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Background: Patients with aortic stenosis (AS) are susceptible to myocardial ischemia and often present acutely, making it challenging to differentiate between a type 1 NSTEMI and acute decompensated aortic stenosis. This study aims to evaluate the diagnostic accuracy of Troponin T (TnT) (>5 fold above the upper limit of normal), ischemic ECG and angina, to predict a type 1 non-ST elevation myocardial infarction (NSTEMI) and obstructive coronary artery disease (CAD) among patients with severe AS and acute presentations., Methods: Patients with severe AS and acute symptoms: angina (Canadian Cardiovascular Society Class 3/4), dyspnea (New York Heart Association 4) and/or syncope were included. The endpoints were a type 1 NSTEMI defined by the presence of a coronary thrombus or > 90% stenosis and obstructive CAD defined as >70% stenosis, by computed tomography (CT) and/or invasive coronary angiography (ICA)., Results: Out of 273 patients, 6.2% had a type 1 NSTEMI. Positive TnT, ischemic ECG and angina demonstrated negative predictive values of 95%, 94% and 97% respectively and positive predictive values of 12%, 9% and 13% respectively. Specificity increased with all three metrics (95%), whilst sensitivity and positive predictive value reduced (18% and 19% respectively). 39.2% of patients had obstructive CAD. Positive TnT, ischemic ECG and angina demonstrated sensitivity of 64%, 34% and 41% respectively and specificity of 57%, 77% and 77% respectively., Conclusions: Angina, ischemic ECG and positive TnT are common among patients with AS presenting acutely and often not associated with a type 1 NSTEMI. These metrics, if positive, cannot reliably differentiate between a type 1 NSTEMI and acute decompensated AS. Coronary imaging using either CT or ICA is necessary to make a definitive diagnosis of a type 1 NSTEMI in patients with severe AS., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Kush Patel reports financial support was provided by Edwards Lifesciences Corp. Kush Patel reports financial support was provided by British Heart Foundation. Francesca Pugliese reports financial support was provided by Siemens Healthineers. Michael Mullen reports financial support was provided by Edwards Lifesciences Corp. Michael Mullen reports financial support was provided by Abbott Vascular. Andreas Baumbach reports financial support was provided by Abbott Vascular. Andreas Baumbach reports financial support was provided by Astra Zeneca. Andreas Baumbach reports financial support was provided by Sinomed. Andreas Baumbach reports financial support was provided by Microport. Andreas Baumbach reports financial support was provided by Cardinal Health. Andreas Baumbach reports financial support was provided by KSH., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Aortic stenosis (AS) and coronary artery disease (CAD) frequently coexist, with up to two thirds of patients with AS having significant CAD. Given the challenges when both disease states are present, these patients require a tailored approach diagnostically and therapeutically. In this review the authors address the impact of AS and aortic valve replacement (AVR) on coronary hemodynamic status and discuss the assessment of CAD and the role of revascularization in patients with concomitant AS and CAD. Remodeling in AS increases the susceptibility of myocardial ischemia, which can be compounded by concomitant CAD. AVR can improve coronary hemodynamic status and reduce ischemia. Assessment of the significance of coexisting CAD can be done using noninvasive and invasive metrics. Revascularization in patients undergoing AVR can benefit certain patients in whom CAD is either prognostically or symptomatically important. Identifying this cohort of patients is challenging and as yet incomplete. Patients with dual pathology present a diagnostic and therapeutic challenge; both AS and CAD affect coronary hemodynamic status, they provoke similar symptoms, and their respective treatments can have an impact on both diseases. Decisions regarding coronary revascularization should be based on understanding this complex relationship, using appropriate coronary assessment and consensus within a multidisciplinary team., Competing Interests: Funding Support and Author Disclosures Dr Patel is supported by a clinical research training fellowship from the British Heart Foundation (FS/19/48/34523) and an unrestricted research grant from Edwards Lifesciences. Dr Treibel is directly and indirectly supported by the University College London Hospital and Barts National Institute for Health Research Biomedical Research Units. Dr Mullen has received grants and personal fees from Edwards Lifesciences; and has received personal fees from Abbott Vascular. