Low-Flow, Low-Gradient Severe Aortic Stenosis: Cardiac Computed Tomography Findings and Clinical Outcomes After Aortic Valve Replacement

Low-Flow, Low-Gradient Severe Aortic Stenosis: Cardiac Computed Tomography Findings and Clinical Outcomes After Aortic Valve Replacement | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Low-Flow, Low-Gradient Severe Aortic Stenosis: Cardiac Computed Tomography Findings and Clinical Outcomes After Aortic Valve Replacement Se Jin Choi, Yura Ahn, Hyun Jung Koo, Dae-Hee Kim, Soyeon Lim, and 7 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-1151439/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Aortic valve calcium scoring by cardiac computed tomographic (CT) has been recommended as an alternative to classify the AS severity, but it is unclear that whether CT findings can predict and have prognostic implication in low-flow, low-gradient aortic stenosis (LF-LG AS), which has fewer benefit from surgery among the AS subtypes. In this study, we examined the clinical and cardiac CT findings of LF-LG AS patients and evaluated factors affecting outcomes after surgical aortic valve replacement (AVR). This study included 511 (66.9±8.8 years, 55% men) consecutive patients with severe AS who underwent surgical AVR. Aortic valve area (AVA) was obtained by echocardiography (AVA echo ) and by CT (AVA CT ) using each modalities measurement of the left ventricular outflow tract. Patients with AS were classified as 1) high-gradient severe (n=438), 2) classic LF-LG (n=18), and 3) paradoxical LF-LG (n=55) based on echocardiography. Classic LF-LG AS patients had higher end-systolic and end-diastolic volume indices, lower left ventricular ejection fraction, larger AVA echo and AVA CT , and larger aortic annulus compared to high-gradient severe AS (P<0.05, for all). In classic LF-LG AS group, 27.8% of patients presented AVA CT ≥1.2 cm 2 . After multivariable adjustment, old age (hazard ratio [HR], 1.04, P=0.049), high B-type natriuretic peptide (BNP) (HR, 1.005; P<0.001), preoperative atrial fibrillation (HR, 2.75; P=0.003), classic LF-LG AS (HR, 5.53, P=0.004), and small aortic annulus (HR, 0.57; P=0.002) were independently associated with major adverse cardiac and cerebrovascular events (MACCE). The classic LF-LG AS group presented larger AVA CT and aortic annulus than those in high-gradient severe AS group and one third of them had AVA CT ≥1.2 cm 2 . Old age, high BNP, atrial fibrillation, classic LF-LG AS, and small aortic annulus were associated with MACCE in severe AS patients after surgical AVR. Cardiac & Cardiovascular Systems cardiac computed tomographic Aortic valve calcium echocardiography surgical AVR Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Classic low-flow, low-gradient (LF-LG) severe aortic stenosis (AS) is defined by a small aortic valve (AV) area (AVA) on echocardiography (AVA echo <1 cm 2 ), a low mean pressure gradient (PG<40 mmHg), and low flow (stroke volume [SV]<35 mL/m 2 ). The condition is characterised by low cardiac output due to a reduced left ventricular ejection fraction (LVEF< 50%). 1–5 Conversely, LF-LG AS may occur despite preserved LVEF and is classified as paradoxical LF-LG AS. Assessment of disease severity, management, and prediction of post-surgical outcome in patients with LF-LG AS is currently challenging. Since LF-LG AS presents fewer potential benefits from AV replacement (AVR) and considerable operation risks compared to true-severe AS, a classification for AS is important. 5 Although the planimetry of the AVA using three-dimensional transoesophageal echocardiography has been reported to be more accurate than transthoracic echocardiography, 6 measurement issues still remain unresolved. Even in patients with normal systolic LV function, the grading of AS on echocardiography is inconsistent, and this is partly due to reduced SV. 7 , 8 In patients with low-flow state, AS severity may be underestimated due to lower mean PG, while incomplete opening of the AV may overestimate stenosis severity because of the reduced opening forces to the AV. 9 In patients with low-flow state, there can be a discrepancy between the EOA and the PG. Moreover, the continuity equation assumes circular LVOT which is elliptical shape, and echocardiography may underestimate LVOT. Additional diagnostic tests, dobutamine stress echocardiography (DSE) 2 , 10 and AV calcium score (AVC) obtained by computed tomography (CT) scan 11 12 , have been used for the confirmation of severity and therapeutic guidance, and there is a chance that the patients with severe AS may be reclassified into the moderate range. However, reference standards used in these studies consisted of subjective assessment of the valve severity by cardiac surgeons and the AVC on CT images, which do not reflect hemodynamic severity. Cardiac CT is recommended as an alternative to assess AS severity when DSE is inconclusive. 13 However, discrepancies have been reported between the measured AVA on cardiac CT (AVA CT ) and AVA echo . 14 , 15 AVA CT was significantly greater than the AVA echo calculated by continuity equation, and suggested cut-off of AVA CT for severe AS was <1.2 cm 2 . Moreover, CT findings of LF-LG AS and imaging prognostic values remain undefined. Thus, we sought to (i) determine the CT characteristics of LF-LG AS, and (ii) evaluate prognostic factors affecting major adverse cardiovascular and cerebrovascular events (MACCE) of AS after AVR. Results Patient characteristics High-gradient severe AS (85.7% [438/511]) was most common among patients, followed by paradoxical LF-LG AS (10.8% [55/511]) and classic LF-LG AS (3.5% [18/511]). (Supplementary Table 1). Half of the patients had tricuspid valves (48.1% [246/511]) and bicuspid valves were detected in the remaining patients. The median follow-up period for all patients was 4.12 (IQR, 3.19–5.50) years. MACCE occurred in 43 (8.4%) patients, and the overall mortality was 13.9% (n=71). Among the groups with high-gradient severe AS, classic LF-LG AS, and paradoxical LF-LG AS, the age of patients were not statistically different (P=0.93) (Table 1 ). The number of concurrent percutaneous coronary artery intervention or CABG with AVR was highest in classic LF-LG AS group (50%, P=0.02). BNP was highest in classic LF-LG AS (median 944.5 pg/mL, P<0.001). MACCE was more common in the classic LF-LG AS than in the high-gradient severe AS (27.8 vs. 7.8%, P=0.01). Table 1 Clinical and imaging characteristics of high-gradient severe, classic LF-LG, paradoxical LF-LG AS groups (n=511) Characteristic High-gradient severe AS Classic LF-LG AS Paradoxical LF-LG AS P-value No. of patients (%) 438 (85.7) 18 (3.5) 55 (10.8) Age, years 66.8 ± 8.8 66.8 ± 6.2 67.3 ± 9.4 0.93 Male 236 (53.9) 13 (72.2) 31 (56.4) 0.30 Body surface area, m 2 1.6 ± 0.2 1.7 ± 0.2 1.6 ± 0.2 0.56 Hypertension 231 (52.7) 12 (66.7) 30 (54.5) 0.50 Atrial fibrillation 65 (14.8) 4 (22.2) 4 (7.3) 0.20 PCI or CABG 94 (21.5) 9 (50.0) * 14 (25.5) 0.02 BNP, pg/mL 99.5 (43.0 – 280.5) 944.5 (304.8 – 3066.0) * 70.0 (35.0 – 190.0) <0.001 lnBNP 4.6 (3.8 – 5.6) 6.8 (5.7 – 8.0) * 4.2 (3.6 – 5.2) <0.001 Echocardiography LVEF, % 60.3 ± 10.0 36.0 ± 10.3 * 62.6 ± 5.3 <0.001 Peak velocity, m/s 5.2 ± 0.7 3.6 ± 0.5 * 3.5 ± 0.5 † <0.001 Peak PG, mmHg 108.5 ± 30.5 52.0 ± 13.1 * 50.1 ± 16.0 † <0.001 Mean PG, mmHg 66.5 ± 19.4 29.8 ± 7.9 * 28.0 ± 9.5 † <0.001 LVMI, gm/ m 2 135.4 ± 35.8 149.6 ± 31.1 124.9 ± 36.2 0.03 AV VTI, cm 124.6 ± 26.1 94.9 ± 33.3 * 112.0 ± 27.7 † <0.001 LVOT VTI, cm 21.4 ± 4.1 16.0 ± 4.4 * 21.2 ± 3.7 <0.001 LVOT diameter, mm 21.0 ± 1.5 21.8 ± 1.9 21.2 ± 1.6 0.06 LVOT diameter/BSA 12.9 ± 1.3 13.1 ± 1.6 13.0 ± 1.3 0.55 AVA echo , mm 2 61.3 ± 14.7 66.9 ± 15.1 69.5 ± 13.8 † <0.001 ESVI, mL/m 2 27.7 ± 16.8 63.4 ± 27.0 * 24.5 ± 11.4 <0.001 EDVI, mL/m 2 66.8 ± 23.7 96.3 ± 29.3 * 64.3 ± 24.5 <0.001 SAC, mL/m 2 /mmHg 0.8 ± 0.3 0.7 ± 0.3 0.8 ± 0.3 0.28 Zva, mmHg/mL/m 2 5.3 ± 1.6 5.0 ± 1.9 4.4 ± 1.4 † <0.001 CT findings Valve morphology 0.04 Tricuspid 204 (46.6) 14 (77.8) 28 (50.9) Bicuspid with raphe 106 (24.2) 3 (16.7) 17 (30.9) Bicuspid without raphe 128 (29.2) 1 (5.6) 10 (18.2) AVC 3027.2 ± 1872.0 2895.5 ± 1624.5 2363.1 ± 1605.8 * 0.04 LVOT mean diameter 24.8 ± 2.9 27.1 ± 2.7 * 24.7 ± 