title: The impact of calcium volume and distribution in aortic root injury related to balloon-expandable transcatheter aortic valve replacement.
abstract: BACKGROUND
  A detailed assessment of calcium within the aortic root may provide important additional information regarding the risk of aortic root injury during transcatheter heart valve replacement (TAVR).
  
  
  OBJECTIVE
  We sought to delineate the effect of calcium volume and distribution on aortic root injury during TAVR.
  
  
  METHODS
  Thirty-three patients experiencing aortic root injury during TAVR with a balloon-expandable valve were compared with a control group of 153 consecutive TAVR patients without aortic root injury (as assessed by post-TAVR multidetector CT). Using commercial software to analyze contrast-enhanced pre-TAVR CT scans, calcium volume was determined in 3 regions: (1) the overall left ventricular outflow tract (LVOT), extending 10 mm down from the aortic annulus plane; (2) the upper LVOT, extending 2 mm down from the annulus plane; and (3) the aortic valve region.
  
  
  RESULTS
  Calcium volumes in the upper LVOT (median, 29 vs 0 mm(3); P < .0001) and overall LVOT (median, 74 vs 3 mm(3); P = .0001) were higher in patients who experienced aortic root injury compared with the control group. Calcium in the aortic valve region did not differ between groups. Upper LVOT calcium volume was more predictive of aortic root injury than overall LVOT calcium volume (area under receiver operating curve [AUC], 0.78; 95% confidence interval, 0.69-0.86 vs AUC, 0.71; 95% confidence interval, 0.62-0.82; P = .010). Upper LVOT calcium below the noncoronary cusp was significantly more predictive of aortic root injury compared to calcium underneath the right coronary cusp or the left coronary cusp (AUC, 0.81 vs 0.68 vs 0.64). Prosthesis oversizing >20% (likelihood ratio test, P = .028) and redilatation (likelihood ratio test, P = .015) improved prediction of aortic root injury by upper LVOT calcium volume.
  
