Format

Send to

Choose Destination
J Am Coll Cardiol. 2013 Dec 17;62(24):2329-38. doi: 10.1016/j.jacc.2013.08.1621. Epub 2013 Sep 24.

The complex nature of discordant severe calcified aortic valve disease grading: new insights from combined Doppler echocardiographic and computed tomographic study.

Author information

1
Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota.
2
Cardiology Department, AP-HP, Bichat Hospital, Paris, France; INSERM U698 and University Paris 7-Diderot, Paris, France.
3
Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Quebec City, Québec, Canada.
4
Cardiology Department, AP-HP, Bichat Hospital, Paris, France.
5
Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota. Electronic address: sarano.maurice@mayo.edu.

Abstract

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.

KEYWORDS:

AU; AVAi; AVC; AVCd; AVCi; CG; DG; Doppler echocardiography; LV; LVEF; LVOT; MDCT; MG; ROC; SV; SVi; Vmax; aortic valve area indexed to body surface area; aortic valve calcification; aortic valve calcification indexed to body surface area; aortic valve calcification indexed to the cross-sectional area of the aortic annulus; aortic valve stenosis; arbitrary units; concordant grading; discordant grading; left ventricular; left ventricular ejection fraction; left ventricular outflow tract; mean gradient; multidetector computed tomography; peak aortic jet velocity; receiver-operating characteristic; stroke volume; stroke volume indexed to body surface area

PMID:
24076528
DOI:
10.1016/j.jacc.2013.08.1621
[Indexed for MEDLINE]
Free full text

Supplemental Content

Full text links

Icon for Elsevier Science
Loading ...
Support Center