% p = 0.01), higher gradients previous TAVR (mean 57 mmHg in the group with versus mean 53 mmHg in the group without PVL, p = 0.01), bigger annulus diameters and perimeters as well as reduce left ventricular ejection fraction and a degree of aortic regurgitation previous TAVR were present more frequently in the group of residual PVL. Aortic valve calcification was the only predictor after the bivariate and multivariate analysis that showed an association with the presence of PVL after TAVR. The calculated cut-off value of calcium score was 2970 Agatston units, with a sensitivity of 70% and a specificity of 60% as a predictor for PVL.

The results are consistent with the previous data and there are no greater differences in the Mexican population. The severity of the aortic valve calcification is an independent predictor of PVL in patients who underwent TAVR.

Less pronounced calcification of the aortic valve (AVC) was observed in women with aortic stenosis (AS) when compared with men. Since women have smaller aortic valves (AVs), this could explain a lower calcium load. We aimed to analyse the association of AV size with AVC independent from sex.

Consecutive patients with high-gradient AS, who underwent cardiac computed tomography (CT), were assessed. AV annulus area and AVC with the Agatston score were measured on CT. In total, 601 patients (mean age 80 ± 7 years, 45% female) were included. Women had smaller AV annulus areas (4.12 ± 0.67 vs. 5.15 ± 0.78 cm2, P < 0.001) and lower Agatston scores [2018 (1456-3017) vs. 3394 (2562-4530), P < 0.001] than men. We found a significant correlation (r = 0.594, P < 0.001) and independent association (β = 926.20, P < 0.001) of AV annulus area with AVC. On separate regression analyses for men and women, AVC was independently associated with AV annulus area in both sexes (βmen = 887.77; βwomen = 863.48, both P < 0.001). When patients were stratified into AV size quartiles, patients in the lower quartiles were more likely to have AVC values below recommended sex-specific AVC thresholds. In the lowest quartile, 28% of female and 27% of male patients had Agatston scores below 1200 Agatston units (AU) (women) and 2000 AU (men), while this proportion decreased to 6 and 2%, respectively, in the quartiles with the largest annulus areas.

In high-gradient AS, AVC strongly depends on AV annulus area. This association is not dependent on sex. Thus, AVC should be indexed to AV size in addition to sex.

(A) Very severe aortic valve stenosis (VSAS; Vmax ≥ 5 ​m/s, MPG ≥60 ​mmHg) is a critical condition with unfavorable clinical outcomes. Guidelines regard VSAS as one criterion for considering valve replacement in asymptomatic patients. (B) Guidelines recommend the use of aortic valve calcium (AVC) scoring as a parameter to differentiate between moderate and severe aortic valve stenosis (SAS). The aim of our study is to propose AVC thresholds for the discrimination between SAS and VSAS.

Data of patients from a single center who underwent transcatheter aortic valve implantation (n ​= ​523) were retrospectively analyzed. Patients with concordant AS (n ​= ​430) were divided into SAS (n ​= ​344) and VSAS (n ​= ​86) groups and compared in terms of absolute AVC and indexed AVC (body surface area; aortic valve annulus area).

Mean AVC was significantly higher in men (m) than in women (w), and significantly higher in VSAS than in SAS (m: SAS 3572.0 AU; VSAS 5465.0 AU; w: SAS 2252.5 AU; VSAS 3064.5 AU; all p ​< ​0,001). ROC curve analyses showed AVC to be a predictor of VSAS in both sexes (m: AUC 0.794; p ​< ​0.001; w: AUC 0.725; p ​< ​0.001), with optimal cut-off values of 3706.5 AU (m) and 2374.5 (w). Some indexed AVC had a slightly, but not relevantly, better predictive value.

The proposed AVC thresholds - approximately 3700 AU (m) and 2400 AU (w) - showed significant predictive power to differentiate SAS from VSAS in the study cohort.

Low-gradient (LG) aortic stenosis (AS) has not been fully characterized compared with high-gradient (HG) AS in terms of cardiac damage, frailty, aortic valve calcification, and clinical outcomes.

The aim of this study was to compare the clinical characteristics and outcomes between each hemodynamic type of LG AS and HG AS.

