Imaging methods for the assessment of aortic valve calcification_West China Medical Journal

Authors：

PENG Gang , JIA Yuheng ,  CHEN Mao

1. Department of Cardiology, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, P. R. China;

Corresponding author：

CHEN Mao, Email: hmaochen@vip.sina.com

Keywords：

Aortic valve calcification; aortic stenosis; transcatheter aortic valve replacement

DOI：

10.7507/1002-0179.202312244

Video：

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Aortic valve calcification (AVC) is one of the major causes of aortic stenosis (AS), and its pathogenesis is related to inflammation infiltration, lipid deposition, endothelial damage, calcification osteogenesis and angiogenesis. Previous studies have shown that AVC is associated with the severity of AS, the incidence of cardiovascular events, mortality, and surgical outcomes. The quantitative analysis of AVC using imaging methods not only has diagnostic value for AS, but also has guiding significance for the selection of surgical timing, assessment of surgical risk, and prognosis prediction. This article comprehensively elaborates on the methods and values of evaluating AVC using echocardiography, CT, and positron emission tomography.

Citation： PENG Gang, JIA Yuheng, CHEN Mao. Imaging methods for the assessment of aortic valve calcification. West China Medical Journal, 2024, 39(3): 500-504. doi: 10.7507/1002-0179.202312244 Copy

