title: A revised methodology for aortic-valvar complex calcium quantification for transcatheter aortic valve implantation.
abstract: OBJECTIVE
  We sought to optimize a method for quantification of the calcium in the aortic-valvar complex for the prediction of significant paravalvular leak (PVL) after transcatheter aortic valve implantation (TAVI).
  
  
  RESULTS
  All patients had severe symptomatic aortic stenosis and were treated with balloon-expandable TAVI (Sapien/Sapien-XT, Edwards Lifesciences LLC, Irvine, CA, USA). In order to correct for precise annular sizing, only patients with available contrast computed tomography (CT) data for measurements were included (n = 198). Paravalvular leak was quantified using peri-procedural transoesophageal echocardiography by Valve Academic Research Consortium-2 (VARC-2) criteria (grade ≥ moderate was considered significant). A detailed region-of-interest methodology separated quantification of calcium in each of the aortic leaflets to that in the left ventricular outflow tract (LVOT) and was used to predict PVL in receiver operator characteristic curve analyses. For non-contrast scans, the greatest discriminatory value for PVL was seen at the 450 Hounsfield Unit (HU) threshold for detection (volume ≥626 mm(3)), whereas for contrast scans it was at 850 HU (≥235 mm(3)). Left ventricular outflow tract calcium predicted PVL but only as a binary variable with no incremental value of quantification. In a multivariable binary logistic regression model, annulus area ≥ prosthesis area (OR 3.5, 95% CI 1.5-8.2, P = 0.005), contrast leaflet calcium volume (850-HU threshold) ≥235 mm(3) (OR 2.8, 95% CI 1.2-6.7, P = 0.023), and presence of LVOT calcium (OR 2.8, 95% CI 1.2-7.0, P = 0.022) were independent predictors for PVL ≥ moderate.
  
  
  CONCLUSIONS
  Both leaflet and LVOT calcium are significant predictors of PVL and exert an important synergistic influence on this complication, even in appropriately sized valves. With careful attention to thresholds for detection, clinically relevant leaflet calcium volumes can be identified with either non-contrast or contrast CT scans.
authors.affiliation: Advanced Health Sciences Pavillion, Cedars-Sinai Heart Institute, 127 S. San Vicente Blvd, Third Floor, Suite A3600, Los Angeles, CA 90048, USA hasanjilaihawi@gmail.com.
authors.forename: Hasan
authors.initials: H
authors.lastname: Jilaihawi
authors.affiliation: Advanced Health Sciences Pavillion, Cedars-Sinai Heart Institute, 127 S. San Vicente Blvd, Third Floor, Suite A3600, Los Angeles, CA 90048, USA.
authors.forename: Raj R
authors.initials: RR
authors.lastname: Makkar
authors.affiliation: Advanced Health Sciences Pavillion, Cedars-Sinai Heart Institute, 127 S. San Vicente Blvd, Third Floor, Suite A3600, Los Angeles, CA 90048, USA.
authors.forename: Mohammad
authors.initials: M
authors.lastname: Kashif
authors.affiliation: Advanced Health Sciences Pavillion, Cedars-Sinai Heart Institute, 127 S. San Vicente Blvd, Third Floor, Suite A3600, Los Angeles, CA 90048, USA.
authors.forename: Kazuaki
authors.initials: K
authors.lastname: Okuyama
authors.affiliation: Advanced Health Sciences Pavillion, Cedars-Sinai Heart Institute, 127 S. San Vicente Blvd, Third Floor, Suite A3600, Los Angeles, CA 90048, USA.
authors.forename: Tarun
authors.initials: T
authors.lastname: Chakravarty
authors.affiliation: Advanced Health Sciences Pavillion, Cedars-Sinai Heart Institute, 127 S. San Vicente Blvd, Third Floor, Suite A3600, Los Angeles, CA 90048, USA.
authors.forename: Takahiro
authors.initials: T
authors.lastname: Shiota
authors.affiliation: Advanced Health Sciences Pavillion, Cedars-Sinai Heart Institute, 127 S. San Vicente Blvd, Third Floor, Suite A3600, Los Angeles, CA 90048, USA.
