Aortic Valve Calcification as an Incidental Finding at CT of the Elderly: Severity and Location as Predictors of Aortic Stenosis

Prevalence and clinical characteristics of non-malignant CT detected incidental findings in the SUMMIT lung cancer screening cohort

BACKGROUND

Pulmonary and extrapulmonary incidental findings are frequently identified on CT scans performed for lung cancer screening. Uncertainty regarding their clinical significance and how and when such findings should be reported back to clinicians and participants persists. We examined the prevalence of non-malignant incidental findings within a lung cancer screening cohort and investigated the morbidity and relevant risk factors associated with incidental findings. We quantified the primary and secondary care referrals generated by our protocol.

METHODS

The SUMMIT study (NCT03934866) is a prospective observational cohort study to examine the performance of delivering a low-dose CT (LDCT) screening service to a high-risk population. Spirometry, blood pressure, height/weight and respiratory history were assessed as part of a Lung Health Check. Individuals at high risk of lung cancer were offered an LDCT and returned for two further annual visits. This analysis is a prospective evaluation of the standardised reporting and management protocol for incidental findings developed for the study on the baseline LDCT.

RESULTS

In 11 115 participants included in this analysis, the most common incidental findings were coronary artery calcification (64.2%) and emphysema (33.4%). From our protocolised management approach, the number of participants requiring review for clinically relevant findings in primary care was 1 in 20, and the number potentially requiring review in secondary care was 1 in 25.

CONCLUSIONS

Incidental findings are common in lung cancer screening and can be associated with reported symptoms and comorbidities. A standardised reporting protocol allows systematic assessment and standardises onward management.

Different calcification patterns of tricuspid and bicuspid aortic valves and their clinical impact

OBJECTIVES

Mechanical strain plays a major role in the development of aortic calcification. We hypothesized that (i) valvular calcifications are most pronounced at the localizations subjected to the highest mechanical strain and (ii) calcification patterns are different in patients with bicuspid and tricuspid aortic valves.

METHODS

Multislice computed tomography scans of 101 patients with severe aortic stenosis were analysed using a 3-dimensional post-processing software to quantify calcification of tricuspid aortic valves (n = 51) and bicuspid aortic valves (n = 50) after matching.

RESULTS

Bicuspid aortic valves exhibited higher calcification volumes and increased calcification of the non-coronary cusp with significantly higher calcification of the free leaflet edge. The non-coronary cusp showed the highest calcium load compared to the other leaflets. Patients with annular calcification above the median had an impaired survival compared to patients with low annular calcification, whereas patients with calcification of the free leaflet edge above the median did not (P = 0.53).

CONCLUSIONS

Calcification patterns are different in patients with aortic stenosis with bicuspid and tricuspid aortic valves. Patients with high annular calcification might have an impaired prognosis.

Sex Differences in the Impact of Aortic Valve Calcium Score on Mortality After Transcatheter Aortic Valve Replacement

BACKGROUND

Transcatheter aortic valve replacement (TAVR) is now an approved alternative to surgical aortic valve replacement for the treatment of severe aortic stenosis. As the clinical adoption of TAVR expands, it remains important to identify predictors of mortality after TAVR. We aimed to evaluate the impact of sex differences in aortic valve calcium score (AVCS) on long-term mortality following TAVR in a large patient sample.

METHODS

We included consecutive patients who successfully underwent TAVR for treatment of severe native aortic valve stenosis from June 2010 to May 2021 across all US Mayo Clinic sites with follow-up through July 2021. AVCS values were obtained from preoperative computed tomography of the chest. Additional clinical data were abstracted from medical records. Kaplan-Meier curves and Cox-proportional hazard regression models were employed to evaluate the effect of AVCS on long-term mortality.

RESULTS

A total of 2543 patients were evaluated in the final analysis. Forty-one percent were women, median age was 82 years (Q1: 76, Q3: 86), 18.4% received a permanent pacemaker following TAVR, and 88.5% received a balloon expandable valve. We demonstrate an increase in mortality risk with higher AVCS after multivariable adjustment (P<0.001). When stratified by sex, every 500-unit increase in AVCS was associated with a 7% increase in mortality risk among women (adjusted hazard ratio, 1.07 [95% CI, 1.02-1.12]) but not in men.