The current study included 3,363 patients in the CURRENT AS (Contemporary outcomes after sURgery and medical tREatmeNT in patients with severe Aortic Stenosis) Registry-2 after excluding patients without indexed stroke volume or left ventricular ejection fraction (LVEF) data. Patients were divided into 4 groups (LG AS with reduced LVEF: n = 285; paradoxical low flow, low gradient [LFLG]: n = 220; normal flow, low gradient [NFLG]: n = 872; HG: n = 1,986).

Compared with HG AS, LG AS with reduced LVEF more often had cardiovascular comorbidities, advanced cardiac damage, and frailty with less severe valve calcification and paradoxical LFLG AS more often had atrial fibrillation, advanced cardiac damage, and frailty with less severe valve calcification, while NFLG AS had comparable cardiac damage and frailty with less severe valve calcification. Cumulative 3-year incidence of death or heart failure hospitalization was higher in LG AS with reduced LVEF and paradoxical LFLG than in HG AS. After adjusting for confounders, LG AS with reduced LVEF and paradoxical LFLG compared with HG AS were independently associated with higher risk for death or heart failure hospitalization (HR: 1.82; 95% CI: 1.49-2.23; P < 0.001; and HR: 1.43; 95% CI: 1.13-1.82; P = 0.003, respectively) but NFLG AS was not (HR: 1.03; 95% CI: 0.88-1.21; P = 0.68).

Clinical outcomes were significantly worse in LG AS with reduced LVEF and paradoxical LFLG AS and comparable in NFLG AS compared with HG AS.

The frequent association between transthyretin wild-type (TTRwt) cardiac amyloidosis (CA) and aortic stenosis (AS) suggests a bidirectional relationship: TTRwt-CA could induce AS and vice versa. Systemic manifestations may highlight this interaction: systemic amyloidogenesis would lead to systemic symptoms, CA, and AS, whereas the myocardial stresses induced by degenerative AS might promote local amyloidogenesis without systemic symptoms. Carpal tunnel syndrome (CTS) is the most frequently reported extracardiac symptom. Through a comparison of TTRwt-CA patients with and without CTS, we sought to determine whether CTS serves as a reliable indicator of systemic involvement and its impact on cardiac and valvular characteristics.

A total of 411 consecutive patients with TTRwt-CA were included. CTS, present in 70.3%, was associated with a younger age (80 vs. 84 years, p < 0.001), more extracardiac symptoms, and advanced CA, with greater cardiac remodeling and a higher heart-to-mediastinum ratio (1.63 vs. 1.54; p = 0.012) compared to patients without CTS. AS was present in 21% and 31% of patients with and without CTS, respectively (p = 0.024). Except for AS, these associations remained significant after adjusting for confounding factors. In severe AS, patients with CTS exclusively exhibited low-flow low-gradient (LFLG) AS and less severe class of aortic valvular calcium score (5.6% vs. 60%; p = 0.006) compared to those without CTS.

Our findings suggest that CTS may delineate two phenotypes in TTRwt-CA: a systemic phenotype associated with advanced CA and poorly calcified LFLG AS, and a cardiac phenotype characterized by less severe CA and a mixed pattern of highly calcified AS, suggesting disparate pathophysiologies.

Low-gradient (LG) aortic stenosis (AS) poses a diagnostic challenge. Aortic valve calcium score (AVCS) assessment has emerged as a complementary diagnostic method when echocardiography provides discordant results. However, the diagnostic and prognostic values of AVCS in LGAS have not been thoroughly studied. Our aims in this study were to investigate the prognostic importance of AVCS in LGAS and to assess whether symptomatic patients with LGAS and low AVCS may benefit from aortic valve intervention (AVI).

A total of 327 symptomatic patients (78.5 ± 7.3 years, 51% women) with severe AS defined by the aortic valve area who underwent computed tomography for transcatheter aortic valve intervention (TAVI) planning were enrolled. AVCS was measured. AVCS < 2000AU in men and < 1200 AU in women was considered a low AVCS. A total of 243 patients had high gradient (HG) and 84 had LGAS. A low AVCS was present in 25 (10%) patients with HG and 34 (40%) with LGAS. Over a median follow-up period of 4.9 years, 194 deaths occurred. In multivariate analysis, AVCS was a significant independent predictor of all-cause mortality among patients with HGAS [adjusted hazard ratio (aHR): 2.317; CI: 1.104-4.861; P = 0.026] but not among those with LGAS (aHR: 0.848; CI: 0.434-1.658; P = 0.630). After propensity score matching between patients who underwent AVI and those who were medically treated, AVI (94% TAVI) was a significant and independent predictor of survival among LGAS patients with a low AVCS even after adjustment for clinical variables (aHR: 0.102, CI: 0.028-0.369; P < 0.001).

