Author + information
- Received April 17, 2020
- Revision received August 13, 2020
- Accepted August 17, 2020
- Published online October 5, 2020.
- Bin Zhang, MDa,b@BinZhang,
- Erwan Salaun, MD, PhDa,
- Nancy Côté, PhDa,
- Yongjian Wu, MDb,
- Haifa Mahjoub, MD, PhDa,
- Patrick Mathieu, MDa,
- Abdellaziz Dahou, MD, PhDa,
- Anne-Sophie Zenses, PhDa,
- Marine Clisson, MSca,
- Philippe Pibarot, DVM, PhDa@PPibarot and
- Marie-Annick Clavel, DVM, PhDa,∗ (, )@IUCPQ@ClavelLabo
- aInstitut Universitaire de Cardiologie et de Pneumologie de Québec (Quebec Heart & Lung Institute), Université Laval, Québec City, Québec, Canada
- bState Key Laboratory of Cardiovascular Disease, Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, People’s Republic of China
- ↵∗Address for correspondence:
Dr. Marie-Annick Clavel, Institut Universitaire de Cardiologie et de Pneumologie de Québec-Université Laval, 2725 Chemin Sainte-Foy, Québec city, Québec G1V-4G5, Canada.
Background The prognostic value of aortic valve calcification (AVC) measured by using multidetector computed tomography imaging has been well validated in native aortic stenosis, and sex-specific thresholds have been proposed. However, few data are available regarding the impact of leaflet calcification on outcomes after biological aortic valve replacement (AVR).
Objectives The goal of this study was to analyze the association of quantitative bioprosthetic leaflet AVC with hemodynamic and clinical outcomes, as well as its possible interaction with sex.
Methods From 2008 to 2010, a total of 204 patients were prospectively enrolled with a median of 7.0 years (interquartile range: 5.1 to 9.2 years) after biological surgical AVR. AVC measured by using the Agatston method was indexed to the cross-sectional area of aortic annulus measured by echocardiography to calculate the AVC density (AVCd). Presence of hemodynamic valve deterioration (HVD; increase in mean gradient [MG] ≥10 mm Hg and/or increase in transprosthetic regurgitation ≥1) was assessed by echocardiography in 137 patients at the 3-year follow-up. The primary clinical endpoint was mortality or aortic valve re-intervention.
Results There was no significant sex-related difference in the relationship between bioprosthetic AVCd and the progression of MG. Baseline AVCd showed an independent association with HVD at 3 years. During follow-up, there were 134 (65.7%) deaths (n = 100) or valve re-interventions (n = 47). AVCd ≥58 AU/cm2 was independently associated with an increased risk of mortality or aortic valve re-intervention (adjusted hazard ratio: 2.23; 95% confidence interval: 1.44 to 3.35; p < 0.001). The AVCd threshold combined with an MG progression threshold of 10 mm Hg amplified the stratification of patients at risk (log-rank, p < 0.001). The addition of AVCd threshold into the prediction model including traditional risk factors improved outcome prediction (net classification improvement: 0.25, p = 0.04; likelihood ratio test, p < 0.001).
Conclusions Aortic bioprosthetic leaflet calcification is strongly and independently associated with HVD and the risk of death or aortic valve re-intervention. As opposed to native aortic stenosis, there is no sex-related differences in the relationship between AVCd and hemodynamic or clinical outcomes.
- aortic leaflet calcification
- aortic valve replacement
- hemodynamic valve deterioration
- surgical bioprosthesis
This study was funded by a research grant (MOP #86666) from the Canadian Institutes of Health Research. Dr. Zhang holds a State Scholarship Fund from China Scholarship Council (No. 201806210439). Dr. Mathieu holds a Fonds de Recherche du Québec-Santé Research Chair. Dr. Pibarot holds the Canada Research Chair in Valvular Heart Diseases, Canadian Institutes of Health Research. Dr. Clavel holds a National New Investigator award from the Heart and Stroke Foundation of Canada and an Early Career Investigator Awards in Circulatory and Respiratory Health from the Canadian Institutes of Health Research. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the JACC author instructions page.
- Received April 17, 2020.
- Revision received August 13, 2020.
- Accepted August 17, 2020.
- 2020 American College of Cardiology Foundation
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