CONCLUSIONS

We demonstrate a notable sex difference in the association between AVCS and long-term mortality in a large TAVR patient sample. This study highlights the potential value of AVCS in preprocedural risk stratification, specifically among women undergoing TAVR. Additional studies are needed to validate this finding.

Lipoprotein Particle Profiles Compared With Standard Lipids in the Association With Subclinical Aortic Valve Calcification in Apparently Healthy Japanese Men

BACKGROUND

Risk factors for atherosclerotic disease including dyslipidemia have been shown to be associated with aortic valve calcification (AVC). Nuclear magnetic resonance (NMR)-measured lipoprotein particles, low-density and high-density lipoprotein particles (LDL-p, HDL-p) in particular, have emerged as novel markers of atherosclerotic disease; however, whether NMR-measured particles are associated with AVC remains to be determined. This study aimed to examine the association between NMR-based lipoprotein particle measurements and standard lipids with AVC. The primary variables of interest were LDL-p (nmol/L), HDL-p (μmol/L), LDL-cholesterol, and HDL-cholesterol (both in mg/dL).Methods and Results:A community-based random sample of Japanese men aged 40-79 years examined in 2006-2008, in Shiga, Japan was studied. Presence of AVC was defined as an Agatston score >0. Lipoprotein particles were measured using NMR spectroscopy. In the main analysis, multivariable-adjusted odds ratios (ORs) and 95% confidence intervals (95% CIs) for the prevalence of AVC across the higher quartiles of lipids in reference to the lowest ones were obtained. Of 874 participants analyzed, 153 men had AVC. Multivariable-adjusted ORs of prevalent AVC for the highest vs. the lowest quartile were significantly elevated for LDL-p (OR, 2.20; 95% CI: 1.23-3.93) and LDL-cholesterol (OR, 2.16; 95% CI: 1.23-3.78). In contrast, neither HDL-p nor HDL-cholesterol was associated with AVC.

CONCLUSIONS

The association of prevalent AVC with NMR-based LDL-p was comparable to that with LDL-cholesterol.

Prevalence and clinical implications of valvular calcification on coronary computed tomography angiography

AIMS

Valvular heart disease can be identified by calcification on coronary computed tomography angiography (CCTA) and has been associated with adverse clinical outcomes. We assessed aortic and mitral valve calcification in patients presenting with stable chest pain and their association with cardiovascular risk factors, coronary artery disease, and cardiovascular outcomes.

METHODS AND RESULTS

In 1769 patients (58 ± 9 years, 56% male) undergoing CCTA for stable chest pain, aortic and mitral valve calcification were quantified using Agatston score. Aortic valve calcification was present in 241 (14%) and mitral calcification in 64 (4%). Independent predictors of aortic valve calcification were age, male sex, hypertension, diabetes mellitus, and cerebrovascular disease, whereas the only predictor of mitral valve calcification was age. Patients with aortic and mitral valve calcification had higher coronary artery calcium scores and more obstructive coronary artery disease. The composite endpoint of cardiovascular mortality, non-fatal myocardial infarction, or non-fatal stroke was higher in those with aortic [hazard ratio (HR) 2.87; 95% confidence interval (CI) 1.60-5.17; P < 0.001] or mitral (HR 3.50; 95% CI 1.47-8.07; P = 0.004) valve calcification, but this was not independent of coronary artery calcification or obstructive coronary artery disease.

CONCLUSION

Aortic and mitral valve calcification occurs in one in six patients with stable chest pain undergoing CCTA and is associated with concomitant coronary atherosclerosis. Whilst valvular calcification is associated with a higher risk of cardiovascular events, this was not independent of the burden of coronary artery disease.

Patient-specific in vitro testing for evaluating TAVR clinical performance-A complementary approach to current ISO standard testing

Following in vitro tests established for surgical prosthetic heart valves, transcatheter aortic valves (TAV) are similarly tested in idealized geometries-excluding effects that may hamper TAVR performance in situ. Testing in vitro in pulse duplicator systems that incorporated patient-specific replicas would enhance the testing veracity by bringing it closer to the clinical scenario. To that end we compare TAV hemodynamic performance tested in idealized geometries according to the ISO standard (baseline performance) to that obtained by testing the TAVs following deployment in patient-specific replicas. Balloon-expandable (n = 2) and self-expandable (n = 3) TAVs were tested in an idealized geometry in mock-circulation system (following ISO 5840-3 guidelines) and compared to the measurements in a dedicated mock-circulation system adapted for the five patient-specific replicas. Patient-specific deployments resulted in a decline in performance as compared to the baseline idealized testing, as well as a variation in performance that depended on the design features of each device that was further correlated with the radial expansion and eccentricity of the deployed TAV stent (obtained with CT-scans of the deployed valves). By excluding the deployment effects in irregular geometries, the current idealized ISO testing is limited to characterize the baseline device performance. Utilizing patient-specific anatomic contours provides performance indicators under more stringent conditions likely encountered in vivo. It has the potential to enhance testing and development complementary to the ISO standard, for improved TAV safety and effectiveness.