The prevalence of a low AVCS is much higher in patients with LGAS than in those with HGAS. In patients with symptomatic severe LGAS, a low AVCS does not entail a better prognosis. AVI is equally beneficial in LGAS patients with a high or low AVCS, similarly to those with HGAS.

Early menopause has been associated with several cardiovascular diseases. Its effect on the progression of aortic stenosis (AS) remains unknown. We conducted an analysis to examine the effect of early menopause without hormone replacement therapy (HRT) on the progression of AS in postmenopausal women with AS.

This subanalysis included 33 female patients with at least mild AS (mean age 65 ± 10 years) who were prospectively enrolled in the Metabolic Determinants of the Progression of Aortic Stenosis (PROGRESSA) study (NCT01679431). Anatomical assessment of AS was performed using multidetector computed tomography, whereas hemodynamic assessment of AS was performed using Doppler echocardiography.

Over a median follow-up of 2 (25th-75th percentiles, 1-4) years, early menopausal women without HRT showed faster progression of aortic valve calcification (AVC; median, 100 [25th-75th percentiles, 58-130] vs 23 [25th-75th percentiles, 2-71] arbitrary units per year; P = 0.03); mean pressure gradient (median, 2.37 [25th-75th percentiles, 0.82-3.61] vs 0.33 [25th-75th percentiles, 0.01-1.78] mm Hg per year; P = 0.04) and aortic valve area indexed to body surface area (median, -0.12 [25th-75th percentiles, -0.23 to 0.002] vs -0.004 [25th-75th percentile, -0.07 to 0.08] cm2/m2/y; P = 0.07). In multivariate analysis adjusted for several clinical, echocardiographic, and anatomic factors, early menopause without HRT remained independently associated with faster AVC progression (P = 0.003). Women who received HRT showed a slower progression of AVC compared with those who never received HRT (median, 62 [25th-75th percentile, 2-100] vs 20 [25th-75th percentile, 10-42] arbitrary units per year; P = 0.13). Multivariate analysis also showed that AVC progressed less rapidly in women who received HRT (P = 0.04).

In this study of postmenopausal women with AS, early menopause without HRT was associated with faster progression of AS, anatomically and hemodynamically. However, the use of HRT was associated with slower progression of AS.

Aortic valve calcification (AVC) has been shown to be a powerful assessment of aortic stenosis (AS) severity and a predictor of adverse outcomes. However, its accuracy in patients with low-flow AS has not yet been proven. The objective of the study was to assess the predictive value of AVC in patients with classical low-flow (CLF, that is, low-flow reduced left ventricular ejection fraction) or paradoxical low-flow (PLF, that is, low-flow preserved left ventricular ejection fraction) AS.

We prospectively included 641 patients, 319 (49.8%) with CLF-AS and 322 (50.2%) with PLF-AS, who underwent Doppler echocardiography and multidetector computed tomography. AVC ratio (AVCratio) was calculated as AVC divided by the sex-specific AVC threshold for AS severity; AVC score ≥2000 Agatston units in male patients and ≥1200 Agatston units in female patients. The primary end point of the study was all-cause mortality regardless of treatment.

Sex-specific AVC thresholds identified AS severity correctly in 137 (87%) of the patients. During a median follow-up of 4.9 (4.3-5.9) years, there were 265 deaths. After comprehensive adjustment, AVCratio was associated with all-cause mortality in patients with CLF-AS (adjusted hazard ratio, 1.25 [95% CI, 1.01-1.56]; P=0.046) and PLF-AS (adjusted hazard ratio, 1.51 [95% CI, 1.14-2.00]; P=0.004). There was an interaction (P=0.001) between AVC and AS flow patterns (ie, CLF versus PLF) with regard to the prediction of mortality. The best AVCratio threshold to predict mortality was different in patients with CLF-AS (AVCratio ≥0.7) and PLF-AS (AVCratio ≥1). After a comprehensive analysis, AVCratio as a dichotomic variable was associated with all-cause mortality in all groups (P≤0.001). The addition of AVCratio to the models improved all models' predictive value (all net reclassification index >18%; all P≤0.05).