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2021 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Objectives: The purpose of this study was to validate computed tomography measured ECV (ECV CT ) as part of routine evaluation for the detection of cardiac amyloid in patients with aortic stenosis (AS)-amyloid., Background: AS-amyloid affects 1 in 7 elderly patients referred for transcatheter aortic valve replacement (TAVR). Bone scintigraphy with exclusion of a plasma cell dyscrasia can diagnose transthyretin-related cardiac amyloid noninvasively, for which novel treatments are emerging. Amyloid interstitial expansion increases the myocardial extracellular volume (ECV)., Methods: Patients with severe AS underwent bone scintigraphy (Perugini grade 0, negative; Perugini grades 1 to 3, increasingly positive) and routine TAVR evaluation CT imaging with ECV CT using 3- and 5-min post-contrast acquisitions. Twenty non-AS control patients also had ECV CT performed using the 5-min post-contrast acquisition., Results: A total of 109 patients (43% male; mean age 86 ± 5 years) with severe AS and 20 control subjects were recruited. Sixteen (15%) had AS-amyloid on bone scintigraphy (grade 1, n = 5; grade 2, n = 11). ECV CT was 32 ± 3%, 34 ± 4%, and 43 ± 6% in Perugini grades 0, 1, and 2, respectively (p < 0.001 for trend) with control subjects lower than lone AS (28 ± 2%; p < 0.001). ECV CT accuracy for AS-amyloid detection versus lone AS was 0.87 (0.95 for 99m Tc-3,3-diphosphono-1,2-propanodicarboxylic acid Perugini grade 2 only), outperforming conventional electrocardiogram and echocardiography parameters. One composite parameter, the voltage/mass ratio, had utility (similar AUC of 0.87 for any cardiac amyloid detection), although in one-third of patients, this could not be calculated due to bundle branch block or ventricular paced rhythm., Conclusions: ECV CT during routine CT TAVR evaluation can reliably detect AS-amyloid, and the measured ECV CT tracks the degree of infiltration. Another measure of interstitial expansion, the voltage/mass ratio, also performed well., (Copyright © 2020 The Authors. Published by Elsevier Inc. All rights reserved.)

Objectives: To assess whether single-photon emission computed tomography (SPECT/CT) quantification of bone scintigraphy would improve diagnostic accuracy and offer a means of quantifying amyloid burden., Background: Transthyretin-related cardiac amyloidosis is common and can be diagnosed noninvasively using bone scintigraphy; interpretation, however, relies on planar images. SPECT/CT imaging offers 3-dimensional visualization., Methods: This was a single-center, retrospective analysis of 99m Tc-3,3-diphosphono-1,2-propanodicarboxylic acid (DPD) scans reported using the Perugini grading system (0 = negative; 1 to 3 = increasingly positive). Conventional planar quantification techniques (heart/contralateral lung, and heart/whole-body retention ratios) were performed. Heart, adjacent vertebra, paraspinal muscle and liver peak standardized uptake values (SUV peak ) were recorded from SPECT/CT acquisitions. An SUV retention index was also calculated: (cardiac SUV peak /vertebral SUV peak ) × paraspinal muscle SUV peak . In a subgroup of patients, SPECT/CT quantification was compared with myocardial extracellular volume quantification by CT imaging (ECV CT )., Results: A total of 100 DPD scans were analyzed (patient age 84 ± 9 years; 52% male): 40 were Perugini grade 0, 12 were grade 1, 41 were grade 2, and 7 were grade 3. Cardiac SUV peak increased from grade 0 to grade 2; however, it plateaued between grades 2 and 3 (p < 0.001). Paraspinal muscle SUV peak increased with grade (p < 0.001), whereas vertebral SUV peak decreased (p < 0.001). The composite parameter of SUV retention index overcame the plateauing of the cardiac SUV peak and increased across all grades (p < 0.001). Cardiac SUV peak correlated well (r 2  = 0.73; p < 0.001) with ECV CT . Both the cardiac SUV peak and SUV retention index had excellent diagnostic accuracy (area under the curve [AUC]: 0.999). The heart to contralateral lung ratio performed the best of the planar quantification techniques (AUC: 0.987)., Conclusions: SPECT/CT quantification in DPD scintigraphy is possible and outperforms planar quantification techniques. Differentiation of Perugini grade 2 or 3 is confounded by soft tissue uptake, which can be overcome by a composite SUV retention index. This index can help in the diagnosis of cardiac amyloidosis and may offer a means of monitoring response to therapy., (Copyright © 2020 The Authors. Published by Elsevier Inc. All rights reserved.)

