Clin Res Cardiol (2022). https://doi.org/10.1007/s00392-022-02002-5
Characterization of left ventricular outflow tract calcification patterns and its impact on outcome in patients undergoing transfemoral transcatheter aortic valve implantation
L. Waldschmidt1, A. Goßling1, S. Ludwig2, M. Linder3, L. Voigtländer1, O. Bhadra4, T. J. Demal4, H. Reichenspurner4, S. Blankenberg5, D. Westermann1, J. Schirmer4, L. Conradi4, M. Seiffert3, A. Schäfer4, N. Schofer1, für die Studiengruppe: HARbOR
1Allgemeine und Interventionelle Kardiologie, Universitäres Herz- und Gefäßzentrum Hamburg GmbH, Hamburg; 2Klinik für Kardiologie, Universitäres Herz- und Gefäßzentrum Hamburg GmbH, Hamburg; 3Klinik und Poliklinik für Kardiologie, Universitäres Herz- und Gefäßzentrum Hamburg GmbH, Hamburg; 4Klinik und Poliklinik für Herz- und Gefäßchirurgie, Universitäres Herz- und Gefäßzentrum Hamburg GmbH, Hamburg; 5Klinik für Kardiologie, Universitäres Herz- und Gefäßzentrum UKE Hamburg GmbH, Hamburg;

OBJECTIVES

This retrospective analysis aimed to systematically characterize left ventricular outflow tract (LVOT) calcification patterns and assess its impact on outcome in patients undergoing transcatheter aortic valve implantation (TAVI) with severe aortic stenosis.

 

BACKGROUND

LVOT calcification is associated with adverse outcome after TAVI. However, it remains unclear whether certain LVOT calcification patterns have more impact on adverse outcome than others.

 

METHODS

In this retrospective single-center analysis 1207 patients, who underwent transfemoral TAVI and provided adequate contrast-enhanced MSCT imaging were included, among these 226 (18.7%) patients with high LVOT calcium volume were identified, defined as >40mm3 calcium volume. LVOT calcification patterns were characterized quantitively by calculating calcium volume (mm3) according to its location as well as qualitatively by assessing calcium morphology, i.e. number and length of nodules, intraluminal protrusion and circumferential LVOT covering. Primary outcome was defined as VARC3 Device success and secondary outcome as paravalvular leak (PVL) at discharge.

 

RESULTS

Patients with high volume calcification in the LVOT were 81.9 (78.4, 85.3) years old, 51% male with mean STS-PROM 4.9 ± 3.3. Total calcium volume in the LVOT was high in these patients (76.3 (47.1, 129.3) mm3). The highest calcium burden was present below the left coronary cusp (32.0 (2.9, 75.4) mm3) followed by the non-coronary cusp (20.6 (0, 57.2) mm3) and right coronary cusp (0 (0, 8.2) mm3), respectively. In these patients, mean length of calcium in the LVOT was 6.6 (4.3, 9.2) mm, mean width 5.4 (4.3, 7.5) mm with mean intraluminal protrusion of 2.6 (2.0, 3.5) mm and circumferential calcium coffering the LVOT of 9.0 (6.6, 13.5) %. Patients were treated with either self-expandable (50.9%), balloon-expandable (27.4%) or mechanically expandable (21.7%) THVs. At 30 days, patients without VARC-3 “Device success” and >mild PVL had higher calcium volume in the total LVOT, with a significantly higher calcium volume below the non-coronary cusp (see Table 1). In contrast, no association was found between certain calcium morphologies and adverse outcome in terms of device success or PVL.

 

CONCLUSION

Among patients with high calcium burden in the LVOT the sole amount and location of LVOT calcium volume rather than certain calcium morphologies seem to be associated with poor clinical and functional outcome after TAVI. To further optimize treatment strategies in patients with relevant LVOT calcification, these results should be validated in larger observational studies.

 

Table 1: Association of device success/PVL and location of calcium in the LVOT

VARC3 Device Success

 

 

 

 

Success (n= 153)

No Success (n= 63)

P value

Calcium amount in the LVOT (mm3)

70.90 (45.20, 129.20)

88.00 (61.15, 133.85)

0.07

Calcium amount under NCC (mm3)

15.80 (0, 50.50)

44.30 (7.65, 66.30)

0.01

Calcium amount under LCC (mm3)

33.50 (4.20, 71.70)

23.60 (1.25, 77.60)

0.78

Calcium amount under RCC (mm3)

0 (0, 4.70)

0 (0, 9.80)

0.29

More than mild PVL

 

 

 

 

None/mild PVL (n= 192)

> mild PVL (n= 16)

P value

Calcium amount in the LVOT (mm3)

75.95 (46.33, 126.95)

95.80 (69.45, 142.25)

0.06

Calcium amount below NCC (mm3)

17.35 (0, 54.55)

51.85 (38.50, 71.95)

<0.01

Calcium amount below LCC (mm3)

34.55 (3.38, 71.95)

26.30 (0.88, 93.72)

0.96

Calcium amount below RCC (mm3)

0 (0, 6.70)

0.25 (0, 30.88)

0.41

 
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