1.	Koos R, Brandenburg V, Ketteler M, et al. Prevalence and pathogenesis of aortic valve calcifications. Herz, 2006, 31(7): 629-634.
2.	O’Brien KD. Pathogenesis of calcific aortic valve disease: a disease process comes of age (and a good deal more). Arterioscler Thromb Vasc Biol, 2006, 26(8): 1721-1728.
3.	Mohler ER 3rd. Mechanisms of aortic valve calcification. Am J Cardiol, 2004, 94(11): 1396-1402.
4.	Bian W, Wang Z, Sun C, et al. Pathogenesis and molecular immune mechanism of calcified aortic valve disease. Front Cardiovasc Med, 2021, 8: 765419.
5.	Saikrishnan N, Kumar G, Sawaya FJ, et al. Accurate assessment of aortic stenosis: a review of diagnostic modalities and hemodynamics. Circulation, 2014, 129(2): 244-253.
6.	Bonow RO, Leon MB, Doshi D, et al. Management strategies and future challenges for aortic valve disease. Lancet, 2016, 387(10025): 1312-1323.
7.	Rosenhek R, Binder T, Porenta G, et al. Predictors of outcome in severe, asymptomatic aortic stenosis. N Engl J Med, 2000, 343(9): 611-617.
8.	Clavel MA, Pibarot P, Messika-Zeitoun D, et al. Impact of aortic valve calcification, as measured by MDCT, on survival in patients with aortic stenosis: results of an international registry study. J Am Coll Cardiol, 2014, 64(12): 1202-1213.
9.	Pawade T, Sheth T, Guzzetti E, et al. Why and how to measure aortic valve calcification in patients with aortic stenosis. JACC Cardiovasc Imaging, 2019, 12(9): 1835-1848.
10.	Clavel MA, Magne J, Pibarot P. Low-gradient aortic stenosis. Eur Heart J, 2016, 37(34): 2645-2657.
11.	Vahanian A, Beyersdorf F, Praz F, et al. 2021 ESC/EACTS guidelines for the management of valvular heart disease. Eur Heart J, 2022, 43(7): 561-632.
12.	Fletcher AJ, Singh T, Syed MBJ, et al. Imaging aortic valve calcification: significance, approach and implications. Clin Radiol, 2021, 76(1): 15-26.
13.	黄玉明, 陈思, 董念国. 主动脉瓣钙化定量分析方法研究现状. 中国胸心血管外科临床杂志, 2018, 25(10): 900-905.
14.	Baumgartner H, Hung J, Bermejo J, et al. Recommendations on the echocardiographic assessment of aortic valve stenosis: a focused update from the European Association of Cardiovascular Imaging and the American Society of Echocardiography. J Am Soc Echocardiogr, 2017, 30(4): 372-392.
15.	Yousry M, Rickenlund A, Petrini J, et al. Aortic valve type and calcification as assessed by transthoracic and transoesophageal echocardiography. Clin Physiol Funct Imaging, 2015, 35(4): 306-313.
16.	Yousry M, Rickenlund A, Petrini J, et al. Real-time imaging required for optimal echocardiographic assessment of aortic valve calcification. Clin Physiol Funct Imaging, 2012, 32(6): 470-475.
17.	Thomassen HK, Cioffi G, Gerdts E, et al. Echocardiographic aortic valve calcification and outcomes in women and men with aortic stenosis. Heart, 2017, 103(20): 1619-1624.
18.	Rosenhek R, Klaar U, Schemper M, et al. Mild and moderate aortic stenosis. Natural history and risk stratification by echocardiography. Eur Heart J, 2004, 25(3): 199-205.
19.	Dal-Bianco JP, Sengupta PP, Khandheria BK. Role of echocardiography in the diagnosis and management of asymptomatic severe aortic stenosis. Expert Rev Cardiovasc Ther, 2008, 6(2): 223-233.
20.	den Harder AM, Wolterink JM, Willemink MJ, et al. Submillisievert coronary calcium quantification using model-based iterative reconstruction: a within-patient analysis. Eur J Radiol, 2016, 85(11): 2152-2159.
21.	Arjmand Shabestari A. Coronary artery calcium score: a review. Iran Red Crescent Med J, 2013, 15(12): e16616.
22.	Hecht HS, Cronin P, Blaha MJ, et al. 2016 SCCT/STR guidelines for coronary artery calcium scoring of noncontrast noncardiac chest CT scans: a report of the Society of Cardiovascular Computed Tomography and Society of Thoracic Radiology. J Cardiovasc Comput Tomogr, 2017, 11(1): 74-84.
23.	Blaha MJ, Mortensen MB, Kianoush S, et al. Coronary artery calcium scoring: is it time for a change in methodology?. JACC Cardiovasc Imaging, 2017, 10(8): 923-937.
24.	Rouhollahi A, Willi JN, Haltmeier S, et al. CardioVision: a fully automated deep learning package for medical image segmentation and reconstruction generating digital twins for patients with aortic stenosis. Comput Med Imaging Graph, 2023, 109: 102289.