Reporting incidental coronary, aortic valve and cardiac calcification on non-gated thoracic computed tomography, a consensus statement from the BSCI/BSCCT and BSTI

Incidental coronary and cardiac calcification are frequent findings on non-gated thoracic CT. We recommend that the heart is reviewed on all CT scans where it is visualised. Coronary artery calcification is a marker of coronary artery disease and it is associated with an adverse prognosis on dedicated cardiac imaging and on non-gated thoracic CT performed for non-cardiac indications, both with and without contrast. We recommend that coronary artery calcification is reported on all non-gated thoracic CT using a simple patient-based score (none, mild, moderate, severe). Furthermore, we recommend that reports include recommendations for subsequent management, namely the assessment of modifiable cardiovascular risk factors and, if the patient has chest pain, assessment as per standard guidelines. In most cases, this will not necessitate additional investigations. Incidental aortic valve calcification may also be identified on non-gated thoracic CT and should be reported, along with ancillary findings such as aortic root dilation. Calcification may occur in other parts of the heart including mitral valve/annulus, pericardium and myocardium, but in many cases these are an incidental finding without clinical significance.

Why and How to Measure Aortic Valve Calcification in Patients With Aortic Stenosis

The first-line evaluation of aortic stenosis severity is Doppler echocardiography. However, in up to 40% of patients, resting echocardiographic assessment of aortic stenosis severity is discordant, leading to clinical uncertainty. Interest has therefore grown in aortic valve calcium scoring by multidetector computed tomography (CT-AVC) as an alternative load independent assessment of aortic stenosis severity. This paper will briefly review the pathophysiology of aortic stenosis and the crucial role that calcification plays in driving progressive obstruction of the valve. Subsequently, it will describe published reports that have investigated CT-AVC, validating this parameter against histology, and establishing its diagnostic accuracy versus echocardiography as well as its powerful independent prognostic capability. Finally, this review seeks to provide a practical guide about how best to acquire and interpret CT-AVC with a close focus on potential pitfalls and how these might be best avoided as this technique becomes more widely adopted in to clinical practice.

Visual scoring of aortic valve calcifications on low-dose CT in lung cancer screening

OBJECTIVES

To evaluate risk factors for prevalence and progression of aortic valve calcification (AVC) in lung cancer screening participants and also to assess the sensitivity and reliability of visual AVCs on low-dose CT (LDCT) for predicting aortic stenosis (AS) in high-risk smokers.

METHODS

We reviewed 1225 consecutive participants in annual LDCT screening for lung cancer at the Mount Sinai Hospital between 2010 and 2017. Sensitivity and specificity of moderate/severe AVC score on LDCT to identify AS on echocardiogram were calculated for 126 participants who had both within 12 months. Using regression analyses, risk factors for AVC at baseline, for progression, and for new AVC on annual rounds of screening were identified. Reliability of AVC assessment on LDCT was assessed by comparing visual AVC scores (1) with standard-dose, electrocardiography (ECG)-gated CT for 31 participants who had both within 12 months and (2) with Agatston scores of 1225 participants and by determining (3) the intra-reader agreement of 1225 participants.

RESULTS

Visual AVC scores on LDCT had substantial agreement with the severity of AS on echocardiography and substantial inter-observer and excellent intra-observer agreement. Sensitivity and specificity of moderate/severe visual AVC scores for moderate/severe AS on echocardiogram were 100% and 94%, respectively. Significant predictors for baseline AVC were male sex (OR = 2.52), age (OR_{10 years} = 2.87), and coronary artery calcification score (OR = 1.18), the significant predictor for AVC progression after baseline was pack-years of smoking (HR_{10 packyears} = 1.14), and significant predictors for new AVC on annual LDCT were male sex (HR = 1.51), age (HR_{10 years} = 2.17), CAC (HR = 1.09)  and BMI (HR = 1.06).