2.6 0.003 AVA CT , mm 2 84.9 ± 23.4 100.8 ± 22.7 * 94.2 ± 25.0 † 0.001 AVA plani , mm 2 87.2 ± 23.2 99.7 ± 25.5 * 97.5 ± 27.1 † 0.003 Aortic annulus Circularity, % 81.6 ± 7.6 77.4 ± 6.6 82.3 ± 6.0 0.05 Maximal dimeter, mm 27.5 ± 3.2 30.4 ± 3.5 * 27.4 ± 2.8 0.001 Mean diameter, mm 24.9 ± 2.6 26.9 ± 2.5 * 25.0 ± 2.6 0.005 Perimeter, mm 79.5 ± 8.4 85.4 ± 7.7 * 80.0 ± 8.3 0.02 Area, mm 2 481.8 ± 102.4 554.8 ± 101.0 * 489.5 ± 99.9 0.01 Sinus of Valsalva, mm 36.6 ± 4.5 38.4 ± 4.7 36.8 ± 5.0 0.25 ST junction, mm 30.9 ± 4.6 31.7 ± 3.3 31.5 ± 5.9 0.58 Ascending aorta tubular portion, mm 40.7 ± 6.3 38.4 ± 4.6 40.4 ± 7.7 0.31 Normalized to BSA AVA CT , mm 2 51.7 ± 13.6 60.7 ± 15.8 * 58.0 ± 15.6 † <0.001 AVA plani , mm 2 52.6 ± 13.5 59.5 ± 17.5 * 57.8 ± 15.2 † 0.005 Aortic annulus Maximal dimeter, mm 16.8 ± 2.0 18.2 ± 2.6 * 16.9 ± 1.7 0.01 Mean diameter, mm 15.2 ± 1.6 16.1 ± 1.9 15.4 ± 1.6 0.06 Perimeter, mm 48.7 ± 5.2 51.1 ± 5.8 49.2 ± 5.3 0.12 Area, mm 2 293.4 ± 55.5 331.0 ± 56.6 * 299.7 ± 55.9 0.02 Sinus of Valsalva, mm 22.4 ± 2.9 23.0 ± 2.8 22.6 ± 2.9 0.65 ST junction diameter, mm 18.9 ± 2.9 18.9 ± 2.1 19.3 ± 3.2 0.69 Ascending aorta tubular portion, mm 25.0 ± 4.3 23.0 ± 2.9 24.8 ± 4.6 0.15 Surgical valve size, mm 22.1 ± 2.1 23.0 ± 2.1 22.3 ± 2.0 0.18 Surgical valve type N/A CE Magna 144 10 18 ATSAP 82 4 8 Hancock 82 1 13 St. Jude Regent 80 3 11 Others 50 0 5 Operator 0.47 Operator 1 170 5 18 Operator 2 95 2 12 Operator 3 81 4 15 Operator 4 64 4 7 Operator 5 28 3 3 MACCE 34 (7.8) 5 (27.8) * 4 (7.3) 0.01 Overall mortality 57 (13.0) 6 (33.3) 8 (14.5) 0.05 Follow-up duration, d 1517.5 (1188.8 – 2026.5) 1134.0 (26.0 – 1682.0) 1455.0 (1112.0 – 1944.0) 0.007 Values are means ± standard deviations or numbers and percentages in parentheses. * Significant difference between patients with severe aortic stenosis and patients with classic low-flow, low-gradient, severe aortic stenosis (classic LF-LG AS) groups. † Significant difference between severe aortic stenosis and paradoxical LF-LG AS groups. AS, aortic stenosis; AVA, aortic valve area; AVC, aortic valve calcium score; BNP, B-type natriuretic peptide; EDVI, end-diastolic volume index; ESVI, end-systolic volume index; LF-LG, low-flow and low-gradient; lnBNP, log-transformed B-type natriuretic peptide; LVEF, left ventricular ejection fraction; LVMI, left ventricular mass index; LVOT, left ventricular outflow tract; MACCE, major adverse cardiac and cerebrovascular event; N/A, not available; PG, pressure gradient; SAC, systemic arterial compliance; VTI, velocity time integral; Zva, valvulo-arterial impedance. Echocardiography LVEF, transaortic peak velocity and PG were lower in the classic LF-LG AS group and reflected the characteristics of LF-LG AS (P<0.001, for all) (Table 1 ). The ESVI (63.4 vs. 27.7 mL/m 2 , P<0.001) and EDVI (96.3 vs. 66.8 mL/m 2 , P<0.001) were significantly larger in classic LF-LG AS, compared to the high-gradient severe AS group. SAC was not different among the groups (P=0.28), although Zva was lower in paradoxical LF-LG AS compared to others (P<0.001). We found that AVA CT ≥1.2 cm 2 was noted in 27.8% (5/18) of the patients with classic LF-LG AS (Figure 1 ). In classic LF-LG AS, AVA echo was larger in patients with AVA CT ≥1.2 cm 2 than those with AVA CT <1.2cm 2 (61.1 vs. 81.9 mm 2 , P=0.005) (Supplementary Table 2). However, other echocardiography parameters such as LVEF, peak velocity, and PG were not statistically different between subgroups with AVA CT 0.05, for all). In patients with paradoxical LF-LG AS, AVA echo was larger in AVA CT ≥1.2cm 2 group (68.2 vs. 77.3 mm 2 , P=0.08), but without statistical significance. Computed tomography Interobserver agreements for aortic root measurement on CT are high with the range of ICC from 89.2~97.0. (Supplementary Table 3). The pearson correlation coefficient for AVA echo and AVA CT was good (r=0.73, P<0.001). AVA CT is larger than AVA echo and the mean difference between AVA echo and AVA CT was 24.1 mm 2 (95% CI, −8.3 to 56.4 mm 2 , P<0.001) (Figure 2 A and 2 B). Comparison of AVA echo and AVA plani is presented in Supplementary Figure 2. AVC was highest in patients with high-gradient severe S, and statistically lower in paradoxical LF-LG AS and moderate AS groups (P=0.0.04). LVOT dimeter measured on CT was longer in classic LF-LG AS group compared to that in high-gradient severe AS (24.8 vs. 27.1 mm, P=0.003). The mean AVA CT was larger in the classic LF-LG AS group, compared to the high-gradient severe AS group (100.8 vs. 84.9 mm 2 , P=0.001). Normalized aortic annulus maximal diameter was longer (16.8 mm vs. 18.2 mm, P=0.01) and aortic annulus area was larger (293.4 mm 2 vs. 331.0 mm 2 , P=0.02) in classic LF-LG AS group compared to those in high-gradient severe AS. In classic LF-LG AS group, mean AVC was higher in AVA CT <1.2cm 2 group compared to that in AVA CT ≥1.2 cm 2 (3912.2 vs. 1360.1, P=0.002) (Table 2 ). AVA plani was also smaller in AVA CT <1.2cm 2 group compared to that in AVA CT ≥1.2 cm 2 (88.2 vs. 129.9 mm 2 , P<0.001). The normalized annulus sizes and aortic root diameters on CT were not statistically different between AVA CT <1.2cm 2 and AVA CT ≥1.2 cm 2 groups (P<0.05, for all). In paradoxical LF-LG AS patients, LVOT area normalized to BSA (289.3 vs. 345.5 mm 2 , P=0.01), normalized sizes of aortic annulus area (292.7 vs. 341.4 mm 2 , P=0.02), sinus of Valsalva (22.1 vs. 25.2 mm, P=0.003) and ST junction (30.6 vs. 36.7 mm, P=0.006) were larger in AVA CT ≥1.2 cm 2 group, compared to those measured in patients with AVA CT <1.2cm 2 . Table 2 Subgroups of LF-LG AS according to AVA CT Classic LF-LG AS (n = 18) Paradoxical LF-LG AS (n = 55) Characteristic AVA CT <1.2cm 2 AVA CT ≥1.2 cm 2 P-value AVA CT <1.2 cm 2 AVA CT ≥1.2 cm 2 P-value No. of patients (%) 13 (72.2) 5 (27.8) 47 (85.5) 8 (14.5) Age, years 66.1 ± 5.8 68.6 ± 7.7 0.46 67.3 ± 9.2 67.3 ± 10.9 0.99 Male 9 (69.2) 4 (80.0) 1.00 25 (53.2) 6 (75.0) 0.72 BSA, m 2 1.7 ± 0.2 1.6 ± 0.2 0.12 1.6 ± 0.2 1.7 ± 0.1 0.34 Hypertension 7 (53.8) 5 (100.0) 0.11 26 (55.3) 4 (50.0) 1.00 Atrial fibrillation 3 (23.1) 1 (20.0) 1.00 2 (4.3) 2 (25.0) 0.10 PCI or CABG 6 (46.2) 3 (60.0) 1.00 14 (25.5) 0 (0.0) 0.10 Rheumatic valvular disease 2 (15.4) 0 (0.0) 1.00 6 (12.8) 2 (25.0) 0.33 B-type natriuretic peptide, pg/mL 1118.0 (304.8 – 3066.0) 738.5 (239.3 – 3227.5) 0.80 59.0 (32.5 – 180.5) 200.5 (59.0 – 305.3) 0.38 lnBNP 7.0 (5.7 – 8.0) 6.6 (5.0 – 7.9) 0.60 4.1 (3.5 – 5.2) 5.2 (4.1 – 5.7) 0.12 Blood urea nitrogen, mg/dL 25.2 ± 16.7 18.6 ± 4.7 0.22 18.8 ± 8.5 18.0 ± 4.7 0.81 Creatinine, mg/dL 2.1 ± 2.3 1.9 ± 1.3 0.76 1.0 ± 0.4 0.9 ± 0.1 0.46 Echocardiography LVEF, % 36.9 ± 11.2 33.8 ± 8.0 0.59 62.8 ± 5.4 61.5 ± 4.6 0.53 Peak velocity, m/s 3.6 ± 0.4 3.4 ± 0.7 0.37 3.5 ± 0.5 3.6 ± 0.6 0.67 Peak PG, mmHg 53.5 ± 11.7 48.0 ± 17.0 0.44 49.5 ± 16.0 53.4 ± 16.9 0.53 Mean PG, mmHg 30.8 ± 6.8 27.2 ± 10.6 0.41 27.7 ± 9.4 29.8 ± 10.2 0.59 LVMI, gm/ m 2 151.5 ± 33.5 144.7 ± 26.3 0.69 121.5 ± 32.7 144.6 ± 50.6 0.10 AV TVI, cm 101.3 ± 34.2 78.2 ± 26.9 0.20 114.2 ± 28.2 98.9 ± 21.3 0.15 LVOT TVI, cm 16.0 ± 4.8 16.2 ± 3.8 0.92 21.4 ± 3.6 19.7 ± 3.7 0.24 LVOT diameter, mm 22.1 ± 2.2 21.2 ± 0.2 0.22 21.0 ± 1.4 22.2 ± 2.2 0.18 LVOT diameter/BSA 12.9 ± 1.6 13.6 ± 1.4 0.40 13.0 ± 1.4 13.2 ± 1.2 0.75 AVA echo , mm 2 61.1 ± 12.8 81.9 ± 9.1 0.005 68.2 ± 13.6 77.3 ± 12.7 0.08 ESVI 63.0 ± 30.0 64.4 ± 20.0 0.92 23.4 ± 10.6 30.7 ± 14.5 0.10 EDVI 96.4 ± 32.6 95.9 ± 21.3 0.98 62.0 ± 22.6 78.4 ± 31.5 0.08 SAC, mL/m 2 /mmHg 0.7 ± 0.3 0.6 ± 0.1 0.52 0.7 ± 0.3 1.0 ± 0.5 0.21 Zva, mmHg/mL/m 2 4.7 ± 1.7 5.8 ± 2.2 0.82 4.5 ± 1.4 3.8 ± 1.5 0.21 CT findings Valve morphology 0.28 0.14 Tricuspid 9 (69.2) 5 (100.0) 26 (55.3) 2 (25.0) Bicuspid 4 (30.8) 0 (0.0) 21 (44.7) 6 (75.0) AVC 3912.2 (2247.0 – 4496.1) 1360.1 (960.1 – 2108.6) 0.002 2002.4 (1192.2 – 2841.6) 2584.3 (1306.5 – 5172.0) 0.12 AVA CT 92.4 ± 15.5 122.7 ± 25.2 0.007 90.2 ± 22.4 117.7 ± 27.9 0.003 AVA plani , mm 2 88.2 ± 20.0 129.9 ± 5.4 <0.001 90.1 ± 21.2 140.9 ± 13.8 <0.001 LVOT area 587.5 ± 129.7 572.3 ± 79.9 0.81 468.9 ± 94.5 581.3 ± 94.9 0.003 Aortic annulus Maximum diameter, mm 30.6 ± 3.9 30.0 ± 2.1 0.77 27.1 ± 2.6 29.0 ± 3.6 0.05 Circularity, % 77.6 ± 7.5 76.9 ± 4.4 0.84 82.0 ± 5.7 83.8 ± 7.6 0.18 Mean diameter, mm 