Association of aortic valve size with the degree of aortic valve calcification in severe high-gradient aortic stenosis.

Aims: Less pronounced calcification of the aortic valve (AVC) was observed in women with aortic stenosis (AS) when compared with men. Since women have smaller aortic valves (AVs), this could explain a lower calcium load. We aimed to analyse the association of AV size with AVC independent from sex.

Methods and results: Consecutive patients with high-gradient AS, who underwent cardiac computed tomography (CT), were assessed. AV annulus area and AVC with the Agatston score were measured on CT. In total, 601 patients (mean age 80 ± 7 years, 45% female) were included. Women had smaller AV annulus areas (4.12 ± 0.67 vs. 5.15 ± 0.78 cm2, P < 0.001) and lower Agatston scores [2018 (1456-3017) vs. 3394 (2562-4530), P < 0.001] than men. We found a significant correlation (r = 0.594, P < 0.001) and independent association (β = 926.20, P < 0.001) of AV annulus area with AVC. On separate regression analyses for men and women, AVC was independently associated with AV annulus area in both sexes (βmen = 887.77; βwomen = 863.48, both P < 0.001). When patients were stratified into AV size quartiles, patients in the lower quartiles were more likely to have AVC values below recommended sex-specific AVC thresholds. In the lowest quartile, 28% of female and 27% of male patients had Agatston scores below 1200 Agatston units (AU) (women) and 2000 AU (men), while this proportion decreased to 6 and 2%, respectively, in the quartiles with the largest annulus areas.

Conclusion: In high-gradient AS, AVC strongly depends on AV annulus area. This association is not dependent on sex. Thus, AVC should be indexed to AV size in addition to sex.