CONCLUSIONS

AVC scores on LDCT should be documented, especially in lung cancer screening program.

KEY POINTS

• LDCT screening for lung cancer provides an opportunity to identify lung cancer and cardiovascular disease in asymptomatic smokers. • Visual aortic valve calcification scores could be reliably evaluated on LDCT and had substantial agreement with the severity of aortic valve stenosis on echocardiography. • Sensitivity and specificity of moderate/severe visual AVC scores on LDCT for moderate/severe AS on echocardiogram were 100% and 94%, respectively.

Association between aortic valvular calcification and characteristics of the aortic valve in patients with bicuspid aortic valve stenosis

BACKGROUND

Aortic valve calcification quantification using cardiac computed tomography (CCT) is a reliable marker for aortic stenosis (AS) in patients with bicuspid aortic valve (BAV) disease.

PURPOSE

To determine the association of Agatston aortic valve calcium score (AVCS) with morphological and hemodynamic characteristics of BAV and define cut-off AVCS for optimizing the grade of AS in patients with bicuspid AS.

MATERIAL AND METHODS

This study included 161 BAV patients with AS regardless of aortic regurgitation who underwent transthoracic echocardiography and CCT. BAVs were classified according to orientation of cusps and presence of raphe. Associations of AVCS with characteristics of BAV morphology and functional variables were determined by linear regression analysis. Area under the receiver operating characteristic curve (AUC) was used to determine the cut-off AVCS greater than which the diagnosis of severe AS was optimized.

RESULTS

AVCS was significantly different according to sex ( P < 0.001), AS severity ( P < 0.001), type of valvular dysfunction ( P = 0.011), and orientation of cusps ( P = 0.028). Multiple linear regression showed that AVCS was significantly associated with sex (estimate = -0.583, P < 0.001) and AS severity (estimate = 0.817, P < 0.001). AVCS was a predictor for severe AS with AUC of 0.80 in both women ( P = 0.002) and men ( P < 0.001). Its cut-off value was 1423 Agatston unit (AU) in women and 2573 AU in men.

CONCLUSIONS

In patients with bicuspid AS, AVCS was significantly higher in men and those with severe AS. However, AVCS was not significantly associated with morphological characteristics of BAV or the type of valvular dysfunction.

Cardiovascular findings on cross-sectional imaging: spectrum of incidental and critical findings and clinical relevance for the abdominal radiologist

Although not the primary focus of the exams, cardiovascular structures are included to some extent on all abdominal or whole-body cross-sectional studies. Cardiovascular findings often present incidentally and may range from chronic to acute and emergent pathologies. Among the most common cardiovascular findings are the presence of cardiac calcifications, most commonly coronary, which correlate with the presence of coronary artery and valvular disease. Signs of myocardial ischemia, both acute and chronic, and its complications may also be visualized. Cardiac filling defects most commonly represent thrombus and are associated with systemic arterial embolic complications. Pericardial findings often manifest as effusion or thickening, which may lead to hemodynamic consequences visible at imaging. Incidental pulmonary emboli and systemic venous thrombi may be incidentally detected, particularly in hospitalized and oncologic patients, and warrant immediate attention. This review will highlight the appearance of common and important incidental cardiovascular findings and related pitfalls and discuss reporting and follow-up recommendations relevant to the abdominal radiologist.

Quantification of Aortic Valve Calcifications Detected During Lung Cancer-Screening CT Helps Stratify Subjects Necessitating Echocardiography for Aortic Stenosis Diagnosis

No study has been published on aortic valve calcification (AVC) extent at lung cancer screening low-dose CT (LDCT) and its relationship with aortic stenosis (AS). The purpose of this study was to estimate the cutoff value of AVC on LDCT for detecting AS in asymptomatic Asian subjects. Six thousand three hundred thirty-eight subjects (mean age, 55.9 years ± 8.6) self-referred to health-promotion center underwent LDCT, coronary calcium scoring CT (CSCT), and echocardiography. AVC was quantified using Agatston methods on CT. AVC extent on LDCT was compared with that on CSCT, and AVC threshold for diagnosing AS was calculated. Clinical factors associated with AS and AVC were sought.AVC was observed in 403 subjects (64.9 years ± 8.7) on LDCT (6.4%), and AVC score measured from LDCT showed strong positive correlation with that from CSCT (r = 0.83, P < 0.0001). Of 403 subjects, 40 (10%) were identified to have AS on echocardiography. Cutoff value of AVC score for detecting AS was 138.37 with sensitivity of 90.0% and specificity 83.2%. On multivariate analysis, age (odds ratio [OR] = 1.10, 95% CI: 1.09-1.12) and hypertension (OR = 1.39, 95% CI: 1.10-1.76) were associated with the presence of AVC, whereas AVC extent at LDCT (OR = 104.32, 95% CI: 16.16-673.70) was the only significant clinical factor associated with AS; AVC extent on LDCT (OR = 104.32, 95% CI: 16.16-673.70) was the significant clinical factor associated with AS.The AVC extent on LDCT is significantly related to the presence of AS, and we recommend echocardiography for screening AS based on quantified AVC values on LDCT.