27.1 ± 2.9 26.5 ± 1.4 0.70 24.7 ± 2.3 27.0 ± 3.0 0.01 Perimeter, mm 86.0 ± 8.9 83.8 ± 3.7 0.46 78.7 ± 7.4 87.3 ± 10.0 0.01 Area, mm 2 563.3 ± 116.1 532.8 ± 45.9 0.44 475.2 ± 91.3 572.9 ± 113.2 0.009 Sinus of Valsalva, mm 39.3 ± 4.9 36.1 ± 3.4 0.20 35.9 ± 4.6 42.0 ± 4.2 0.001 ST junction, mm 32.1 ± 3.5 30.7 ± 2.8 0.44 30.6 ± 5.1 36.7 ± 7.7 0.006 Ascending aorta, mm 39.5 ± 4.4 35.5 ± 4.2 0.10 39.6 ± 7.1 45.1 ± 9.8 0.06 Normalized to BSA AVA CT 53.9 ± 9.4 78.3 ± 16.1 0.001 55.9 ± 14.3 70.3 ± 17.9 0.01 AVA plani , mm 2 51.5 ± 12.3 82.7 ± 6.0 <0.001 55.7 ± 12.7 84.1 ± 10.4 <0.001 LVOT area, mm 2 341.2 ± 69.4 365.5 ± 54.6 0.50 289.3 ± 55.3 345.5 ± 54.4 0.01 Aortic annulus Maximal dimeter, mm 17.9 ± 2.8 19.2 ± 2.0 0.35 16.8 ± 1.7 17.4 ± 1.6 0.37 Mean diameter, mm 15.8 ± 2.0 17.0 ± 1.7 0.27 15.3 ± 1.6 16.1 ± 1.6 0.20 Perimeter, mm 50.2 ± 6.0 53.6 ± 5.0 0.28 48.7 ± 4.9 52.0 ± 6.8 0.10 Area, mm 2 327.6 ± 65.3 339.7 ± 26.4 0.70 292.7 ± 50.4 341.4 ± 71.4 0.02 Sinus of Valsalva 22.9 ± 3.0 23.0 ± 2.4 0.95 22.1 ± 2.6 25.1 ± 3.5 0.007 ST junction diameter 18.7 ± 1.9 19.6 ± 2.5 0.40 18.9 ± 2.5 21.9 ± 5.3 0.01 Ascending aorta tubular portion 23.1 ± 3.0 22.6 ± 2.9 0.78 24.5 ± 4.3 26.9 ± 5.7 0.18 Surgical valve size, mm 23.2 ± 2.3 22.6 ± 1.7 0.63 22.1 ± 2.1 23.3 ± 1.7 0.14 MACCE (cardiovascular death) 2 (15.4) 3 (60.0) 0.10 4 (8.5) 0 (0.0) 1.00 Overall mortality 4 (30.8) 2 (40.0) 1.00 7 (14.9) 1 (12.5) 1.00 AS, aortic stenosis; AVA, aortic valve area; AVA CT , AVA measured on CT; AVC, aortic valve calcium score; BSA, body surface area; EDVI, end-diastolic volume index; ESVI, end-systolic volume index; LF-LG, low-flow and low-gradient; lnBNP, log-transformed B-type natriuretic peptide; LVEF, left ventricular ejection fraction; LVMI, left ventricular mass index; LVOT, left ventricular outflow tract; MACCE, major adverse cardiac and cerebrovascular event; VTI, velocity time integral. Outcome analysis MACCE were composed of arrhythmia (n=6), nonfatal cerebrovascular accident (CVA) (n=10), nonfatal myocardial infarction (n=4), heart failure (n=4), reoperation (n=1), and cardiovascular death (n=18). To identify clinical and radiological factors that affect MACCE, cox-proportional hazard regression analysis was performed (Table 3 ). In univariate analysis, older age, high BNP, high blood urea nitrogen and creatinine, presence of preoperative AF, tricuspid AV, classic LF-LG AS, small AV VTI and LVOT VTI, and small aortic annulus were factors significantly associated with MACCE (P<0.05, for all). Table 3 Cox proportional hazard regression model for prediction of MACCE Univariate Multivariable Parameter HR (95% CI) P-value HR (95% CI) P-value Age, years 1.06 (1.02–1.10) 0.005 1.04 (1.00–1.09) 0.049 Body surface area, m 2 0.49 (0.08–3.15) 0.45 B-type natriuretic peptide, 10 pg/mL 1.01 (1.003–1.01) <0.001 1.005 (1.003–1.01) <0.001 lnBNP 1.42 (1.13–1.77) 0.002 Atrial fibrillation, (%) 3.22 (1.70–6.11) <0.001 2.75 (1.40–5.40) 0.003 LVEF, % 0.98 (0.96–1.01) 0.20 Peak velocity, m/s 0.80 (0.57–1.12) 0.19 Mean PG, mmHg 0.99 (0.98–1.01) 0.21 LVMI, gm/ m 2 0.99 (0.99–1.00) 0.18 ESVI, mL/m 2 1.01 (0.99–1.02) 0.55 EDVI, mL/m 2 1.00 (0.99–1.01) 0.90 SAC, mL/m 2 /mmHg 0.57 (0.21–1.53) 0.27 Zva, mmHg/mL/m 2 1.00 (0.83–1.20) 0.98 Bicuspid aortic valve 0.40 (0.21–0.77) 0.006 Classic LF-LG AS 5.04 (1.98–12.84) 0.001 5.53 (1.74–17.56) 0.004 AVA echo , m 2 1.01 (0.99–1.03) 0.60 AV VTI, cm 0.98 (0.96–0.99) <0.001 LVOT VTI, cm 0.92 (0.86–0.99) 0.02 lnAVC 0.89 (0.71–1.09) 0.26 Normalized AVA plani , mm 2 1.00 (0.98–1.03) 0.76 Normalized AVA CT , mm 2 1.02 (1.00–1.04) 0.50 Annulus circularity, % 0.34 (0.01–18.69) 0.59 Aortic annulus area, cm 2 0.73 (0.53 – 1.01) 0.06 0.57 (0.40 – 0.81) 0.002 Surgical valve size, mm 0.89 (0.77–1.04) 0.13 Surgical valve type CE Magna 1 0.63 ATSAP 0.55 (0.20 – 1.48) 0.24 Hancock 1.09 (0.50 – 2.38) 0.83 St. Jude Regent 0.63 (0.25 – 1.59) 0.32 Others 0.85 (0.31 – 2.31) 0.75 Operator Operator 1 1 0.33 Operator 2 1.63 (0.78 – 3.38) 0.19 Operator 3 0.37 (0.05 – 2. 76) 0.33 Operator 4 0.94 (0.37 – 2.41) 0.90 Operator 5 0.73 (0.30 – 1.78) 0.49 AS, aortic stenosis; AVA, aortic valve area; AVC, aortic valve calcium score; EDVI, end-diastolic volume index; ESVI, end-systolic volume index; HR, hazard ratio; LF-LG, low-flow and low-gradient; lnBNP, log-transformed B-type natriuretic peptide;LVEF, left ventricular ejection fraction; LVMI, left ventricular mass index; LVOT, left ventricular outflow tract; MACCE, major adverse cardiac and cerebrovascular event; PG, Pressure gradient; SAC, systemic arterial compliance; VTI, velocity time integral; Zva, valvulo-arterial impedance. On multivariable analysis, old age (hazard ratio [HR], 1.04, 95%CI, 1.00–1.09; P=0.049), high BNP (HR, 1.005; 95%CI, 1.003–1.01 P<0.001), AF (HR, 2.75; 95% CI, 1.40–5.40; P=0.003), classic LF LG AS (HR, 5.53; 95%CI, 1.74–17.56; P=0.004), and small aortic annulus area (cm 2 ), [HR, 0.57; 95%CI, 0.40–0.81; P=0.002]) were factors significantly associated with MACCE (Table 3 ). Normalized aortic annulus area (cm 2 ) (HR, 0.40; 95%CI, 0.22–0.74; P=0.004) was also a significantly associated factor when the parameter was substitute instead of aortic annulus area in multivariable analysis. When the normalized aortic sinus of Valsalva diameter instead of the aortic annulus size was substituted in the calculation, the weight of the other factors remained almost unchanged, while the normalized aortic sinus of Valsalva diameter (cm) (HR, 0.30; 95%CI, 0.09–0.98; P=0.04) was also identified as a significant factor. Kaplan-Meier curves indicated significant mortality in the high BNP group (BNP>700 pg/mL) compared to the low BNP group (P=0.001) (Figure 3 A). Furthermore, preoperative AF was also associated with significant mortality (Figure 3 B) (P<0.001), and the outcome of classic LF-LG AS was worse in the cumulative survival curve (Figure 3 C) (P=0.001). Discussion This study highlights the characteristics of LF-LG AS focusing on CT findings. The AVA CT and aortic annulus were larger in classic LF-LG AS compared to those in high-gradient severe AS and 27.8% of classic LF-LG AS patients presented AVA CT ≥1.2 cm 2 . High BNP, preoperative AF, classic LF-LG AS, and smaller aortic root were associated with MACCE after AVR. Classic LF-LG AS patients demonstrated higher ESVI and EDVI, lower LVEF, larger AVA echo and AVA CT , and larger aortic annulus compared to high-gradient severe AS. The key messages of this study are demonstrated in Figure 4 . In a previous study, patients with severe AS had significantly larger aortic annulus and ST junction diameters compared with those measured in control groups. 16 This could be attributed to aortic root remodelling: as severe AS progresses ESVI and EDVI increase to compensate, and dilated LV cavity may lead to dilatation of the aortic annulus. Failure to compensate may result in heart failure. Since the BNP was higher in classic LF-LG AS and the group presented poor outcome compared to high-gradient severe AS, classic LF-LG AS may be a compensation failure of high-gradient severe AS. Paradoxical LF-LG AS presented preserved ESVI, EDVI, and LVEF, although AVA echo and AVA CT were larger than in high-gradient severe AS. In this study, we used cut-off value of AVA CT <1.2 cm 2 as this value was suggested for severe AS in a previous study. 