In patients with CLF-AS or PLF-AS, AVC is a major predictor of mortality. Thus, AVC should be used in low-flow patients to assess AS severity and stratify risk. Importantly, in patients with reduced left ventricular ejection fraction, a nonsevere AS (ie, AVC 70% of severe) could be associated with reduced survival.

Transcatheter aortic valve implantation (TAVI) has been established as an effective treatment modality in patients with severe aortic stenosis (AS) and the uptake of TAVI is rapidly growing in the Asia-Pacific region. However, there exist a heterogeneity in the management of aortic stenosis and the use of TAVI among countries in the region. Reasons for these differences include anatomic variations, disparity in healthcare resources and infrastructure, and the lack of consensus on the optimal management of AS in the Asia-Pacific region. Hence, an Asian Pacific Society of Cardiology (APSC) working group, including a multidisciplinary group of general and interventional cardiologists, cardiac surgeons, imaging specialists, developed a position statement on the recommendations for TAVI in the management of aortic stenosis. The APSC expert panel reviewed and appraised the available evidence using the Grading of Recommendations Assessment, Development, and Evaluation system. Recommendations were developed and put to an online vote. Consensus was reached when 80% of votes for a given recommendation were in support of "agree" or "neutral." The resulting 28 statements provide guidance for clinical practitioners in the region on the use of TAVI in the treatment of patients with aortic stenosis.

Aortic stenosis (AS) is characterized by calcification and fibrosis. The ability to quantify these processes simultaneously has been limited with previous imaging methods.

The purpose of this study was to evaluate the aortic valve fibrocalcific volume by computed tomography (CT) angiography in patients with AS, in particular, to assess its reproducibility, association with histology and disease severity, and ability to predict/track progression.

In 136 patients with AS, fibrocalcific volume was calculated on CT angiograms at baseline and after 1 year. CT attenuation distributions were analyzed using Gaussian-mixture-modeling to derive thresholds for tissue types enabling the quantification of calcific, noncalcific, and fibrocalcific volumes. Scan-rescan reproducibility was assessed and validation provided against histology and in an external cohort.

Fibrocalcific volume measurements took 5.8 ± 1.0 min/scan, demonstrating good correlation with ex vivo valve weight (r = 0.51; P < 0.001) and excellent scan-rescan reproducibility (mean difference -1%, limits of agreement -4.5% to 2.8%). Baseline fibrocalcific volumes correlated with mean gradient on echocardiography in both male and female participants (rho = 0.64 and 0.69, respectively; both P < 0.001) and in the external validation cohort (n = 66, rho = 0.58; P < 0.001). The relationship was driven principally by calcific volume in men and fibrotic volume in women. After 1 year, fibrocalcific volume increased by 17% and correlated with progression in mean gradient (rho = 0.32; P = 0.003). Baseline fibrocalcific volume was the strongest predictor of subsequent mean gradient progression, with a particularly strong association in female patients (rho = 0.75; P < 0.001).

The aortic valve fibrocalcific volume provides an anatomic assessment of AS severity that can track disease progression precisely. It correlates with disease severity and hemodynamic progression in both male and female patients.

Studies in paradoxical low-flow low-gradient aortic stenosis (PLFAS) have demonstrated conflicting outcomes with variable survival advantage from aortic valve replacement (AVR). PLFAS is a heterogeneous composition of patients with uncertainty regarding true stenosis severity that continues to confound decision-making for AVR.

The purpose of this study was to investigate the utility of the Doppler acceleration (AT) to ejection (ET) time ratio (AT:ET) for prediction of prognosis and benefit from AVR in undifferentiated PLFAS.

Patients with echocardiographic findings of PLFAS (aortic valve area <1.0 cm2 or indexed aortic valve area <0.6 cm2/m2, mean gradient <40 mm Hg, indexed stroke volume <35 mL/m2, and left ventricular ejection fraction ≥50%) were identified and grouped according to an AT:ET cutoff of 0.35. The primary outcome was a 5-year composite of cardiac mortality or AVR. Secondary outcomes included the individual components of the primary endpoint and all-cause mortality at 5 years. Effect of AVR was analyzed in the AT:ET <0.35 and ≥0.35 groups.