Comparison of calcification potential of valvular interstitial cells isolated from individual aortic valve cusps

BACKGROUND

Calcific aortic valve disease (CAVD) is one of the most prevalent disorders among the elderly in developed countries. CAVD develops via cell-mediated processes, and clinical data show that CAVD initiates mostly in the noncoronary cusp of the aortic valve. Valvular interstitial cells (VICs) populate the inside of heart valves and are a heterogeneous cell population. The goal of this study is to elucidate the difference in calcification potential among VICs isolated from the left, right, and noncoronary cusps of porcine aortic valves.

METHODS AND RESULTS

VICs were isolated from each of the aortic valve cusps and cultured in calcifying medium for 14days to induce calcification. The samples were assessed for calcium deposits, nodule formation, and calcific markers using alizarin red and Von Kossa staining, alkaline phosphatase (ALP) staining, ALP enzyme activity assay, and Western blot. Extracellular matrix production and degradation were measured using collagen and glycosaminoglycan (GAG) assay and gelatin zymography. We observed that VICs isolated from the noncoronary cusp expressed greatest amount of the above calcific markers as compared to the coronary cusps. Also, collagen and GAG content was the greatest in noncoronary VICs. However, our zymography results showed significant difference only for active matrix metalloproteinase-2 expression between right and noncoronary VICs.

CONCLUSION

Our results suggest that VICs among the three cusps within aortic valve might be inherently different, where a subpopulation of VICs might be predisposed to calcification.

The prevalence, incidence, progression, and risks of aortic valve sclerosis: a systematic review and meta-analysis

OBJECTIVES

The aim of this study was to comprehensively review the epidemiology of aortic sclerosis (ASc) and its association with cardiovascular events.

BACKGROUND

ASc, which is defined as thickening or calcification of the aortic valve without significant obstruction of blood flow, is a common finding on cardiac imaging.

METHODS

We searched MEDLINE and EMBASE from inception to April 2013 for studies describing the epidemiology of ASc and performed a meta-analysis of the risk of adverse events using a random effects model.

RESULTS

Twenty-two studies were identified from the systematic review. The prevalence of ASc increased in proportion to the average age of study participants, ranging from 9% in a study in which the mean age was 54 years to 42% in a study in which the mean age was 81 years. In total, 1.8% to 1.9% of participants with ASc had progression to clinical aortic stenosis per year. There was a 68% increased risk of coronary events in subjects with ASc (hazard ratio [HR]: 1.68; 95% confidence interval [CI]: 1.31 to 2.15), a 27% increased risk of stroke (HR: 1.27; 95% CI: 1.01 to 1.60), a 69% increased risk of cardiovascular mortality (HR: 1.69; 95% CI: 1.32 to 2.15), and a 36% increased risk of all-cause mortality (HR: 1.36; 95% CI: 1.17 to 1.59).

CONCLUSIONS

ASc is a common finding that is more prevalent with older age. Despite low rates of progression to ASc, there is an independent increase in morbidity and mortality associated with the condition.

The role of computed tomography in pre-procedural planning of cardiovascular surgery and intervention

Advances in our knowledge of cardiovascular disorders coupled with technological innovations have enabled the increased use of minimally invasive cardiovascular surgeries and transcatheter interventions, with resultant reduced morbidity and hospital stay. Three-dimensional imaging, particularly computed tomography (CT) is increasingly used for patient selection, providing a roadmap of the anatomy and identifying factors that may complicate these procedures. Advantages of CT are the rapid turnaround time, good spatial and temporal resolutions, wide field of view and three-dimensional multi-planar reconstruction capabilities. This pictorial review describes the role of CT in the pre-operative evaluation of patients undergoing cardiovascular surgeries and intervention. Main Messages • CT scan is valuable in pre-operative evaluation for cardiac surgeries • Cardiovascular structures, including bypass grafts should be located >10 mm from the sternum in patients for reoperative cardiothoracic surgeries • Knowledge of variations in pulmonary venous anatomy are essential for planning radiofrequency ablation.