14 However, in classic LF-LG AS group, approximately one third of the patients exhibited AVA CT ≥1.2 cm 2 . AVC was lower in the AVA CT ≥1.2 cm 2 compared to that of AVA CT <1.2cm 2 group, and in this group, moderate AS patients might be misclassified as severe AS and vice versa. This can also be applied to paradoxical LF-LG patients, despite 14.5% of these patients presenting AVA CT ≥1.2 cm 2 . Although we could not derive the role of AVA CT in diagnosing LF-LG AS patients, further studies whether AVA CT could be used to discriminate true LF-LG AS are would be of value. The outcome of AS after AVR was associated with preoperative high BNP levels, AF, classic LF-LG AS, and small aortic root. The plasma BNP level was associated with LV dysfunction in AS, and was a well-known predictor of poor outcome in patients with AS overall and after AVR. 17 – 19 AF is also a dominant predictor in both asymptomatic and symptomatic patients with moderate to severe AS, and after AVR. 20 – 22 Classic LF-LG AS was associated with worse outcomes after AVR compared those observed in high-gradient AS patients, although LF-LG AS patients have displayed survival benefits with AVR. 3 Finally, small aortic root measured on CT was an independent prognostic factor. This finding should be interpreted cautiously. When AS severity progresses, the increased LV cavity volume may increase the size of the aortic annulus and sinus of Valsalva. However, a small aortic root has also been associated with increased ischemic cardiovascular events and mortality in patients with AS, 23 possibly reflecting impaired root remodelling process and atherosclerotic changes. Our study has several limitations. Because this is a retrospective study using a patient cohort that underwent AVR, patients not indicated for surgery due to poor general conditions or comorbidities or who declined operation were not included. The selection bias may affect the outcome assessment, and AVR itself was not used as an outcome parameter. Instead, we used MACCE after AVR. Therefore, the outcomes of this study may not directly infer the outcomes of AS population managed with diverse treatment options. Further studies with AS managed by conservative treatment, surgical AVR, and transcatheter AVR could be of value to evaluate overall outcomes of AS patients. Second, because the small number of LF-LG AS patients, we could not observe the role of AVA CT for reclassification of LF-LG AS. However, we showed the CT characteristics of LF-LG AS: AVA CT and aortic annulus were larger in classic LF-LG AS compared to those in high-gradient severe AS. This finding may be explained by the aortic root remodelling which is associated with the dilated LV. Third, although classic LF-LG patients showed higher overall mortality and a large aortic annulus, a small aortic root was one of the factors associated with MACCE. Both decreased LV function in classic LF-LG AS and impaired aortic root remodelling may contribute to the outcome, respectively, but further studies are necessary to provide more evidences. In conclusion, classic LF-LG AS presented larger AVA CT and aortic annulus than high-gradient severe AS. Old age, high BNP, AF, classic LF-LG AS and small aortic root on CT were associated with MACCE after AVR. These findings suggest the potential role of cardiac CT in classification and outcome assessment of severe AS. Methods Patients This retrospective study was approved by the institutional review board committee of the Asan Medical Center, University of Ulsan College of Medicine (approval number: 2018-0233) and informed consent was waived by the institutional review board committee of the Asan Medical Center, University of Ulsan College of Medicine due to the retrospective nature of observational study. This study was performed in accordance with the Helsinki Declaration. Between June 2011 and Mar 2016, 781 patients underwent surgical AVR. The use of CT was determined mainly by clinician’s decision, but in our hospital, cardiac CT examination is generally performed in most of the patients who have performed planned surgical AVR for evaluation of AV and root morphology based on the guidelines for the appropriate use of cardiac CT 24 – 27 . After excluding patients with moderate AS (n=24), moderate degree of concomitant aortic regurgitation or other valvular heart disease (n=177), patients not subjected to preoperative cardiac CT (n=47) or CT without multiphase data (n=21), and a patient with quadricuspid AV (n=1), 511 patients were included. High-gradient severe AS was defined as AVA echo <1 cm 2 and a mean trans-valvular gradient ≥40 mmHg with LVEF < 50%. Classic LF-LG severe AS was defined as AVA echo <1 cm 2 , but with a low-gradient (<40 mmHg). Low-gradient severe AS with preserved LVEF was defined as paradoxical LF-LG AS. We classified patients with AS into three groups: 1) high-gradient severe; 2) classic LF-LG; and 3) paradoxical LF-LG AS. Clinical findings including age, body surface area (BSA), hypertension, atrial fibrillation (AF), B-type natriuretic peptide (BNP), echocardiography parameters, and cardiac CT data were collected. Postoperative echocardiography findings and reported clinical outcomes were comprehensively reviewed. Clinical outcomes included all-cause mortality and MACCE (composite of cardiac death, cerebrovascular accident or stroke, coronary artery revascularization or myocardial infarction, and redo-AVR) were evaluated. Echocardiography Preoperatively, all patients underwent transthoracic echocardiography using commercially available ultrasound machines with 3–5 MHz real-time transducers (iE33, EPIC; Philips Medical Systems, Andover, MA; Vivid 7, E9, General Electric Healthcare, Waukesha, WI, USA). Comprehensive two-dimensional and Doppler images were obtained by expert cardiologists according to American Society of Echocardiography recommendations. 28 End-systolic volume, end-diastolic volume, and LVEF were obtained with the biplane Simpson method. The maximal aortic jet velocity was recorded with the apical, right parasternal, or suprasternal window that yielded the highest-velocity signal. The maximal and mean PG across the AV were estimated using a modified Bernoulli equation, and the AVA was calculated from the continuity equation. LV mass and LV mass indexed to body surface area calculated by LV cavity dimension and LV wall thickness at end-diastole. Systemic arterial compliance (SAC) was calculated as the ratio of SV index (SVI)/pulse pressure, 29 and valvulo-arterial impedance (Zva), which is a parameter for global LV load, was defined as (systolic blood pressure + mean net aortic gradient)/SVI. 30 Cardiac CT protocol and image analysis Preoperative cardiac CT was performed using a second-generation dual-source CT scanner (Somatom Definition Flash; Siemens Medical Solutions, Forchheim, Germany). Detailed CT protocol is described in supplementary file 1. Post-processing was conducted using an external workstation (AquariusNet; TeraRecon, Foster City, CA, USA) using multiphase CT data sets reconstructed by a 10% R-R interval. CT analysis methods are described in supplementary figure 1. CT characteristics such as AV morphology (tricuspid, bicuspid with raphe, and bicuspid without raphe), AVA CT , AVA obtained by planimetry (AVA plani ), aortic annulus diameter, perimeter, and area, circularity (minimum annulus diameter/maximum annulus diameter×100), and diameters of sinus of Valsalva, sinotubular (ST) junction, and ascending aorta tubular portion were measured by two experienced radiologists in consensus (BLINDED). AVA CT was calculated by using the LV outflow tract (LVOT) area measured on CT in the continuity equation with velocity time integrals (VTI) at LVOT and transaortic flow: AVA CT =LVOT CT ×VTI LVOT /VTI Ao . AVC was defined as a CT density of 130 Hounsfield units or greater confined to AV on non-enhanced cardiac gated images and measured using the methods suggested by Agatston et al. The AVC was measured using a commercially available software (Syngo.via Siemens Healthcare, Berlin, Germany). 