Characteristics and outcomes of patients with eccentric aortic valve calcification undergoing transcatheter aortic valve implantation

Hatim Seoudy (Kiel)1, J. Voran (Kiel)1, A. Pohlmeyer (Kiel)1, M. Müller (Kiel)1, J. Frank (Kiel)1, M. Salem (Kiel)1, S. Wundram (Kiel)1, G. Lutter (Kiel)2, M. Saad (Kiel)1, D. Frank (Kiel)1

1Universitätsklinikum Schleswig-Holstein Innere Medizin III mit den Schwerpunkten Kardiologie, Angiologie und internistische Intensivmedizin Kiel, Deutschland; 2Universitätsklinikum Schleswig-Holstein Klinik für Herz- und Gefäßchirurgie Kiel, Deutschland


Background: Transcatheter aortic valve implantation (TAVI) has become the standard therapy for the majority of patients with aortic valve stenosis. As TAVI expands to patients across the whole spectrum of surgical risk, optimal patient selection becomes increasingly important. Eccentric aortic valve calcification may pose a challenge during TAVI by interfering with precise valve implantation and full valve expansion. As data on this issue are still limited, the objective of this study was to assess the clinical characteristics and outcomes of eccentric aortic valve calcification in patients undergoing TAVI.

Methods: A total of 452 patients undergoing elective transfemoral TAVI between January 2017 and June 2023 were included in the analysis. Patients with bicuspid aortic valve or valve-in-valve procedures were excluded. Calcium volume of each individual aortic valve cusp was measured using 3mensio Structural Heart software (3mensio Medical Imaging BV, Bilthoven, The Netherlands). Eccentric calcification was defined based on the following eccentricity index (EI): EI = (1 – calcium volume of the two other cusps/calcium volume of the cusp with the highest calcium volume). An EI of >0.2 was considered significant. Clinical characteristics and outcomes of patients with eccentric versus symmetric calcification were analysed.

Results: Eccentric aortic valve calcification was present in 136 patients (30%). Patients with eccentric aortic valve calcification were significantly older (82.4 vs. 80.9 years, p=0.022) compared to patients with symmetric calcification. There were no significant differences regarding BMI (27.5 vs. 27.2 kg/m²) and comorbidities including coronary artery disease, hypertension, diabetes and chronic kidney disease compared to patients with symmetric calcification (p>0.05, respectively). Patients with eccentric aortic valve calcification had lower mean pressure gradients (31 vs. 39 mmHg, p<0.001) and greater valve areas (0.9 vs. 0.7 cm², p=0.003) at baseline. There were no significant differences in the use of self-expanding vs. balloon-expandable transcatheter heart valves (p=0.062), device success rates (p=0.443) as well as procedural complications including pacemaker rates (p=0.809) and paravalvular regurgitation (p=0.369). After a median follow-up of 336 days, there was no significant difference in mortality rates between patients with eccentric versus symmetric aortic valve calcification (log-rank test, p=0.645).

Conclusion: Eccentric aortic valve calcification is a common finding in patients with symptomatic aortic valve stenosis and can be safely and effectively treated with TAVI.


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