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Impact Of Aortic Valve Calcification Measured By Multidetector Computed Tomography On Survival In Patients With Aortic Stenosis: Results Of An International Registry
Marie-Annick Clavel1, Philippe Pibarot2, David Messika-Zeitoun3, Romain Capoulade2, Joseph Malouf1, Phillip A. Araoz1, Hector I. Michelena1, Caroline Cueff3, Eric Larose2, Jordan D. Miller1, Alec Vahanian3, Maurice Enriquez-Sarano1.
1Mayo Clinic, Rochester, MN, USA, 2Institut Universitaire de Cardiologie et de Pneumologie de Quebec, Quebec, QC, Canada, 3AP-HP, Bichat Hospital, Paris, France.

OBJECTIVE: Aortic valve calcification (AVC) measures lesion severity of aortic stenosis (AS) and is useful for diagnostic purposes. Whether AVC predicts survival after diagnosis, independently of clinical and Doppler-echocardiographic AS characteristics, has not been studied. Our objective was to evaluate the impact of AVC on overall mortality under conservative treatment and without regards to treatment.
METHODS and RESULTS: We enrolled in 3 academic centers 794 patients (73±12 years, 274 women) diagnosed with AS by Doppler-echocardiography who underwent multi-detector-computed-tomography (MDCT) within the same episode of care. Absolute-AVC load and AVCdensity (ratio of absolute-AVC to left-ventricular-outflow-tract-area) were measured blinded to all other characteristics and severe AVC was separately defined for men and women. Indexed aortic-valve-area was 0.58±0.20 cm2/m2, mean-gradient 35±19mmHg and ejection fraction 60±12%. During follow-up there were 440 Aortic-Valve-Replacements (AVR) and 194 deaths (115 under medical treatment). Univariable analysis showed strong association of absolute-AVC and AVCdensity to survival (both p<0.0001) with spline-curve-analysis pattern of threshold and plateau of risk. Adjusting for age, gender, coronary-artery-disease, diabetes, symptoms, hemodynamic AS severity (indexed-aortic-valve-area and mean-gradient) and ejection fraction, severe absolute-AVC (adjusted-hazard-ratio: 1.75[1.04-2.92]; p=0.03) or severe AVCdensity (adjusted-hazard-ratio: 2.44[1.37-4.37]; p=0.002) independently predicted mortality under medical treatment with additive model predictive value (all p≤0.04). Severe absolute-AVC (adjusted-hazard-ratio: 1.71[1.12-2.62]; p=0.01) and severe AVCdensity (adjusted-hazard-ratio: 2.22[1.40-3.52]; p=0.001) also independently predicted overall mortality, after adjusting for time-dependent AVR. In patients with severe AVC, AVR was associated with marked mortality reduction (adjusted-hazard-ratio: 0.370.25-0.56]; p<0.0001).
CONCLUSIONS: This large multicenter outcome study of quantitative Doppler-echocardiographic and MDCT assessment of AS shows that measuring AVC load provides incremental survival prognostic value beyond clinical and Doppler-echocardiographic assessment. Severe AVC independently predicts excess mortality after AS diagnosis which is greatly alleviated by AVR. Thus, measurement of AVC by MDCT should be considered, not only for diagnostic but also for risk stratification purposes in patients AS.

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