31 Systolic phase with largest AVA (20~30% RR) was selected and thick multiplanar reconstruction images were used to demarcate the tips of the aortic cusps for measuring AVA plani . To evaluate reliability of CT measurements, a third experienced radiologist (BLINDED) measured CT parameters in 100 randomly selected cases and interobserver agreement was determined. Observers were blinded to clinical data including echocardiography findings and operation records. Statistics Continuous variables were expressed as mean ± standard deviation or median with interquartile range (IQR) and categorical variables are presented as numbers and percentages. Interobserver agreement of CT findings was determined using a two-way random model intra-class correlation coefficient (ICC) with consistency assumption. Comparison of AVA measured on echocardiography (AVA echo ) and CT including AVA CT and AVA plani was performed using Pearson correlations and Bland-Altman plots were graphed. One way ANOVA with post-hoc (Tukey) test or Kruskall-Wallis test and Chi-square test were used to compare baseline clinical and radiological findings among high-gradient severe AS, classic LF-LG AS, paradoxical LF-LG AS, and moderate AS groups. Bonferroni correction was applied to control the type I error for multiple comparison, and P-value 0.05/4=0.0125 was used for comparing the three groups. Student t-test and Chi-square test were performed to compare two subgroups among the three groups. In LF-LG AS patients, clinical and CT findings for AVA CT <1.2 cm 2 and AVA CT ≥1.2 cm 2 were compared using the Student t-test and Chi-square test or Fisher’s exact test. For the stratification of risk factors for MACCE after AVR, cox proportional hazard models were used. Kaplan-Meier survival curves were drawn for statistically significant factors to predict MACCE. The 95% confidence intervals (CIs) were calculated and factors with P<0.10 were included for multivariable cox regression analysis with enter method. To avoid multicollinearity, one of the aortic root parameters was included in the multivariable analysis among the CT parameters significantly associated with MACCE in univariate analysis. For BNP analysis, a continuous parameter was used and a cut-off of 700 pg/mL 32 was set for outcome analysis using Kaplan-Meier curves. 19 P<0.05 was considered statistically significant, except for multiple dependant variable analyses. Statistical analysis was performed using commercial software (SPSS, version 20; SPSS, Chicago, IL, USA). Declarations Data availability All data used during the current study are included in this published article or are available from the corresponding author upon reasonable request. Contributions Conception: H.J.K. and D.K., Data curation: H.J.K., S.L., J.B.K. J-M.S. D-K.K, J-K. S., J-W. K., D.H.Y., Statistical analyses, H.J.K., and H.J.K, Manuscript writing: S.J.C., Y.A., H.J.K., Revising the manuscript: H.J.K. and D.K. All authors approved the final version of this manuscript. Funding This study was supported by a grant (2021IT0006) from the Asan Institute for Life Sciences, Asan Medical Center, Seoul, Korea. Competing interests The authors declare no competing interests. References Adda, J. et al. Low-flow, low-gradient severe aortic stenosis despite normal ejection fraction is associated with severe left ventricular dysfunction as assessed by speckle-tracking echocardiography: a multicenter study. Circ Cardiovasc Imaging 5 , 27-35, doi:10.1161/CIRCIMAGING.111.967554 (2012). Annabi, M. S. et al. Dobutamine Stress Echocardiography for Management of Low-Flow, Low-Gradient Aortic Stenosis. Journal of the American College of Cardiology 71 , 475-485, doi:10.1016/j.jacc.2017.11.052 (2018). Clavel, M. A., Magne, J. & Pibarot, P. Low-gradient aortic stenosis. European heart journal 37 , 2645-2657, doi:10.1093/eurheartj/ehw096 (2016). Nishimura, R. A. et al. 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 129 , 2440-2492, doi:10.1161/CIR.0000000000000029 (2014). Pibarot, P. & Dumesnil, J. G. Low-flow, low-gradient aortic stenosis with normal and depressed left ventricular ejection fraction. Journal of the American College of Cardiology 60 , 1845-1853, doi:10.1016/j.jacc.2012.06.051 (2012). Dumesnil, J. G. & Pibarot, P. Low gradient severe aortic stenosis with preserved ejection fraction: don't forget the flow! Rev Esp Cardiol (Engl Ed) 66 , 245-247, doi:10.1016/j.rec.2012.10.019 (2013). Minners, J. et al. Inconsistencies of echocardiographic criteria for the grading of aortic valve stenosis. European heart journal 29 , 1043-1048, doi:10.1093/eurheartj/ehm543 (2008). Minners, J. et al. Inconsistent grading of aortic valve stenosis by current guidelines: haemodynamic studies in patients with apparently normal left ventricular function. Heart (British Cardiac Society) 96 , 1463-1468, doi:10.1136/hrt.2009.181982 (2010). Oh, J. K. et al. Prediction of the severity of aortic stenosis by Doppler aortic valve area determination: prospective Doppler-catheterization correlation in 100 patients. Journal of the American College of Cardiology 11 , 1227-1234 (1988). deFilippi, C. R. et al. Usefulness of dobutamine echocardiography in distinguishing severe from nonsevere valvular aortic stenosis in patients with depressed left ventricular function and low transvalvular gradients. The American journal of cardiology 75 , 191-194 (1995). Koos, R. et al. Aortic valve calcification as a marker for aortic stenosis severity: assessment on 16-MDCT. AJR. American journal of roentgenology 183 , 1813-1818, doi:10.2214/ajr.183.6.01831813 (2004). Pawade, T. et al. Computed Tomography Aortic Valve Calcium Scoring in Patients With Aortic Stenosis. Circ Cardiovasc Imaging 11 , e007146, doi:10.1161/circimaging.117.007146 (2018). Cueff, C. et al. Measurement of aortic valve calcification using multislice computed tomography: correlation with haemodynamic severity of aortic stenosis and clinical implication for patients with low ejection fraction. Heart (British Cardiac Society) 97 , 721-726, doi:10.1136/hrt.2010.198853 (2011). Clavel, M. A. et al. Aortic valve area calculation in aortic stenosis by CT and Doppler echocardiography. JACC. Cardiovascular imaging 8 , 248-257, doi:10.1016/j.jcmg.2015.01.009 (2015). Halpern, E. J., Mallya, R., Sewell, M., Shulman, M. & Zwas, D. R. Differences in aortic valve area measured with CT planimetry and echocardiography (continuity equation) are related to divergent estimates of left ventricular outflow tract area. AJR. American journal of roentgenology 192 , 1668-1673, doi:10.2214/ajr.08.1986 (2009). Stolzmann, P. et al. Remodelling of the aortic root in severe tricuspid aortic stenosis: implications for transcatheter aortic valve implantation. European radiology 19 , 1316-1323, doi:10.1007/s00330-009-1302-0 (2009). Iwahashi, N., Nakatani, S., Umemura, S., Kimura, K. & Kitakaze, M. Usefulness of plasma B-type natriuretic peptide in the assessment of disease severity and prediction of outcome after aortic valve replacement in patients with severe aortic stenosis. Journal of the American Society of Echocardiography : official publication of the American Society of Echocardiography 24 , 984-991, doi:10.1016/j.echo.2011.03.012 (2011). Capoulade, R. et al. Prognostic value of plasma B-type natriuretic peptide levels after exercise in patients with severe asymptomatic aortic stenosis. Heart (British Cardiac Society) 100 , 1606-1612, doi:10.1136/heartjnl-2014-305729 (2014). Dahou, A. et al. B-Type Natriuretic Peptide and High-Sensitivity Cardiac Troponin for Risk Stratification in Low-Flow, Low-Gradient Aortic Stenosis: A Substudy of the TOPAS Study. JACC. Cardiovascular imaging 11 , 939-947, doi:10.1016/j.jcmg.2017.06.018 (2018). Minamino-Muta, E. et al. Causes of Death in Patients with Severe Aortic Stenosis: An Observational study. Scientific reports 7 , 14723, doi:10.1038/s41598-017-15316-6 (2017). Thourani, V. H. et al. Outcomes in 937 Intermediate-Risk Patients Undergoing Surgical Aortic Valve Replacement in PARTNER-2A. The Annals of thoracic surgery 105 , 1322-1329, doi:10.1016/j.athoracsur.2017.10.062 (2018). Bahler, R. C. et al. Predicting Outcomes in Patients With AsymptomaticModerate to Severe Aortic Stenosis. The American journal of cardiology 122 , 851-858, doi:10.1016/j.amjcard.2018.05.027 (2018). Bahlmann, E. et al. Small aortic root in aortic valve stenosis: clinical characteristics and prognostic implications. European heart journal cardiovascular Imaging 18 , 404-412, doi:10.1093/ehjci/jew159 (2017). Beck KS, K. J., Choe YH, Hian SK, Hoe J, Hong YJ, et al. . 