A total of 171 PLFAS patients (median age 77.0 years, 57% women) were followed for a median of 8.9 years. AT:ET ≥0.35 was an independent predictor of the primary outcome (HR: 4.77 [95% CI: 2.94-7.75]; P < 0.001) with incremental value over standard indices of stenosis severity (net reclassification improvement: 0.57 [95% CI: 0.14-0.84]). AT:ET ≥0.35 also remained predictive of increased cardiac death (HR: 2.91 [95% CI: 1.47-5.76]; P = 0.002) and AVR (HR: 8.45 [95% CI: 4.16-17.1]; P < 0.001), respectively, following competing risk analysis. No difference in all-cause mortality was observed. AVR in the AT:ET ≥0.35 group was associated with significant reductions in 5-year cardiac (HR: 0.09 [95% CI: 0.02-0.36]; P < 0.001) and all-cause mortality (HR: 0.16 [95% CI: 0.07-0.38]; P < 0.001). No improvement in survival from AVR was demonstrated in AT:ET <0.35 patients.

AT:ET ≥0.35 in PLFAS predicts poorer outcomes and/or need for AVR. In undifferentiated PLFAS patients, AT:ET may have a potential role in improving patient selection for prognostic AVR.

Aortic stenosis (AS) is the most common valvular heart disease growing in parallel to the increment of life expectancy. Besides the valve, the degenerative process affects the aorta, impairing its elastic properties and leading to increased systemic resistance. The composite of valvular and systemic afterload mediates ventricular damage. The first step of a thorough evaluation of AS should include a detailed assessment of valvular anatomy and hemodynamics. Subsequently, the ventricle, and the global afterload should be assessed to define disease stage and prognosis. Multimodality imaging is of paramount importance for the comprehensive evaluation of these three elements. Echocardiography is the cornerstone modality whereas Multi-Detector Computed Tomography and Cardiac Magnetic Resonance provide useful complementary information. This review comprehensively examines the merits of these imaging modalities in AS for the evaluation of the valve, the ventricle, and the afterload and ultimately endeavors to integrate them in a holistic assessment of AS.

Guidelines recommend the use of dobutamine stress echocardiography (DSE) in patients with low-gradient aortic stenosis (AS) and left ventricular ejection fraction (LVEF) <50%. However, a paucity of DSE data exists when LVEF >35%.

To examine the diagnostic accuracy of DSE in patients with low-gradient AS with a wide range of LVEF and to examine the interaction between the diagnostic accuracy of DSE and LVEF.

Patients with mean gradient <40 mm Hg, aortic valve area <1.0 cm2, and stroke volume index ≤35 mL/m2 undergoing DSE and cardiac computer tomography (C-CT) were identified from 3 prospectively collected patient cohorts and stratified according to LVEF: LVEF<35%, LVEF 35% to 50%, and LVEF>50%.

Dobutamine stress echocardiography and C-CT were performed on patients with low-gradient AS.

Severe AS was defined as aortic valve calcification score ≥2,000 arbitrary units (AU) among men and ≥1,200 AU for women on C-CT.

Of 221 patients included in the study, 78 (35%) presented with LVEF <35%, 67 (30%) with LVEF 35% to 50%, and 76 (34%) with LVEF >50%. Mean-gradient and aortic valve peak velocity during DSE showed significant diagnostic heterogeneity between LVEF groups, being most precise when LVEF <35% (both areas under the curve [AUC] = 0.90), albeit with optimal thresholds of 30 mm Hg and 377 cm/sec and a limited diagnostic yield in patients with LVEF ≥35% (AUC = 0.67 and 0.66 in LVEF 35% to 50% and AUC = 0.65 and 0.60 in LVEF ≥50%). Using guideline thresholds led to a sensitivity/specificity of 49%/84% for all patients with LVEF <50%.

While DSE is safe and leads to an increase in stroke volume in patients with low-gradient AS regardless of LVEF, the association between DSE gradients and AS severity assessed by C-CT demonstrates important heterogeneity depending on LVEF, with the highest accuracy in patients with LVEF <35%.