Mogensen Nils Sofus Borg, Sanchez Dahl Jordi, Ali Mulham, Annabi Mohamed-Salah, Haujir Amal, Powers Andréanne, Carter-Storch Rasmus, Grenier-Delaney Jasmine, Møller Jacob Eifer, Øvrehus Kristian Altern, Pibarot Philippe, Clavel Marie-Annick
Department of Cardiology, Odense University Hospital, Denmark (N.S.B.M., J.S.D., M.A., A.H., R.C.-S., J.E.M., K.A.Ø., M.-A.C.).
Research center, Institut Universitaire de Cardiologie et de Pneumologie de Québec (Québec Heart and Lung Institute), Laval University, Canada (N.S.B.M., M.-S.A., A.H., A.P., J.G.-D., P.P., M.-A.C.).
Circ Cardiovasc Imaging. 2025 Jan;18(1):e017122. doi: 10.1161/CIRCIMAGING.124.017122. Epub 2025 Jan 8.
Aortic valve calcification (AVC) has been shown to be a powerful assessment of aortic stenosis (AS) severity and a predictor of adverse outcomes. However, its accuracy in patients with low-flow AS has not yet been proven. The objective of the study was to assess the predictive value of AVC in patients with classical low-flow (CLF, that is, low-flow reduced left ventricular ejection fraction) or paradoxical low-flow (PLF, that is, low-flow preserved left ventricular ejection fraction) AS.
We prospectively included 641 patients, 319 (49.8%) with CLF-AS and 322 (50.2%) with PLF-AS, who underwent Doppler echocardiography and multidetector computed tomography. AVC ratio (AVCratio) was calculated as AVC divided by the sex-specific AVC threshold for AS severity; AVC score ≥2000 Agatston units in male patients and ≥1200 Agatston units in female patients. The primary end point of the study was all-cause mortality regardless of treatment.
Sex-specific AVC thresholds identified AS severity correctly in 137 (87%) of the patients. During a median follow-up of 4.9 (4.3-5.9) years, there were 265 deaths. After comprehensive adjustment, AVCratio was associated with all-cause mortality in patients with CLF-AS (adjusted hazard ratio, 1.25 [95% CI, 1.01-1.56]; =0.046) and PLF-AS (adjusted hazard ratio, 1.51 [95% CI, 1.14-2.00]; =0.004). There was an interaction (=0.001) between AVC and AS flow patterns (ie, CLF versus PLF) with regard to the prediction of mortality. The best AVCratio threshold to predict mortality was different in patients with CLF-AS (AVCratio ≥0.7) and PLF-AS (AVCratio ≥1). After a comprehensive analysis, AVCratio as a dichotomic variable was associated with all-cause mortality in all groups (≤0.001). The addition of AVCratio to the models improved all models' predictive value (all net reclassification index >18%; all ≤0.05).
In patients with CLF-AS or PLF-AS, AVC is a major predictor of mortality. Thus, AVC should be used in low-flow patients to assess AS severity and stratify risk. Importantly, in patients with reduced left ventricular ejection fraction, a nonsevere AS (ie, AVC 70% of severe) could be associated with reduced survival.
主动脉瓣钙化（AVC）已被证明是评估主动脉瓣狭窄（AS）严重程度的有力指标及不良结局的预测因子。然而，其在低流量AS患者中的准确性尚未得到证实。本研究的目的是评估AVC在经典低流量（CLF，即低流量伴左心室射血分数降低）或矛盾性低流量（PLF，即低流量伴左心室射血分数保留）AS患者中的预测价值。
我们前瞻性纳入了641例患者，其中319例（49.8%）为CLF-AS患者，322例（50.2%）为PLF-AS患者，这些患者均接受了多普勒超声心动图和多排螺旋计算机断层扫描检查。AVC比率（AVCratio）的计算方法为AVC除以根据性别确定的AS严重程度的AVC阈值；男性患者AVC评分≥2000阿加斯顿单位，女性患者AVC评分≥1200阿加斯顿单位。本研究的主要终点是全因死亡率，无论治疗情况如何。
根据性别确定的AVC阈值在137例（87%）患者中正确识别了AS严重程度。在中位随访4.9（4.3 - 5.9）年期间，有265例死亡。经过全面调整后，AVCratio与CLF-AS患者的全因死亡率相关（调整后风险比，1.25 [95%CI，1.01 - 1.56]；P = 0.046），也与PLF-AS患者的全因死亡率相关（调整后风险比，1.51 [95%CI，1.14 - 2.00]；P = 0.004）。在死亡率预测方面，AVC与AS血流模式（即CLF与PLF）之间存在交互作用（P = 0.001）。预测死亡率的最佳AVCratio阈值在CLF-AS患者（AVCratio≥0.7）和PLF-AS患者（AVCratio≥1）中有所不同。经过全面分析，AVCratio作为二分变量与所有组的全因死亡率相关（P≤0.001）。将AVCratio添加到模型中提高了所有模型的预测价值（所有净重新分类指数>18%；所有P≤0.05）。
在CLF-AS或PLF-AS患者中，AVC是死亡率的主要预测因子。因此，AVC应用于低流量患者以评估AS严重程度并进行风险分层。重要的是，在左心室射血分数降低的患者中，非重度AS（即AVC<重度的70%）可能与生存率降低相关。