2017 Multimodality Appropriate Use Criteria for Noninvasive Cardiac Imaging: Expert Consensus of the Asian Society of Cardiovascular Imaging. Cardiovasc Imag Asia 1 , 156-165 (2017). Kim, Y. J. et al. Korean guidelines for the appropriate use of cardiac CT. Korean journal of radiology 16 , 251-285, doi:10.3348/kjr.2015.16.2.251 (2015). Tsai, I. C. et al. ASCI 2010 appropriateness criteria for cardiac computed tomography: a report of the Asian Society of Cardiovascular Imaging Cardiac Computed Tomography and Cardiac Magnetic Resonance Imaging Guideline Working Group. The international journal of cardiovascular imaging 26 Suppl 1 , 1-15, doi:10.1007/s10554-009-9577-4 (2010). Nishimura, R. A. et al. 2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Journal of the American College of Cardiology, doi:10.1016/j.jacc.2017.03.011 (2017). Mitchell, C. et al. Guidelines for Performing a Comprehensive Transthoracic Echocardiographic Examination in Adults: Recommendations from the American Society of Echocardiography. Journal of the American Society of Echocardiography : official publication of the American Society of Echocardiography 32 , 1-64, doi:10.1016/j.echo.2018.06.004 (2019). de Simone, G. et al. Stroke volume/pulse pressure ratio and cardiovascular risk in arterial hypertension. Hypertension (Dallas, Tex. : 1979) 33 , 800-805 (1999). Briand, M. et al. Reduced systemic arterial compliance impacts significantly on left ventricular afterload and function in aortic stenosis: implications for diagnosis and treatment. Journal of the American College of Cardiology 46 , 291-298, doi:10.1016/j.jacc.2004.10.081 (2005). Agatston, A. S. et al. Quantification of coronary artery calcium using ultrafast computed tomography. Journal of the American College of Cardiology 15 , 827-832, doi:10.1016/0735-1097(90)90282-t (1990). Sakurai, S. et al. Brain natriuretic peptide facilitates severity classification of stable chronic heart failure with left ventricular dysfunction. Heart (British Cardiac Society) 89 , 661-662, doi:10.1136/heart.89.6.661 (2003). Additional Declarations No competing interests reported. Supplementary Files LFLGSupplementaryFile.docx Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Major revision 31 Jan, 2022 Reviews received at journal 23 Jan, 2022 Reviewers agreed at journal 17 Jan, 2022 Reviewers agreed at journal 03 Jan, 2022 Reviewers invited by journal 22 Dec, 2021 Editor assigned by journal 21 Dec, 2021 Editor invited by journal 15 Dec, 2021 Submission checks completed at journal 15 Dec, 2021 First submitted to journal 08 Dec, 2021 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-1151439","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":70338363,"identity":"2f2f0cde-f629-4831-8060-58fb44a5877a","order_by":0,"name":"Se Jin Choi","email":"","orcid":"","institution":"University of Ulsan College of Medicine","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Se","middleName":"Jin","lastName":"Choi","suffix":""},{"id":70338364,"identity":"ccca0f39-302a-46c4-8b1f-0d1f9e160b32","order_by":1,"name":"Yura Ahn","email":"","orcid":"","institution":"University of Ulsan College of Medicine","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Yura","middleName":"","lastName":"Ahn","suffix":""},{"id":70338365,"identity":"a3873f78-1353-496b-b77b-2678e2756325","order_by":2,"name":"Hyun Jung Koo","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAzElEQVRIiWNgGAWjYHACYyC2gfNkGHiI05IG5/EQq+UwCVrM2w9vNvhQcV5et/0A84cPFYeBWs4+wKtF5kxaceKMM7cNt51JYJOccQaohbfdAK8WCYYc48O8bbcZt91gYGPmbQNq4WfD7zAJ/jcgLefsgVqYP/8lSotEjnEyb9uBRKAWBmlGkBbeNkJanhUbzjiTnLztTGKbZM+ZdB42nmOEHJa8WeJDhZ3ttuOHD3/4UWEtx8+Thl8LEmBsAFMEfDIKRsEoGAWjgBgAAA30PvorhjXRAAAAAElFTkSuQmCC","orcid":"","institution":"University of Ulsan College of Medicine","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Hyun","middleName":"Jung","lastName":"Koo","suffix":""},{"id":70338366,"identity":"ccf1243f-2179-4e7e-8b78-12762b3d97ef","order_by":3,"name":"Dae-Hee Kim","email":"","orcid":"","institution":"University of Ulsan College of Medicine","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Dae-Hee","middleName":"","lastName":"Kim","suffix":""},{"id":70338367,"identity":"94edfa40-1102-4f87-9092-376bb8bc5440","order_by":4,"name":"Soyeon Lim","email":"","orcid":"","institution":"Ulsan University Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Soyeon","middleName":"","lastName":"Lim","suffix":""},{"id":70338368,"identity":"dc4bb19c-2078-43eb-9e52-006e0fbe9dc4","order_by":5,"name":"Jun Bum Kim","email":"","orcid":"","institution":"University of Ulsan College of Medicine","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Jun","middleName":"Bum","lastName":"Kim","suffix":""},{"id":70338369,"identity":"d89af8e6-60bb-4801-9ab4-682810bcb428","order_by":6,"name":"Jong-Min Song","email":"","orcid":"","institution":"University of Ulsan College of Medicine","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Jong-Min","middleName":"","lastName":"Song","suffix":""},{"id":70338370,"identity":"0550e1b5-6449-4bf7-9590-9b8effbbb019","order_by":7,"name":"Duk-Hyun Kang","email":"","orcid":"","institution":"University of Ulsan College of Medicine","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Duk-Hyun","middleName":"","lastName":"Kang","suffix":""},{"id":70338371,"identity":"08571f7a-23d3-4caa-86ae-577e15706b2f","order_by":8,"name":"Jae-Kwan Song","email":"","orcid":"","institution":"University of Ulsan College of Medicine","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Jae-Kwan","middleName":"","lastName":"Song","suffix":""},{"id":70338372,"identity":"db8a2529-77e7-45e9-aade-8099941b8058","order_by":9,"name":"Hwa Jung Kim","email":"","orcid":"","institution":"University of Ulsan College of Medicine","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Hwa","middleName":"Jung","lastName":"Kim","suffix":""},{"id":70338373,"identity":"5cfe6219-af66-4b72-bbbf-6fa5fb7b09a5","order_by":10,"name":"Joon-Won Kang","email":"","orcid":"","institution":"University of Ulsan College of Medicine","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Joon-Won","middleName":"","lastName":"Kang","suffix":""},{"id":70338374,"identity":"f9d078b1-3720-46f7-afb5-cbf60d43df05","order_by":11,"name":"Dong Hyun Yang","email":"","orcid":"","institution":"University of Ulsan College of Medicine","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Dong","middleName":"Hyun","lastName":"Yang","suffix":""}],"badges":[],"createdAt":"2021-12-08 09:14:13","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-1151439/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-1151439/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":16550403,"identity":"ea0f315c-da16-4c54-8e3d-f9b6831973fb","added_by":"auto","created_at":"2021-12-17 14:18:06","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":106836,"visible":true,"origin":"","legend":"\u003cp\u003eBox plot to demonstrate the distribution of AVA\u003csub\u003eecho\u003c/sub\u003e, AVA\u003csub\u003eCT\u003c/sub\u003e, and AVA\u003csub\u003eplani\u003c/sub\u003e according to categories of aortic stenosis\u003c/p\u003e\u003cp\u003eAS, aortic stenosis; AVA, aortic valve area; LF-LG, low-flow and low-gradient\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-1151439/v1/38c767ff9e92fea175fc3360.jpg"},{"id":16550406,"identity":"ebf69dd0-cc2d-43e7-8c12-ef179dc2064c","added_by":"auto","created_at":"2021-12-17 14:18:07","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":581347,"visible":true,"origin":"","legend":"\u003cp\u003e(a)\u003cstrong\u003e \u003c/strong\u003ePearson correlation analysis result and (b) Bland−Altman plot to comparison of AVA\u003csub\u003eCT\u003c/sub\u003e and AVA\u003csub\u003eecho\u003c/sub\u003e\u003c/p\u003e\u003cp\u003eAS, aortic stenosis; AVA, aortic valve area; LF-LG, low-flow and low-gradient\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-1151439/v1/15a02cca0b44694faa5e8227.jpg"},{"id":16550405,"identity":"c2b603c6-1b46-4e6c-9d3d-fd3e500ae03b","added_by":"auto","created_at":"2021-12-17 14:18:07","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":281700,"visible":true,"origin":"","legend":"\u003cp\u003eSurvival according to (a) B-type natriuretic peptide, (b) presence of atrial fibrillation, and (c) categories of aortic stenosis\u003c/p\u003e\u003cp\u003eAS, aortic stenosis; LF-LG, low-flow and low-gradient\u003c/p\u003e","description":"","filename":"3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-1151439/v1/7fee268c07092f53c8359ee1.jpg"},{"id":16550407,"identity":"50865747-5956-495d-8cb3-ab1f2c0b184a","added_by":"auto","created_at":"2021-12-17 14:18:07","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":130144,"visible":true,"origin":"","legend":"\u003cp\u003eCharacteristics of classic LF-LG AS\u003c/p\u003e\u003cp\u003eAS, aortic stenosis; BNP, B-type natriuretic peptide; EDVI, end-diastolic volume index; ESVI, end-systolic volume index; LVEF, left ventricular ejection fraction;\u003c/p\u003e","description":"","filename":"4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-1151439/v1/3e83c60431d74a165ac26c1d.jpg"},{"id":16550513,"identity":"85c4b5d5-f59d-4f02-b9d3-cc137c3cf741","added_by":"auto","created_at":"2021-12-17 14:21:10","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":731866,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-1151439/v1/7126421e-00f9-431a-94a2-717a36684695.pdf"},{"id":16550512,"identity":"822f500c-920e-4f4b-af0a-c7569f9ac814","added_by":"auto","created_at":"2021-12-17 14:21:07","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":1675100,"visible":true,"origin":"","legend":"","description":"","filename":"LFLGSupplementaryFile.docx","url":"https://assets-eu.researchsquare.com/files/rs-1151439/v1/b10321eee02d036ffc2dd5b2.