Pertinent reportable incidental cardiac findings on chest CT without electrocardiography gating: review of 268 consecutive cases

BACKGROUND

Pertinent reportable cardiac findings on non-electrocardiography (ECG)-gated chest CT examinations have become easier to detect given recent advancements in multidetector CT technology. However, those findings are easily overlooked on routine chest CT without ECG gating given residual inherent cardiac motion artifact and non-cardiac indications.

PURPOSE

To describe and quantify the types of pertinent reportable cardiac findings that can be detected on chest CT examinations without ECG gating and evaluate how often they were reported.

MATERIAL AND METHODS

Two radiologists retrospectively reviewed (blinded to the original interpretation) 268 consecutive routine adult chest CT examinations without ECG gating for the presence of pertinent reportable cardiac findings. Retrospective interpretations were then compared with the original radiological reports.

RESULTS

One hundred and sixty-three patients (61%) had pertinent reportable cardiac findings. The findings encountered included: coronary artery disease (n = 131; 80.0%), coronary artery bypass grafts (n = 10; 6.1%), left ventricular aneurysm (n = 1; 0.6%), valve calcification (n = 131; 80.0%), valve repair/replacement (n = 5; 3.1%), pericardial effusion (n = 33; 20.2%), left atrial appendage thrombus (n = 1; 0.6%), cardiac mass (n = 1; 0.6%), and cardiac chamber enlargement (n = 29; 17.8%). On the original radiological reports 22.3% of the pertinent reportable cardiac findings, detected by the two radiologists retrospectively, were not reported.

CONCLUSION

Detection of pertinent reportable cardiac findings on routine chest CT examinations without ECG gating is possible. The high volume of chest CT examinations without ECG gating represents an opportunity for radiologists to comment on the presence or absence of cardiac disease which may influence future clinical decisions.

Relationship between incidentally detected calcification of the mitral valve on 64-row multidetector computed tomography and mitral valve disease on echocardiography

Background

Mitral valve calcification is often incidentally detected on chest computed tomography (CT) scans obtained for a variety of noncardiac indications. In this study, we evaluated the association between mitral valve calcification incidentally detected on chest CT and the presence and severity of mitral valve disease on echocardiography.

Methods

Of 760 patients undergoing 64-row multidetector CT of the chest, 50 with mitral valve calcification and 100 controls were referred on for echocardiography. Calcifications of the mitral valve leaflet and annulus were assessed for length, Agatston score, and site, and were compared with echocardiographic findings.

Results

Mitral valve calcification was noted in 59 (7.7%) patients on multidetector CT. Fifty of these patients were assessed by echocardiography, and 32 (64%) were found to have mitral annular calcification. Nine patients (18%) had posterior mitral valve leaflet calcification, and both mitral valve leaflet and annular calcification were detected in nine (18%) cases. Nine (18%) patients had mild, three (6%) had moderate, and one (2%) had severe mitral stenosis. None of the patients with isolated mitral annular calcification had mitral stenosis; however, all the patients with mitral stenosis showed mitral valve leaflet calcification with or without mitral annular calcification (P < 0.001). Moreover, patients with mitral stenosis had a larger mitral calcification length and greater Agatston scores in comparison with those without mitral stenosis (P = 0.001). While 31 patients (62%) with mitral calcification had mitral regurgitation on echocardiography, 21 (21%) in the control group showed mitral regurgitation (P = 0.001).

Conclusion

Mitral valve leaflet calcification, with or without annular calcification, may be an indicator of mitral stenosis. Mitral calcification can also be considered as an indicator for mitral regurgitation in general. Therefore, patients with mitral valve calcification detected incidentally on chest CT scan may benefit from functional assessment of the valve using echocardiography.

Aortic valve calcification - a commonly observed but frequently ignored finding during CT scanning of the chest

AIM

To describe the frequency and severity of Aortic valve calcification (AVC) in an unselected cohort of patients undergoing chest CT scanning and to assess the frequency with which AVC was being reported in the radiology reports.

