These findings suggest a critical role of bone turnover as a determinant of aortic stenosis severity.

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Introduction: Aortic valve calcification (AVC) may predict poor outcome. Bicuspid aortic valve (BAV) leads to several haemodynamic changes accelerating the progress of aortic valve (AV) disease. Aims: To compare the diagnostic accuracy of transoesophageal echocardiography (TEE) and transthoracic echocardiography (TTE) in the assessment of aortic valve phenotype and degree of AVC, with intra-operative evaluation as a reference. Methods: We examined 169 patients (median age 65 years, 51 women) without significant coronary artery disease undergoing AV and/or aortic root surgery. TTE was performed within a week prior to surgery and TEE at the time of surgery. Results: Compared with surgical AVC assessment, visual evaluation using a 5-grade scoring system and real-time images showed a higher correlation (TTE r = 0Á83 and TEE r = 0Á82) than visual (TTE r = 0Á64 and TEE 0Á63) or grey scale mean (GSMn) (TTE r = 0Á63 and TEE r = 0Á52) assessment of end-diastolic still frames. AVC assessment using real-time images showed high intraclass correlation coefficients (TTE 0Á94 and TEE 0Á93). With regard to BAV, TEE was superior to TTE with a higher interobserver agreement, sensitivity and specificity (0Á86, 92% and 94% versus 0Á57, 77% and 82%, respectively). Conclusion: Semi-quantitative AVC assessment of real-time cine loops from both TEE and TTE correlated well with intra-operative evaluation of AVC. Applying a predefined scoring system for AVC evaluation assures a high interobserver correlation. TEE was superior to TTE for evaluation of valve phenotype and should be considered when a diagnosis of BAV is clinically important.