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eLow-Flow, Low-Gradient Severe Aortic Stenosis: Cardiac Computed Tomography Findings and Clinical Outcomes After Aortic Valve Replacement\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eClassic low-flow, low-gradient (LF-LG) severe aortic stenosis (AS) is defined by a small aortic valve (AV) area (AVA) on echocardiography (AVA\u003csub\u003eecho\u003c/sub\u003e\u0026lt;1 cm\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e), a low mean pressure gradient (PG\u0026lt;40 mmHg), and low flow (stroke volume [SV]\u0026lt;35 mL/m\u003csup\u003e2\u003c/sup\u003e). The condition is characterised by low cardiac output due to a reduced left ventricular ejection fraction (LVEF\u0026lt; 50%).\u003csup\u003e1\u0026ndash;5\u003c/sup\u003e Conversely, LF-LG AS may occur despite preserved LVEF and is classified as paradoxical LF-LG AS. Assessment of disease severity, management, and prediction of post-surgical outcome in patients with LF-LG AS is currently challenging. Since LF-LG AS presents fewer potential benefits from AV replacement (AVR) and considerable operation risks compared to true-severe AS, a classification for AS is important.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eAlthough the planimetry of the AVA using three-dimensional transoesophageal echocardiography has been reported to be more accurate than transthoracic echocardiography,\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e measurement issues still remain unresolved. Even in patients with normal systolic LV function, the grading of AS on echocardiography is inconsistent, and this is partly due to reduced SV.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e In patients with low-flow state, AS severity may be underestimated due to lower mean PG, while incomplete opening of the AV may overestimate stenosis severity because of the reduced opening forces to the AV.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e In patients with low-flow state, there can be a discrepancy between the EOA and the PG. Moreover, the continuity equation assumes circular LVOT which is elliptical shape, and echocardiography may underestimate LVOT. Additional diagnostic tests, dobutamine stress echocardiography (DSE) \u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e and AV calcium score (AVC) obtained by computed tomography (CT) scan \u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e 12\u003c/sup\u003e, have been used for the confirmation of severity and therapeutic guidance, and there is a chance that the patients with severe AS may be reclassified into the moderate range. However, reference standards used in these studies consisted of subjective assessment of the valve severity by cardiac surgeons and the AVC on CT images, which do not reflect hemodynamic severity.\u003c/p\u003e \u003cp\u003eCardiac CT is recommended as an alternative to assess AS severity when DSE is inconclusive.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e However, discrepancies have been reported between the measured AVA on cardiac CT (AVA\u003csub\u003eCT\u003c/sub\u003e) and AVA\u003csub\u003eecho\u003c/sub\u003e.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e,\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e AVA\u003csub\u003eCT\u003c/sub\u003e was significantly greater than the AVA\u003csub\u003eecho\u003c/sub\u003e calculated by continuity equation, and suggested cut-off of AVA\u003csub\u003eCT\u003c/sub\u003e for severe AS was \u0026lt;1.2 cm\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. Moreover, CT findings of LF-LG AS and imaging prognostic values remain undefined. Thus, we sought to (i) determine the CT characteristics of LF-LG AS, and (ii) evaluate prognostic factors affecting major adverse cardiovascular and cerebrovascular events (MACCE) of AS after AVR.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatient characteristics\u003c/h2\u003e \u003cp\u003eHigh-gradient severe AS (85.7% [438/511]) was most common among patients, followed by paradoxical LF-LG AS (10.8% [55/511]) and classic LF-LG AS (3.5% [18/511]). (Supplementary Table 1). Half of the patients had tricuspid valves (48.1% [246/511]) and bicuspid valves were detected in the remaining patients. The median follow-up period for all patients was 4.12 (IQR, 3.19\u0026ndash;5.50) years. MACCE occurred in 43 (8.4%) patients, and the overall mortality was 13.9% (n=71).\u003c/p\u003e \u003cp\u003eAmong the groups with high-gradient severe AS, classic LF-LG AS, and paradoxical LF-LG AS, the age of patients were not statistically different (P=0.93) (Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The number of concurrent percutaneous coronary artery intervention or CABG with AVR was highest in classic LF-LG AS group (50%, P=0.02). BNP was highest in classic LF-LG AS (median 944.5 pg/mL, P\u0026lt;0.001). MACCE was more common in the classic LF-LG AS than in the high-gradient severe AS (27.8 vs. 7.8%, P=0.01).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eClinical and imaging characteristics of high-gradient severe, classic LF-LG, paradoxical LF-LG AS groups (n=511)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigh-gradient severe AS\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eClassic LF-LG AS\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eParadoxical LF-LG AS\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo. of patients (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e438 (85.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (3.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e55 (10.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e66.8 \u0026plusmn; 8.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e66.8 \u0026plusmn; 6.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e67.3 \u0026plusmn; 9.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.93\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e236 (53.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (72.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31 (56.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.30\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBody surface area, m\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.6 \u0026plusmn; 0.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.7 \u0026plusmn; 0.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.6 \u0026plusmn; 0.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.56\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypertension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e231 (52.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (66.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30 (54.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.50\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAtrial fibrillation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e65 (14.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (22.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (7.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.20\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePCI or CABG\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e94 (21.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (50.0)\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14 (25.