METHODS AND RESULTS

Consecutive CT scan images of the chest and the radiological reports (December 2009 to May 2010) were reviewed at the district general hospital (DGH). AVC on CT scan was visually graded on a scale ranging from 0 to IV (0 = no calcification, IV = severe calcification). Total of 416 (232 male; 184 female) CT chest scans [Contrast enhanced 302 (72%), unenhanced 114 (28%)] were reviewed. Mean age was 70.55 ± 11.48 years. AVC in CT scans was identified in 95 of the 416 patients (22.83%). AVC classification was as follows: Grade I: 60 (63.15%), Grade II: 22 (23.15%), Grade III: 9 (9.47%), Grade IV: 4 (4.21%). Only one CT report mentioned AVC. Only 31 of 95 AVC had Transthoracic echocardiogram (TTE). The interval time between CT scan and TTE was variable.

CONCLUSION

  Aortic valve calcification in CT chest scans is a common finding and studies have shown that it is strongly related to the presence and severity of aortic valve disease. As CT scans are considered as a valuable additional screening tool for detection of aortic stenosis, AVC should always be commented upon in the radiology reports. Furthermore, patients with at least Grade III and IV AVC should be sent for TTE.

[Prevalence and clinical significance of incidental cardiac findings in non-ECG-gated chest CT scans]

BACKGROUND

The purpose of this study was to evaluate the prevalence and clinical significance of incidental cardiac findings in non-ECG-gated chest CT.

PATIENTS AND METHODS

Non-ECG-gated chest CT examinations of 300 patients were retrospectively analyzed for incidental cardiac findings. Subsequently, these findings were evaluated for their clinical relevance by a cardiologist.

RESULTS

A total of 107 out of 300 examined patients had 174 incidental cardiac findings including coronary calcification (90), aortic/mitral valve calcification (42), iatrogenic changes (23), pericardial effusion (6), dilatation of the heart (4), myocardial changes (3), thrombus in the left ventricle (2), constrictive pericarditis (2) and atrial myxoma (1). Of the cardiac findings 51% were described in the written report and in 53 out of the 107 patients the cardiac findings were unknown. Newly detected incidental findings from 8 patients were rated as clinically significant: pericardial effusion (4), constrictive pericarditis (1), thrombus in the left ventricle (1), atrial myxoma (1) and dilatation of the heart (1).

CONCLUSION

Incidental cardiac findings are frequent in non-ECG-gated chest CT and may have a high clinical relevance.

Relation of aortic valve weight to severity of aortic stenosis

The purpose of this study was to analyze the relation of aortic valve weight to transvalvular gradient and area, with special regard to valve anatomy, size of calcific deposits, gender, and body size. Two hundred forty-two surgically excised stenotic aortic valves of patients (139 men, mean age 72 ± 9 years) who had undergone preoperative cardiac catheterization and echocardiography were weighed and examined with respect to number of cusps (tricuspid vs bicuspid), size of calcium deposits (microaggregates vs nodular macroaggregates), and presence of cholesterol clefts. The relation among valve weight, gradient, and area was studied. Transvalvular gradient was independent of gender or valve anatomy and was linearly correlated with valve weight absolutely (r = 0.33, p <0.01) or normalized by body surface area (r = 0.40, p <0.01). No correlation was evident between valve area and weight. Calcium macroaggregates were mainly present in men (51%) and in bicuspid valves (67%) and were seen to be strong determinants of valve weight (2.84 ± 1.03 g with macroaggregates vs 1.63 ± 0.56 g with microaggregates, p <0.001) but not of transvalvular gradient. Calcium microaggregates characterized tricuspid valves (62%), where transvalvular gradient was determined by valve weight (p = 0.0026). In conclusion, the heavier the valve, the less frequent were hypercholesterolemia, valve cholesterol clefts, hypertension, and diabetes mellitus.

Evaluation of cardiac valves using multidetector CT

Cardiac CT is an accurate and reasonable alternative modality for valvular imaging. It is used primarily for the evaluation of coronary artery disease; however, important information regarding valvular anatomy and function can be derived from CT. Calcification is a common CT finding in various valvular abnormalities and carries important diagnostic and prognostic value. In addition, valvular morphology, stenosis, and regurgitation also are detected on contrast enhanced scans, with good correlation with trans-thoracic echocardiography and other techniques.

