Diagnostic role of aortic valve calcium scoring in aortic stenosis according to etiology

Purpose

To evaluate the diagnostic accuracy of aortic valve calcium scoring (AVC) in aortic stenosis of various etiologies.

Methods

This is a cross sectional study conducted in University Hospital Center "Mother Teresa" from January 2024 to October 2025. A total of 200 patients were included in this study. All patients had a comprehensive echocardiographic exam. The echocardiograms were analyzed by two independent cardiologists. If the results were discordant a third cardiologist would make a decision for identifying etiology and severity of aortic stenosis. All patients were scanned using a third generation dual source CT scanner. Aortic valve calcium scoring and coronary calcium scoring were determined 2-dimensionally by using Calcium score data set in the Syngovia work station and defined by Agatston Unit (AU). The CT scan results were interpreted by two different experienced cardiologists including aortic calcification, coronary calcium score value and patterns of calcification in various etiologies of aortic stenosis.

Results

A total of 200 patients were included in this study. There were 98 males and 102 females. Among these patients, there were 61 patients (30.5 %) with mild stenosis, 51 (25.5 %) with moderate stenosis and 88 (44.0 %) with severe aortic stenosis. In total there were 154 patients (77.0%) with degenerative AS, 16 (8.0%) with bicuspid AS and 30 (15.0%) with rheumatic AS as shown in Table 1. The computed tomography data of calcium score and pattern of calcium distribution is shown in Table 2.

The ROC curves were constructed to identify severe aortic stenosis for each etiology and gender. The AVC score had significant diagnostic accuracy in all groups according to etiology, with the area under the curve (AUC) as following: 0.879 (95% CI, 0.820, 0.930) for all, 0.913 (95% CI, 0.840, 0.968) for male, and 0.854 (95% CI, 0.757, 0.932) for female in degenerative group; 0.984 (95% CI, 0.906, 1.000) for all, and 0.980 (95% CI, 0.878, 1.000) for male in bicuspid group; 0.848 (95% CI, 0.671, 1.000) for all in rheumatic group. Whereas the rheumatic group had the lowest AUC 0.758 (95% CI, 0.500, 0.980) for female.

The best cutoff values to identify severe aortic stenosis in various etiologies were AVC > 1903.8 AU in male and > 2174.5 AU in female for degenerative group, AVC > 3028.5 AU in male for bicuspid group.

Conclusion

Calcium scoring of the aortic valve demonstrates high diagnostic accuracy for identifying severe aortic stenosis, providing a reliable, quantitative marker of disease severity. Moreover, the calcium distribution pattern offers valuable insight into the underlying etiology—distinguishing degenerative, bicuspid, and rheumatic mechanisms. Therefore, aortic valve calcium scoring represents a powerful and reproducible imaging tool for both diagnosis and etiologic characterization of aortic stenosis.Etiology of Aortic Valve StenosisFor image description, please refer to the figure legend and surrounding text.Calcium distributionFor image description, please refer to the figure legend and surrounding text.