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Original research
Computed tomography calcium scoring in aortic stenosis: bicuspid versus tricuspid morphology
  1. Zi Ye1,
  2. Marie-Annick Clavel2,
  3. Thomas A Foley3,
  4. Philippe Pibarot2,
  5. Maurice Enriquez-Sarano1,
  6. Hector I Michelena1
  1. 1Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
  2. 2Cardiology, Quebec Heart and Lung Institute, Quebec, Quebec, Canada
  3. 3Radiology, Mayo Clinic, Rochester, Minnesota, USA
  1. Correspondence to Dr Hector I Michelena, Mayo Clinic, Rochester, Minnesota, USA; michelena.hector{at}


Objective CT aortic valve calcium score (AVCscore) and density (AVCdensity) thresholds have been recommended for aortic stenosis (AS) severity assessment in tricuspid aortic valve (TAV). We aimed to compare AVCscore and AVCdensity in bicuspid aortic valve (BAV) versus TAV.

Methods Retrospective single-centre study of patients with echocardiographic AS-severity and CT-AVC assessments within 6 months, and left ventricular ejection fraction ≥50%, all referred for clinical AS evaluation.

Severe AS was defined as aortic valve area (AVA) ≤1 cm2 or indexed AVA ≤0.6cm2/m2 plus mean gradient ≥40 mm Hg or peak velocity ≥4 m/s. AVC was assessed by Agatston method.

Results Of the 1957 patients, 328 had BAV and 1629 had TAV, age 65±11 vs 80±9 years (p<0.001), men 65% vs 56% (p=0.006), respectively. BAV morphology was associated with higher AVCscore and AVCdensity independent of age, comorbidities and AS severity (p<0.001) in men only (sex and BAV interaction p<0.001). In patients with severe AS, mean AVCscore and AVCdensity were higher in BAV-men than that in TAV-men (both p<0.001), but similar in BAV-women and TAV-women (both p≥0.4). Such patterns remained the same after adjustment for clinical covariates and AS severity. Best thresholds for severe AS diagnosis in BAV-men were 2916 AU by AVCscore and 600 AU/cm2 by AVCdensity which were higher than the guideline-recommended thresholds, while thresholds in BAV-women (1036 AU and 282 AU/cm2) were similar to guideline-recommended ones.

Conclusion Valve calcification in AS differs according to valve morphology and sex. BAV-men with severe AS exhibit greater AVCscore and AVCdensity than TAV-men. This presents a diagnostic challenge to the current guidelines, which needs confirmation in larger studies.

  • Aortic stenosis
  • Echocardiography
  • Multidetector Computed Tomography
  • Aortic Valve Stenosis
  • Congenital Abnormalities

Data availability statement

Data are available upon reasonable request. Data available to share on reasonable request only if approved by Mayo Clinic research authority.

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Data availability statement

Data are available upon reasonable request. Data available to share on reasonable request only if approved by Mayo Clinic research authority.

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  • Twitter @ClavelLabo, @PPibarot, @sarano_maurice, @michelenahector

  • Contributors ZY and HIM contributed to conception and design of the study. ZY performed all the CT-AVC analysis and statistical analysis. ZY and HIM wrote the first draft. All authors contributed to manuscript revision, read and approved the submitted version. HIM is responsible for the overall content as guarantor.

  • Funding This work was supported by the cardiovascular department prospective research grant (CV prospective-2021).

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting or dissemination plans of this research.

  • Provenance and peer review Not commissioned; externally peer reviewed.