Cardiac magnetic resonance imaging findings are useful for differentiating between hypertrophic obstructive cardiomyopathy and aortic valve stenosis in elderly patients

OBJECTIVE

The objective of this study was to assess whether cardiac magnetic resonance (MR) imaging is useful for differentiating between hypertrophic obstructive cardiomyopathy (HOCM) and aortic valve stenosis (AS) in 21 elderly patients (>75 years old).

METHODS

Cine and delayed contrast-enhanced cardiac MR imaging was performed and used to assess the regional wall thickness, myocardial mass, mitral valve motion, and myocardial hyperenhancement in elderly patients with HOCM and AS.

RESULTS

The basal anterior septal and midventricular inferior septal walls were significantly thicker, the ejection fraction was higher, and the ratio between the basal and midventricular inferior wall thicknesses was lower in patients with HOCM than those in patients with AS. Apical wall thinning and abnormal mitral valve motion were detected in patients with HOCM.

CONCLUSIONS

Structural and functional parameters that are characteristic of HOCM can be assessed in cardiac MR imaging, and these parameters may be useful for differentiating between HOCM and AS in elderly patients.

Aortic stenosis: evaluation with multidetector CT angiography and MR imaging

Aortic valvular stenosis (AS) is the most common valve disease which results in the need for a valve replacement. Although a Doppler echocardiography is the current reference imaging method, the multidetector computerized tomograpghy (MDCT) and magnetic resonance imaging (MRI) have recently emerged as a promising method for noninvasive valve imaging. In this study, we briefly describe the usefulness and comparative merits of the MDCT and MRI for the evaluation of AS in terms of valvular morphology (as the causes of AS), quantification of aortic valve area, pressure gradient of flow (for assessment severity of AS), and the evaluation of the ascending aorta and cardiac function (as the secondary effects of AS). The familiarity with the MDCT and MRI features of AS is considered to be helpful for the accurate diagnosis and proper management of patients with a poor acoustic window.

MDCT Detection of Mitral Valve Calcification: Prevalence and Clinical Relevance Compared with Echocardiography

OBJECTIVE

The purpose of this study was to analyze the prevalence and clinical significance of mitral valve calcification incidentally detected on chest CT scans in comparison with echocardiography.

MATERIALS AND METHODS

The data of 390 patients (227 men and 163 women; mean age, 62.4 +/- 12.2 years) who underwent MDCT of the chest and echocardiography were retrospectively evaluated. On MDCT, mitral valve leaflet and annulus calcification were visually graded on a scale of 0-3, with grade 0 denoting no calcification and grade 3 indicating severe calcification. CT findings were correlated with hemodynamic data obtained at echocardiography. Unpaired Student's t tests, chi-square analysis, and a weighted-kappa test were used to compare results.

RESULTS

In 32 (8.2%) of 390 patients, chest MDCT revealed mitral valve leaflet calcification. Fifteen of these patients (15/390, 3.8%) presented with mitral valve stenosis. Excellent agreement (kappa = 0.882) was seen between the presence of mitral valve calcification on MDCT and echocardiographically proven mitral valve sclerosis. Mitral valve leaflet calcification on MDCT and the severity of mitral valve disease on echocardiography showed a substantial agreement (kappa = 0.730). A significant relationship was seen between the degree of mitral valve calcification on MDCT and the echocardiographically determined severity of mitral valve disease (no sclerosis vs mitral sclerosis vs mitral stenosis; p < 0.0001).

CONCLUSION

Mitral valve leaflet calcification on MDCT indicates mitral valve sclerosis or stenosis. Thus, patients presenting with incidentally detected mitral valve leaflet calcification on chest CT may benefit from a functional assessment with echocardiography.

Cardiac Valve Assessment with MR Imaging and 64-Section Multi–Detector Row CT

A variety of noninvasive techniques are available to assess cardiac valve morphologic features and function, with echocardiography currently being the most widely used modality for this purpose. Technical advances in electrocardiographically gated multi-detector row computed tomography (CT) and magnetic resonance (MR) imaging allow the noninvasive visualization of the cardiac valves. At present, 64-section multi-detector row CT and MR imaging are commonly being used for comprehensive examination of the heart. Information about the cardiac valves is routinely provided by MR imaging of cardiac function or coronary CT angiography. Thus, the interpreting physician may have additional information available that can aid in making the diagnosis. Supplemental movie clips are available at http://radiographics.rsnajnls.org/cgi/content/full/26/6/1769/DC1.