Aortic Valve Calcium Score Spectrum and Outcomes After Transcatheter Aortic Valve Implantation

Aortic Valve Calcium Score Spectrum and Transcatheter Outcomes: A Pragmatic View from AMTRAC

• This work analyzes the AMTRAC registry, a retrospective cohort spanning 2013–2024 across 16 centers, primarily in Europe, comprising 3,766 patients with severe aortic stenosis treated with transcatheter aortic valve implantation.
• Patients were stratified into three groups by aortic valve calcium score (AVCS): low, high, and very high.
• The primary endpoint was mortality at 3 years; secondary endpoints included periprocedural outcomes (Valve Academic Research Consortium-3 criteria) and post-implant hemodynamics.

• The cohort represents a spectrum of AVCS in severe aortic stenosis, with additional description noting that those with low AVCS more often presented with low-gradient disease and more advanced heart failure symptoms (New York Heart Association class).

• Mortality over 3 years displayed a bimodal pattern across the AVCS spectrum: 30.5% in the low AVCS group, 26.5% in the high AVCS group, and 31.3% in the very-high AVCS group, indicating no linear relationship between AVCS and 3-year mortality.
• Paravalvular leak of greater than moderate severity rose with AVCS severity: very-high AVCS patients showed higher rates compared with low AVCS patients (0.5% in low, 0.9% in high, 1.9% in very-high; P<0.01).
• Stroke and permanent pacemaker implantation risks were elevated in the very-high AVCS group relative to the other groups (stroke: very-high 4.1%, low 1.4%, high 2.4%; pacemaker: very-high 21.2%, low 14.7%, high 14.2%; P<0.05 for both).

• A low AVCS phenotype is characterized by predominant myocardial fibrosis, more advanced symptomatology, and higher observed mortality despite fewer procedural complications.
• A very-high AVCS phenotype associates with greater procedural risk, higher prevalence of bicuspid valve anatomy, and increased mortality risk.
• The findings question reliance on calcification alone as a determinant for treatment planning and underscore a potential role for fibrosis assessment in guiding strategy.

• The analysis is retrospective and registry-based, with inherent observational limitations.