  
  CONCLUSIONS
  Calcification of the LVOT, especially in the upper LVOT, located below the noncoronary cusp and extending from the annular region, is predictive of aortic root injury during TAVR with a balloon-expandable valve.
authors.affiliation: Department of Cardiology, Aarhus University Hospital, Skejby, Brendstrupgaardsvej 100, DK-8200 Aarhus N, Aarhus, Denmark. Electronic address: nh@dadlnet.dk.
authors.forename: Nicolaj C
authors.initials: NC
authors.lastname: Hansson
authors.affiliation: Department of Cardiology, Aarhus University Hospital, Skejby, Brendstrupgaardsvej 100, DK-8200 Aarhus N, Aarhus, Denmark.
authors.forename: Bjarne L
authors.initials: BL
authors.lastname: Nørgaard
authors.affiliation: St Paul's Hospital, Vancouver, Canada; Ferrarotto Hospital, University of Catania, Catania, Italy.
authors.forename: Marco
authors.initials: M
authors.lastname: Barbanti
authors.affiliation: Linköping University Hospital, Linköping, Sweden.
authors.forename: Niels Erik
authors.initials: NE
authors.lastname: Nielsen
authors.affiliation: St Paul's Hospital, Vancouver, Canada; Busan Paik Hospital, Inje University, Gimhae, South Korea.
authors.forename: Tae-Hyun
authors.initials: TH
authors.lastname: Yang
authors.affiliation: Ferrarotto Hospital, University of Catania, Catania, Italy.
authors.forename: Corrado
authors.initials: C
authors.lastname: Tamburino
authors.affiliation: St Paul's Hospital, Vancouver, Canada.
authors.forename: Danny
authors.initials: D
authors.lastname: Dvir
authors.affiliation: Cedars-Sinai Heart Institute, Los Angeles, CA, USA.
authors.forename: Hasan
authors.initials: H
authors.lastname: Jilaihawi
authors.affiliation: University Hospital Freiburg, Freiburg, Germany.
authors.forename: Phillip
authors.initials: P
authors.lastname: Blanke
authors.affiliation: Cedars-Sinai Heart Institute, Los Angeles, CA, USA.
authors.forename: Raj R
authors.initials: RR
authors.lastname: Makkar
authors.affiliation: EMO-GVM Centro Cuore Columbus, Milan, Italy; San Raffaele Scientific Institute, Milan, Italy.
authors.forename: Azeem
authors.initials: A
authors.lastname: Latib
authors.affiliation: EMO-GVM Centro Cuore Columbus, Milan, Italy; San Raffaele Scientific Institute, Milan, Italy.
authors.forename: Antonio
authors.initials: A
authors.lastname: Colombo
authors.affiliation: University of Padua, Padua, Italy.
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Tarantini
authors.affiliation: St Paul's Hospital, Vancouver, Canada.
authors.forename: Rekha
authors.initials: R
authors.lastname: Raju
authors.affiliation: St Paul's Hospital, Vancouver, Canada.
authors.forename: David
authors.initials: D
authors.lastname: Wood
authors.affiliation: Department of Cardiology, Aarhus University Hospital, Skejby, Brendstrupgaardsvej 100, DK-8200 Aarhus N, Aarhus, Denmark.
authors.forename: Henning R
authors.initials: HR
authors.lastname: Andersen
authors.affiliation: Quebec Heart and Lung Institute, Laval University, Quebec City, Canada.
authors.forename: Henrique B
authors.initials: HB
authors.lastname: Ribeiro
authors.affiliation: Cleveland Clinic, Cleveland, OH, USA.
authors.forename: Samir
authors.initials: S
authors.lastname: Kapadia
authors.affiliation: Cedars-Sinai Heart Institute, Los Angeles, CA, USA.
authors.forename: James
authors.initials: J
authors.lastname: Min
authors.affiliation: Innsbruck Medical University, Innsbruck, Austria.
authors.forename: Gudrun
authors.initials: G
authors.lastname: Feuchtner
authors.affiliation: Royal Melbourne Hospital, Melbourne, Australia.
authors.forename: Ronen
authors.initials: R
authors.lastname: Gurvitch
authors.affiliation: University of Calgary, Calgary, Canada.
authors.forename: Faisal
authors.initials: F
authors.lastname: Alqoofi
authors.affiliation: New Brunswick Heart Centre, Saint John, Canada.
authors.forename: Marc
authors.initials: M
authors.lastname: Pelletier
authors.affiliation: Department of Cardiovascular Disease, Tor Vergata University of Rome, Rome, Italy.
authors.forename: Gian Paolo
authors.initials: GP
authors.lastname: Ussia
authors.affiliation: EMO-GVM Centro Cuore Columbus, Milan, Italy; San Raffaele Scientific Institute, Milan, Italy.
authors.forename: Massimo
authors.initials: M
authors.lastname: Napodano
authors.affiliation: Hospital Israelita Albert Einstein, Sao Paulo, Brazil.
authors.forename: Fabio
authors.initials: F
authors.lastname: Sandoli de Brito
authors.affiliation: Columbia University Medical Center/New York-Presbyterian Hospital, New York, NY, USA.
authors.forename: Susheel
authors.initials: S
authors.lastname: Kodali
authors.affiliation: University Hospital Freiburg, Freiburg, Germany.
authors.forename: Gregor
authors.initials: G
authors.lastname: Pache
authors.affiliation: Arrixaca University Hospital, Murcia, Spain.
authors.forename: Sergio J
authors.initials: SJ
authors.lastname: Canovas
authors.affiliation: St Paul's Hospital, Vancouver, Canada.
authors.forename: Adam
authors.initials: A
authors.lastname: Berger
authors.affiliation: St Paul's Hospital, Vancouver, Canada.
authors.forename: Darra
authors.initials: D
authors.lastname: Murphy
authors.affiliation: Cleveland Clinic, Cleveland, OH, USA.
authors.forename: Lars G
authors.initials: LG
authors.lastname: Svensson
authors.affiliation: Quebec Heart and Lung Institute, Laval University, Quebec City, Canada.
authors.forename: Josep
authors.initials: J
authors.lastname: Rodés-Cabau
authors.affiliation: Columbia University Medical Center/New York-Presbyterian Hospital, New York, NY, USA.
authors.forename: Martin B
authors.initials: MB
authors.lastname: Leon
authors.affiliation: St Paul's Hospital, Vancouver, Canada.
authors.forename: John G
authors.initials: JG
authors.lastname: Webb
authors.affiliation: St Paul's Hospital, Vancouver, Canada.
authors.forename: Jonathon
authors.initials: J
authors.lastname: Leipsic
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001018:Aortic Diseases / Q000150:complications* / Q000175:diagnosis; D001021:Aortic Valve / Q000000981:diagnostic imaging / Q000293:injuries / Q000473:pathology*; D001024:Aortic Valve Stenosis / Q000150:complications / Q000175:diagnosis / Q000628:therapy*; D001027:Aortography / Q000379:methods; D002114:Calcinosis / Q000150:complications / Q000175:diagnosis / Q000628:therapy*; D006328:Cardiac Catheterization / Q000009:adverse effects* / Q000379:methods; D016022:Case-Control Studies; D005260:Female; D006335:Heart Injuries / Q000175:diagnosis / Q000209:etiology*; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects* / Q000379:methods; D006801:Humans; D058498:Kyphoplasty / Q000009:adverse effects*; D008297:Male; D061330:Multidetector Computed Tomography; D011237:Predictive Value of Tests; D018570:Risk Assessment; D012307:Risk Factors; D012720:Severity of Illness Index; D016896:Treatment Outcome; D061205:Vascular Calcification / Q000150:complications* / Q000175:diagnosis; D057772:Vascular System Injuries / Q000175:diagnosis / Q000209:etiology*
keywords: Aortic root calcification; Aortic root injury; Multidetector computed tomography; Transcatheter aortic valve replacement