What is the significance of moderate aortic valve leaflet calcification on echocardiogram (echo)?

From the Guidelines

Moderate aortic valve leaflet calcification on echocardiogram is a significant finding that requires regular monitoring and management of cardiovascular risk factors to prevent progression to severe aortic stenosis.

Key Considerations

• The degree of aortic valve calcification is a strong predictor of clinical outcome, even when evaluated qualitatively by echocardiography 1.
• Patients with moderate aortic valve leaflet calcification should undergo follow-up echocardiograms every 1-2 years to track progression, with more frequent monitoring if symptoms develop.
• Controlling cardiovascular risk factors is essential, including maintaining blood pressure below 130/80 mmHg with medications like ACE inhibitors or ARBs if needed, achieving optimal lipid levels (LDL <70 mg/dL) with statins such as atorvastatin 20-40 mg daily, and managing diabetes with a target HbA1c <7% 1.
• Lifestyle modifications including regular exercise, smoking cessation, weight management, and a heart-healthy diet are crucial.
• Patients should be educated about symptoms requiring prompt evaluation, including chest pain, shortness of breath, dizziness, or fainting.

Management and Monitoring

• The key measurements for clinical decision-making in patients with aortic stenosis are the maximum aortic velocity, mean pressure gradient, and valve area 1.
• Dobutamine stress echocardiography may be useful in patients with severe AS and LV systolic dysfunction to distinguish between true severe AS and pseudo-severe AS 1.
• TAVR is a recommended treatment option for patients with severe, symptomatic, calcific stenosis of a trileaflet aortic valve who have aortic and vascular anatomy suitable for TAVR and a predicted survival of 12 months 1.

Important Considerations for TAVR

• Accurate sizing of the aortic annulus is critical to TAVR procedural success, and undersizing or oversizing the prosthesis can result in complications 1.
• TEE is recommended prior to TAVR if there are any concerns about the assessment of the aortic root anatomy, aortic annular size, or number of cusps 1.
• The presence of haemodynamically significant LVOT obstruction due to basal septal hypertrophy represents a contraindication to TAVR, and the presence of an LV thrombus must be excluded 1.

From the Research

Aortic Valve Leaflet Calcification on Echo

• Aortic valve leaflet calcification is a condition where calcium deposits form on the aortic valve leaflets, which can lead to aortic stenosis 2, 3, 4, 5, 6.
• The severity of aortic valve calcification can be assessed using echocardiography, which can help identify patients with moderate or severe calcification 3, 5, 6.
• Studies have shown that the number of calcified aortic valve leaflets is associated with an increased risk of developing aortic stenosis and mortality 3.
• The pathophysiological mechanism of valvular calcification is not fully understood, but it is thought to involve osteogenic transformation of valvular interstitial cells mediated by local and systemic inflammatory processes 2, 4.
• Certain factors, such as aging, bicuspid aortic valve, and chronic kidney disease, are associated with an increased risk of developing calcific aortic valve disease 2, 3, 4.

Diagnosis and Prognosis

• Echocardiography is a useful tool for assessing aortic valve calcification and predicting outcomes in patients with aortic stenosis 3, 5, 6.
• The severity of aortic valve calcification can be graded using a visual score, which can help predict the risk of major cardiovascular events and mortality 5.
• Sex differences in risk factors for aortic valve calcification have been reported, with men having a higher prevalence of moderate or severe calcification than women 5.
• A novel grading classification of anatomic aortic stenosis severity based on sex-specific thresholds of aortic valve calcification has been proposed, which can provide significant prognostic value for predicting mortality 6.

Management and Treatment

• Guideline-directed medical therapy for heart failure with reduced ejection fraction may be initiated in patients with moderate aortic stenosis and left ventricular dysfunction, but surgical aortic valve replacement may be considered in selected patients 2.
• The use of denosumab, a human monoclonal antibody targeting the receptor activator of nuclear factor-κB ligand, has been shown to inhibit induced calcium deposition in an in vitro model of aortic valve interstitial cells 4.