Objectives: We sought to determine the impact of aortic root calcium on the risk of significant paravalvular regurgitation (sPAR) in transcatheter aortic valve replacement (TAVR)., Methods: In 302 consecutive patients from 3 centers, aortic root calcium was quantified volumetrically on pre-TAVR multidetector computed tomography (MDCT) in three regions: 1) the aortic valve region, 2) the overall left ventricular outflow tract (LVOT) and 3) the upper LVOT. Transcathether heart valve (THV) oversizing was calculated as (THV nominal area/MDCT annular area-1) × 100. The study endpoint sPAR was a composite of post-dilatation (PD) and PAR > mild., Results: sPAR occurred in 15% (46/302) of patients. Upper LVOT calcium volume was more predictive of sPAR than overall LVOT calcium volume, with an area under the receiver operating curve (AUC) (95% confidence interval [CI]) of 0.80 (0.67-0.89) vs. 0.60 (0.51-0.70); p = 0.0001. The optimal cut-off calcium volume thresholds determined from receiver operating curves were 21 mm 3 and 30 mm 3 for upper LVOT and overall LVOT calcium, respectively. Upper LVOT calcium ≥ 21 mm 3 , but not overall LVOT calcium ≥ 30 mm 3 , independently predicted sPAR, odds ratio (95%CI): 9.5 (4.1-22.3) vs 1.6 (0.6-2.7). Upper LVOT calcium was more predictive of sPAR in patients with THV oversizing ≥ 13% compared to patients with THV oversizing <13%, AUC (95% CI): 0.83 (0.72-0.93) vs. 0.67 (0.51-0.74); p < 0.0001., Conclusions: Upper LVOT calcium predicts more-than-mild paravalvular regurgitation following TAVR or the need for postdilatation. Upper LVOT calcium is most predictive of paravalvular regurgitation in the event of THV oversizing ≥ 13%., (Copyright © 2018 Society of Cardiovascular Computed Tomography. Published by Elsevier Inc. All rights reserved.)

Background: Coronary artery disease (CAD) and aortic stenosis share pathophysiological mechanisms and risk factors. We evaluated the clinical utility of coronary computed tomography angiography (CTA) to identify CAD and revascularization requirement in patients with severe aortic stenosis considered for transcatheter aortic valve replacement (TAVR)., Methods: Consecutive patients without known CAD underwent calcium scoring, CTA and invasive coronary angiography (ICA). A second-generation dual-source CT scanner was used. ICA-quantitative coronary angiography (QCA) served as reference standard. CAD was reported using a lenient threshold of ≥50% and a stricter threshold of ≥70% diameter reduction. Findings of ≥70% diameter reduction and of high-risk CAD were used to predict revascularization., Results: The study included 140 patients [68 males; 82.3 (7.7) years]. CAD defined by the 50% threshold on ICA was found in 58/140 (41%) patients. CAD by the 70% threshold was found in 23/140 (16%) patients. High-risk CAD was found in 16/140 (11%) patients. CTA and ICA had similar odd-ratios of 3.22 (1.26-8.23) and 4.62 (1.64-13.05), respectively, in predicting revascularization. Forty-two/140 (30%) patients had <400 Agatston calcium score, 98/140 (70%) patients had ≥400 calcium score. The diagnostic performance of CTA in the low calcium score group was better than the high calcium score group (AUC 0.81 vs. 0.63)., Conclusion: CTA remained questionable to rule-out CAD as gatekeeper to ICA in TAVR candidates who had severe coronary calcifications. In patients with less severe coronary calcifications, accounting for 30% of participants in this study, CTA may play a clinical role., (Copyright © 2017 Society of Cardiovascular Computed Tomography. Published by Elsevier Inc. All rights reserved.)