authors.forename: Gerald
authors.initials: G
authors.lastname: Friede
authors.affiliation: Advanced Health Sciences Pavillion, Cedars-Sinai Heart Institute, 127 S. San Vicente Blvd, Third Floor, Suite A3600, Los Angeles, CA 90048, USA.
authors.forename: Mamoo
authors.initials: M
authors.lastname: Nakamura
authors.affiliation: Advanced Health Sciences Pavillion, Cedars-Sinai Heart Institute, 127 S. San Vicente Blvd, Third Floor, Suite A3600, Los Angeles, CA 90048, USA.
authors.forename: Niraj
authors.initials: N
authors.lastname: Doctor
authors.affiliation: Advanced Health Sciences Pavillion, Cedars-Sinai Heart Institute, 127 S. San Vicente Blvd, Third Floor, Suite A3600, Los Angeles, CA 90048, USA.
authors.forename: Asim
authors.initials: A
authors.lastname: Rafique
authors.affiliation: Advanced Health Sciences Pavillion, Cedars-Sinai Heart Institute, 127 S. San Vicente Blvd, Third Floor, Suite A3600, Los Angeles, CA 90048, USA.
authors.forename: Kentaro
authors.initials: K
authors.lastname: Shibayama
authors.affiliation: Advanced Health Sciences Pavillion, Cedars-Sinai Heart Institute, 127 S. San Vicente Blvd, Third Floor, Suite A3600, Los Angeles, CA 90048, USA.
authors.forename: Hirotsugu
authors.initials: H
authors.lastname: Mihara
authors.affiliation: Advanced Health Sciences Pavillion, Cedars-Sinai Heart Institute, 127 S. San Vicente Blvd, Third Floor, Suite A3600, Los Angeles, CA 90048, USA.
authors.forename: Alfredo
authors.initials: A
authors.lastname: Trento
authors.affiliation: Advanced Health Sciences Pavillion, Cedars-Sinai Heart Institute, 127 S. San Vicente Blvd, Third Floor, Suite A3600, Los Angeles, CA 90048, USA.
authors.forename: Wen
authors.initials: W
authors.lastname: Cheng
authors.affiliation: Advanced Health Sciences Pavillion, Cedars-Sinai Heart Institute, 127 S. San Vicente Blvd, Third Floor, Suite A3600, Los Angeles, CA 90048, USA.
authors.forename: John
authors.initials: J
authors.lastname: Friedman
authors.affiliation: Advanced Health Sciences Pavillion, Cedars-Sinai Heart Institute, 127 S. San Vicente Blvd, Third Floor, Suite A3600, Los Angeles, CA 90048, USA.
authors.forename: Daniel
authors.initials: D
authors.lastname: Berman
authors.affiliation: Lenox Hill Heart and Vascular Institute of New York, New York, NY, USA.
authors.forename: Gregory P
authors.initials: GP
authors.lastname: Fontana
mesh_terms: D000369:Aged, 80 and over; D001021:Aortic Valve / Q000737:chemistry* / Q000000981:diagnostic imaging / Q000473:pathology; D001022:Aortic Valve Insufficiency / Q000601:surgery*; D001024:Aortic Valve Stenosis / Q000601:surgery*; D002114:Calcinosis / Q000175:diagnosis* / Q000000981:diagnostic imaging; D002118:Calcium / Q000032:analysis*; D003287:Contrast Media; D017548:Echocardiography, Transesophageal; D004562:Electrocardiography; D005260:Female; D006350:Heart Valve Prosthesis / Q000009:adverse effects; D006801:Humans; D008297:Male; D011237:Predictive Value of Tests; D011474:Prosthesis Design; D011475:Prosthesis Failure; D015203:Reproducibility of Results; D012307:Risk Factors; D012680:Sensitivity and Specificity; D012720:Severity of Illness Index; D013997:Time Factors; D014057:Tomography, X-Ray Computed / Q000379:methods; D065467:Transcatheter Aortic Valve Replacement / Q000009:adverse effects
chemical_list: D003287:Contrast Media; D002118:Calcium
keywords: Calcification; Calcium score; TAVI; TAVR; Transcatheter aortic valve