Purposewe compared between patients with low gradient (LG) and high gradient (HG) severe aortic stenosis (AS) as regard the burden of aortic valve calcium (AVC) using different methodologies. Moreover, we evaluated the accuracy of published thresholds for the diagnosis of severe AS in both groups. Methodswe measured the calcium volume and score using Agatston methodology in non-contrast (n-c) CT and with modified and fixed 850 Hounsfield unit (HU) thresholds in contrast enhanced (ce) CT. ResultsThe medians (IQR) of Agatston score, score with 850 HU and modified thresholds were 1288 AU (750-1815), 101 (65-256), 701 (239-1632), respectively. The calcium volume in ceCT using fixed 850 HU thresholds is significantly lower than the assessed volume in ncCT or in ceCT using modifiable threshold. LG patients were more obese; BMI 31.2 (29.1-35.1) vs 27.6 (26-31) and presented more with coronary artery disease (71.4% vs 40%). AF was documented in 42% in LG-patients vs 30% in HG patients. LVEF was severely depressed (less than 30%) in 28.6% in LG-patients. LG patients were more symptomatic (NYHA ≥ III in 71.4% patients vs 42%).The LG patients had smaller anatomy: annulus diameter 23.5mm (21.5-27) vs 25mm (23-25.5), LVOT diameter 23mm (20-20) vs 25mm (23-26.7mm). The annulus geometry was more eccentric; eccentric index 0.23 (0.19-0.27) vs 0.11 (0.1-0.2). Agatston score and calcium volume were lower in patients with LG; 1641AU (1292-1990) vs 928AU (572-1284) and 1537mm³ (644-1860) vs 286mm³ (160-700), respectively. Only 20% of patients with LG had Agatston score less than the previously supposed AVC score threshold for the diagnosis of severe AS (>2000AU in men and >1200 in women). The elimination of ncCT from the protocol reduced significantly the radiation dose by 400.3 ± 140 mGy*cm and 2.4 ± 2.8mSv.ConclusionThe diagnosis of severe LGAS should not depend on a single parameter as calcium score. The measurement of calcium score in contrast CT underestimate the calcium load significantly.
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