25.	Linde L, Carter-Storch R, Christensen NL, et al. Strong correlation between aortic valve calcification score by cardiac computed tomography and total valve calcium in patients with severe aortic valve stenosis. J Am Coll Cardiol, 2018, 71(11S): A1985-A1985.
26.	Koos R, Kühl HP, Mühlenbruch G, et al. Prevalence and clinical importance of aortic valve calcification detected incidentally on CT scans: comparison with echocardiography. Radiology, 2006, 241(1): 76-82.
27.	Gunning S, Murphy D, Charters PFP, et al. 171 diagnostic accuracy and prognostic value of aortic valve calcification on routine non-gated ct thorax. Heart, 2023, 109: A202.
28.	Simard L, Côté N, Dagenais F, et al. Sex-related discordance between aortic valve calcification and hemodynamic severity of aortic stenosis: is valvular fibrosis the explanation?. Circ Res, 2017, 120(4): 681-691.
29.	Chiocchi M, Forcina M, Morosetti D, et al. The role of computed tomography in the planning of transcatheter aortic valve implantation: a retrospective analysis in 200 procedures. J Cardiovasc Med (Hagerstown), 2018, 19(10): 571-578.
30.	Milhorini Pio S, Bax J, Delgado V. How valvular calcification can affect the outcomes of transcatheter aortic valve implantation. Expert Rev Med Devices, 2020, 17(8): 773-784.
31.	Abramowitz Y, Jilaihawi H, Chakravarty T, et al. Balloon-expandable transcatheter aortic valve replacement in patients with extreme aortic valve calcification. Catheter Cardiovasc Interv, 2016, 87(6): 1173-1179.
32.	石亚男, 门素珍, 孙孟华, 等. PET-CT 在心力衰竭中的临床应用. 中国循证心血管医学杂志, 2018, 10(2): 244-245.
33.	Irkle A, Vesey AT, Lewis DY, et al. Identifying active vascular microcalcification by 18F-sodium fluoride positron emission tomography. Nat Commun, 2015, 6(1): 7495.
34.	Dweck MR, Jones C, Joshi NV, et al. Assessment of valvular calcification and inflammation by positron emission tomography in patients with aortic stenosis. Circulation, 2012, 125(1): 76-86.
35.	Dweck MR, Jenkins WS, Vesey AT, et al. 18F-sodium fluoride uptake is a marker of active calcification and disease progression in patients with aortic stenosis. Circ Cardiovasc Imaging, 2014, 7(2): 371-378.
36.	Nakamoto Y, Kitagawa T, Sasaki K, et al. Clinical implications of ¹⁸F-sodium fluoride uptake in subclinical aortic valve calcification: its relation to coronary atherosclerosis and its predictive value. J Nucl Cardiol, 2021, 28: 1522-1531.
37.	Cartlidge TRG, Doris MK, Sellers SL, et al. Detection and prediction of bioprosthetic aortic valve degeneration. J Am Coll Cardiol, 2019, 73(10): 1107-1119.
38.	Lindman BR, Sukul D, Dweck MR, et al. Evaluating medical therapy for calcific aortic stenosis: JACC state-of-the-art review. J Am Coll Cardiol, 2021, 78(23): 2354-2376.
39.	Baumgartner H, Falk V, Bax JJ, et al. 2017 ESC/EACTS guidelines for the management of valvular heart disease. Eur Heart J, 2018, 39(21): 1980.
40.	Wu C, Vasseur B, Maisel W. The march of transcatheter aortic valve replacement therapy-US Food and Drug Administration perspectives on device approval for patients at low surgical risk. JAMA Cardiol, 2020, 5(1): 5-6.
41.	蔡欢, 朱嘉俊, 赵倩, 等. 经导管主动脉瓣置换术的临床应用进展. 华西医学, 2023, 38(9): 1297-1302.
42.	张恒, 吴士礼. 经导管主动脉瓣置换术后相关并发症的研究进展. 牡丹江医学院学报, 2023, 44(1): 160-163.
43.	Ewe SH, Ng AC, Schuijf JD, et al. Location and severity of aortic valve calcium and implications for aortic regurgitation after transcatheter aortic valve implantation. Am J Cardiol, 2011, 108(10): 1470-1477.
44.	Akodad M, Lattuca B, Agullo A, et al. Prognostic impact of calcium score after transcatheter aortic valve implantation performed with new generation prosthesis. Am J Cardiol, 2018, 121(10): 1225-1230.
45.	Fujita B, Kütting M, Seiffert M, et al. Calcium distribution patterns of the aortic valve as a risk factor for the need of permanent pacemaker implantation after transcatheter aortic valve implantation. Eur Heart J Cardiovasc Imaging, 2016, 17(12): 1385-1393.
46.	Doerner J, Kupczyk PA, Wilsing M, et al. Cerebral white matter lesion burden is associated with the degree of aortic valve calcification and predicts peri-procedural cerebrovascular events in patients undergoing transcatheter aortic valve implantation (TAVI). Catheter Cardiovasc Interv, 2018, 91(4): 774-782.

