Letter to the editor Aortic valve calcium score is a significant predictor for the occurrence of post-interventional paravalvular leakage after transcatheter aortic valve implantation — Results from a single center analysis of 260 consecutive patients Jovana Pavicevic a , Thi Dan Linh Nguyen b , Etem Caliskan a , Diana Reser a , Thomas Frauenfelder b , André Plass a , Barbara E. Stähli c , Willibald Maier c , Burkhardt Seifert d , Francesco Maisano a , Volkmar Falk a , Roberto Corti c , Jürg Grünenfelder a , Maximilian Y. Emmert a, ⁎ a Clinic for Cardiovascular Surgery, University Hospital Zürich, Zürich, Switzerland b Institute of Diagnostic and Interventional Radiology, University Hospital Zürich, Zürich, Switzerland c Clinic for Cardiology, University Hospital Zürich, Zürich, Switzerland d Division of Biostatistics, Institute for Social and Preventive Medicine, University of Zürich, Zürich, Switzerland article info Article history: Received 29 November 2014 Accepted 2 December 2014 Available online 3 December 2014 Keywords: Aortic valve Transcatheter aortic valve replacement Paravalvular leak Calcium score Post-interventional paravalvular leakage (PVL) still represents a major problem after transcatheter aortic-valve implantation (TAVI) and has been recently shown to be associated with increased mortality and morbidity [1]. It occurs in 65%–85% of treated patients with the ma- jority being trivial to mild, up to 26% being moderate, and up to 10% being severe [2–4]. The main reasons for the occurrence of PVL comprise heavily calcified cusps, prosthesis malpositioning, and/or annulus- prosthesis size mismatch [5]. Thus, adequate patient selection and imaging-guided preoperative anatomical assessment of the aortic-root are mandatory. Multi-slice computed-tomography (MSCT) plays an im- portant role for preoperative patient screening. It allows for detailed anatomic-assessment and importantly, it also allows for accurate detec- tion, localization and quantification of aortic-valve calcification. In this study, using standardized preoperative MSCT, we evaluate the impact of aortic-valve calcification and its distribution on the occurrence of post-procedural PVL. From 2008–2012 369 pts underwent TAVI. Of these, 260 pts had a preoperative MSCT and were included in this study. Informed consent was obtained from each patient and the study protocol conformed to the ethical guidelines of the 1975 Declaration of Helsinki as reflected in a priori approval by the institution's human research committee. To evaluate the calcification of the aortic-valve a scoring analogous to the Agatston calcium scoring of coronary-arteries [aortic-valve calcium scoring (AVCS)] was used. Severity of aortic-valve regurgitation was graded according to the ACC/AHA guidelines [6]. Paravalvular leaks were assessed intra-operatively by transoesophageal echocardiogra- phy and aortic-root angiography. All examinations were performed using a second-generation, 128-slice dualsource computed-tomography (DSCT) system (Somatom Definition Flash, Siemens Healthcare, Forchheim, Germany). Based on post-procedural transesophageal echo- cardiography the PVL was divided into 4 grades of none (0), minimal (1), mild (2) or moderate (3) grade. For further details and statistics please see Supplementary file. TAVI was successfully performed in 254 patients (97.7%) either using a CoreValve-Medtronic (n = 144), Edwards-SAPIEN (n = 111), Symetis-Acurate (n = 1) or Medtronic-Engager prosthesis (n = 4). Baseline characteristics are summarized in Table 1. Major intraoperative complications occurred in six patients. Overall in-hospital mortality was 7.5% (n = 19) and MACCE (major adverse cardiac and cerebrovascular events) occurred in 11.4% (n = 29) of all cases (Suppl. Table 1). A new pacemaker implantation was necessary in 22.4% (n = 57) of patients and the mean hospital length of stay was 11.3 ± 8.3 days. PVL occurred in 195 pts including 105 pts with grade-1, 78 pts with grade-2, and 12 pts with grade-3 (Suppl. Table 2). AVCS significantly in- creased with the degree of post-interventional PVL (Grades 0–1; 550.4 ± 377.2 mg, n = 164), Grade 2 (755.6 ± 470.6 mg; n = 78; p b 0.001) and Grade 3 (825 ± 460.8 mg, n = 12; p = 0.04) (Fig. 1 and Suppl. Fig. 1). AVCS was compared for the entire valve, leaflets and com- missures. In detail, a significant difference with regard to the degree of calcification and its distribution was found between the right and non-coronary leaflet (173.3 ± 149.3 mg vs. 263.2 ± 220.7 mg; p b 0.001) and the left and non-coronary leaflet (203.2 ± 207.9 mg vs. 263.2 ± 220.7 mg; p = 0.002). However, there was no significant International Journal of Cardiology 181 (2015) 185–187 ⁎ Corresponding author at: Clinic for Cardiovascular Surgery, University Hospital Zürich, Zürich, Switzerland, Raemistrasse 100, 8091 CH-Zürich, Switzerland. E-mail address: maximilian.emmert@usz.ch (M.Y. Emmert). http://dx.doi.org/10.1016/j.ijcard.2014.12.032 0167-5273/© 2014 Elsevier Ireland Ltd. 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