1. Koos R, Brandenburg V, Ketteler M, et al. Prevalence and pathogenesis of aortic valve calcifications. Herz, 2006, 31(7): 629-634.
2. O’Brien KD. Pathogenesis of calcific aortic valve disease: a disease process comes of age (and a good deal more). Arterioscler Thromb Vasc Biol, 2006, 26(8): 1721-1728.
3. Mohler ER 3rd. Mechanisms of aortic valve calcification. Am J Cardiol, 2004, 94(11): 1396-1402.
4. Bian W, Wang Z, Sun C, et al. Pathogenesis and molecular immune mechanism of calcified aortic valve disease. Front Cardiovasc Med, 2021, 8: 765419.
5. Saikrishnan N, Kumar G, Sawaya FJ, et al. Accurate assessment of aortic stenosis: a review of diagnostic modalities and hemodynamics. Circulation, 2014, 129(2): 244-253.
6. Bonow RO, Leon MB, Doshi D, et al. Management strategies and future challenges for aortic valve disease. Lancet, 2016, 387(10025): 1312-1323.
7. Rosenhek R, Binder T, Porenta G, et al. Predictors of outcome in severe, asymptomatic aortic stenosis. N Engl J Med, 2000, 343(9): 611-617.
8. Clavel MA, Pibarot P, Messika-Zeitoun D, et al. Impact of aortic valve calcification, as measured by MDCT, on survival in patients with aortic stenosis: results of an international registry study. J Am Coll Cardiol, 2014, 64(12): 1202-1213.
9. Pawade T, Sheth T, Guzzetti E, et al. Why and how to measure aortic valve calcification in patients with aortic stenosis. JACC Cardiovasc Imaging, 2019, 12(9): 1835-1848.
10. Clavel MA, Magne J, Pibarot P. Low-gradient aortic stenosis. Eur Heart J, 2016, 37(34): 2645-2657.
11. Vahanian A, Beyersdorf F, Praz F, et al. 2021 ESC/EACTS guidelines for the management of valvular heart disease. Eur Heart J, 2022, 43(7): 561-632.
12. Fletcher AJ, Singh T, Syed MBJ, et al. Imaging aortic valve calcification: significance, approach and implications. Clin Radiol, 2021, 76(1): 15-26.
13. 黄玉明, 陈思, 董念国. 主动脉瓣钙化定量分析方法研究现状. 中国胸心血管外科临床杂志, 2018, 25(10): 900-905.
14. Baumgartner H, Hung J, Bermejo J, et al. Recommendations on the echocardiographic assessment of aortic valve stenosis: a focused update from the European Association of Cardiovascular Imaging and the American Society of Echocardiography. J Am Soc Echocardiogr, 2017, 30(4): 372-392.
15. Yousry M, Rickenlund A, Petrini J, et al. Aortic valve type and calcification as assessed by transthoracic and transoesophageal echocardiography. Clin Physiol Funct Imaging, 2015, 35(4): 306-313.
16. Yousry M, Rickenlund A, Petrini J, et al. Real-time imaging required for optimal echocardiographic assessment of aortic valve calcification. Clin Physiol Funct Imaging, 2012, 32(6): 470-475.
17. Thomassen HK, Cioffi G, Gerdts E, et al. Echocardiographic aortic valve calcification and outcomes in women and men with aortic stenosis. Heart, 2017, 103(20): 1619-1624.
18. Rosenhek R, Klaar U, Schemper M, et al. Mild and moderate aortic stenosis. Natural history and risk stratification by echocardiography. Eur Heart J, 2004, 25(3): 199-205.
19. Dal-Bianco JP, Sengupta PP, Khandheria BK. Role of echocardiography in the diagnosis and management of asymptomatic severe aortic stenosis. Expert Rev Cardiovasc Ther, 2008, 6(2): 223-233.
20. den Harder AM, Wolterink JM, Willemink MJ, et al. Submillisievert coronary calcium quantification using model-based iterative reconstruction: a within-patient analysis. Eur J Radiol, 2016, 85(11): 2152-2159.
21. Arjmand Shabestari A. Coronary artery calcium score: a review. Iran Red Crescent Med J, 2013, 15(12): e16616.
22. Hecht HS, Cronin P, Blaha MJ, et al. 2016 SCCT/STR guidelines for coronary artery calcium scoring of noncontrast noncardiac chest CT scans: a report of the Society of Cardiovascular Computed Tomography and Society of Thoracic Radiology. J Cardiovasc Comput Tomogr, 2017, 11(1): 74-84.
23. Blaha MJ, Mortensen MB, Kianoush S, et al. Coronary artery calcium scoring: is it time for a change in methodology?. JACC Cardiovasc Imaging, 2017, 10(8): 923-937.
24. Rouhollahi A, Willi JN, Haltmeier S, et al. CardioVision: a fully automated deep learning package for medical image segmentation and reconstruction generating digital twins for patients with aortic stenosis. Comput Med Imaging Graph, 2023, 109: 102289.
25. Linde L, Carter-Storch R, Christensen NL, et al. Strong correlation between aortic valve calcification score by cardiac computed tomography and total valve calcium in patients with severe aortic valve stenosis. J Am Coll Cardiol, 2018, 71(11S): A1985-A1985.
26. Koos R, Kühl HP, Mühlenbruch G, et al. Prevalence and clinical importance of aortic valve calcification detected incidentally on CT scans: comparison with echocardiography. Radiology, 2006, 241(1): 76-82.
27. Gunning S, Murphy D, Charters PFP, et al. 171 diagnostic accuracy and prognostic value of aortic valve calcification on routine non-gated ct thorax. Heart, 2023, 109: A202.
28. Simard L, Côté N, Dagenais F, et al. Sex-related discordance between aortic valve calcification and hemodynamic severity of aortic stenosis: is valvular fibrosis the explanation?. Circ Res, 2017, 120(4): 681-691.
29. Chiocchi M, Forcina M, Morosetti D, et al. The role of computed tomography in the planning of transcatheter aortic valve implantation: a retrospective analysis in 200 procedures. J Cardiovasc Med (Hagerstown), 2018, 19(10): 571-578.
30. Milhorini Pio S, Bax J, Delgado V. How valvular calcification can affect the outcomes of transcatheter aortic valve implantation. Expert Rev Med Devices, 2020, 17(8): 773-784.
31. Abramowitz Y, Jilaihawi H, Chakravarty T, et al. Balloon-expandable transcatheter aortic valve replacement in patients with extreme aortic valve calcification. Catheter Cardiovasc Interv, 2016, 87(6): 1173-1179.
32. 石亚男, 门素珍, 孙孟华, 等. PET-CT 在心力衰竭中的临床应用. 中国循证心血管医学杂志, 2018, 10(2): 244-245.
33. Irkle A, Vesey AT, Lewis DY, et al. Identifying active vascular microcalcification by 18F-sodium fluoride positron emission tomography. Nat Commun, 2015, 6(1): 7495.
34. Dweck MR, Jones C, Joshi NV, et al. Assessment of valvular calcification and inflammation by positron emission tomography in patients with aortic stenosis. Circulation, 2012, 125(1): 76-86.
35. Dweck MR, Jenkins WS, Vesey AT, et al. 18F-sodium fluoride uptake is a marker of active calcification and disease progression in patients with aortic stenosis. Circ Cardiovasc Imaging, 2014, 7(2): 371-378.
36. Nakamoto Y, Kitagawa T, Sasaki K, et al. Clinical implications of ¹⁸F-sodium fluoride uptake in subclinical aortic valve calcification: its relation to coronary atherosclerosis and its predictive value. J Nucl Cardiol, 2021, 28: 1522-1531.
37. Cartlidge TRG, Doris MK, Sellers SL, et al. Detection and prediction of bioprosthetic aortic valve degeneration. J Am Coll Cardiol, 2019, 73(10): 1107-1119.
38. Lindman BR, Sukul D, Dweck MR, et al. Evaluating medical therapy for calcific aortic stenosis: JACC state-of-the-art review. J Am Coll Cardiol, 2021, 78(23): 2354-2376.
39. Baumgartner H, Falk V, Bax JJ, et al. 2017 ESC/EACTS guidelines for the management of valvular heart disease. Eur Heart J, 2018, 39(21): 1980.
40. Wu C, Vasseur B, Maisel W. The march of transcatheter aortic valve replacement therapy-US Food and Drug Administration perspectives on device approval for patients at low surgical risk. JAMA Cardiol, 2020, 5(1): 5-6.
41. 蔡欢, 朱嘉俊, 赵倩, 等. 经导管主动脉瓣置换术的临床应用进展. 华西医学, 2023, 38(9): 1297-1302.
42. 张恒, 吴士礼. 经导管主动脉瓣置换术后相关并发症的研究进展. 牡丹江医学院学报, 2023, 44(1): 160-163.
43. Ewe SH, Ng AC, Schuijf JD, et al. Location and severity of aortic valve calcium and implications for aortic regurgitation after transcatheter aortic valve implantation. Am J Cardiol, 2011, 108(10): 1470-1477.
44. Akodad M, Lattuca B, Agullo A, et al. Prognostic impact of calcium score after transcatheter aortic valve implantation performed with new generation prosthesis. Am J Cardiol, 2018, 121(10): 1225-1230.
45. Fujita B, Kütting M, Seiffert M, et al. Calcium distribution patterns of the aortic valve as a risk factor for the need of permanent pacemaker implantation after transcatheter aortic valve implantation. Eur Heart J Cardiovasc Imaging, 2016, 17(12): 1385-1393.
46. Doerner J, Kupczyk PA, Wilsing M, et al. Cerebral white matter lesion burden is associated with the degree of aortic valve calcification and predicts peri-procedural cerebrovascular events in patients undergoing transcatheter aortic valve implantation (TAVI). Catheter Cardiovasc Interv, 2018, 91(4): 774-782.

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