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.02\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBNP, pg/mL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e99.5 (43.0 \u0026ndash; 280.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e944.5 (304.8 \u0026ndash; 3066.0)\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e70.0 (35.0 \u0026ndash; 190.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003elnBNP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.6 (3.8 \u0026ndash; 5.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.8 (5.7 \u0026ndash; 8.0)\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.2 (3.6 \u0026ndash; 5.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEchocardiography\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLVEF, %\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e60.3 \u0026plusmn; 10.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36.0 \u0026plusmn; 10.3\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e62.6 \u0026plusmn; 5.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePeak velocity, m/s\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.2 \u0026plusmn; 0.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.6 \u0026plusmn; 0.5\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.5 \u0026plusmn; 0.5\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePeak PG, mmHg\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e108.5 \u0026plusmn; 30.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e52.0 \u0026plusmn; 13.1\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e50.1 \u0026plusmn; 16.0\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean PG, mmHg\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e66.5 \u0026plusmn; 19.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29.8 \u0026plusmn; 7.9\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28.0 \u0026plusmn; 9.5\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLVMI, gm/ m\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e135.4 \u0026plusmn; 35.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e149.6 \u0026plusmn; 31.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e124.9 \u0026plusmn; 36.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.03\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAV VTI, cm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e124.6 \u0026plusmn; 26.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e94.9 \u0026plusmn; 33.3\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e112.0 \u0026plusmn; 27.7\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLVOT VTI, cm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21.4 \u0026plusmn; 4.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16.0 \u0026plusmn; 4.4\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21.2 \u0026plusmn; 3.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLVOT diameter, mm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21.0 \u0026plusmn; 1.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21.8 \u0026plusmn; 1.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21.2 \u0026plusmn; 1.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.06\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLVOT diameter/BSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12.9 \u0026plusmn; 1.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13.1 \u0026plusmn; 1.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13.0 \u0026plusmn; 1.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.55\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAVA\u003csub\u003eecho\u003c/sub\u003e, mm\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e61.3 \u0026plusmn; 14.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e66.9 \u0026plusmn; 15.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e69.5 \u0026plusmn; 13.8\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eESVI, mL/m\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27.7 \u0026plusmn; 16.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e63.4 \u0026plusmn; 27.0\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24.5 \u0026plusmn; 11.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEDVI, mL/m\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e66.8 \u0026plusmn; 23.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e96.3 \u0026plusmn; 29.3\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e64.3 \u0026plusmn; 24.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSAC, mL/m\u003csup\u003e2\u003c/sup\u003e/mmHg\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.8 \u0026plusmn; 0.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.7 \u0026plusmn; 0.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.8 \u0026plusmn; 0.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.28\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eZva, mmHg/mL/m\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.3 \u0026plusmn; 1.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.0 \u0026plusmn; 1.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.4 \u0026plusmn; 1.4\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCT findings\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eValve morphology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.04\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTricuspid\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e204 (46.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (77.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28 (50.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBicuspid with raphe\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e106 (24.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (16.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17 (30.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBicuspid without raphe\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e128 (29.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (5.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10 (18.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAVC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3027.2 \u0026plusmn; 1872.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2895.5 \u0026plusmn; 1624.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2363.1 \u0026plusmn; 1605.8\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.04\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLVOT mean diameter\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24.8 \u0026plusmn; 2.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27.1 \u0026plusmn; 2.7\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24.7 \u0026plusmn; 2.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAVA\u003csub\u003eCT\u003c/sub\u003e, mm\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e84.9 \u0026plusmn; 23.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100.8 \u0026plusmn; 22.7\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e94.2 \u0026plusmn; 25.0\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAVA\u003csub\u003eplani\u003c/sub\u003e, mm\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e87.2 \u0026plusmn; 23.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e99.7 \u0026plusmn; 25.5\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e97.5 \u0026plusmn; 27.1\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAortic annulus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCircularity, %\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e81.6 \u0026plusmn; 7.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e77.4 \u0026plusmn; 6.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e82.3 \u0026plusmn; 6.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaximal dimeter, mm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27.5 \u0026plusmn; 3.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30.4 \u0026plusmn; 3.5\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27.4 \u0026plusmn; 2.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean diameter, mm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24.9 \u0026plusmn; 2.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26.9 \u0026plusmn; 2.5\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25.0 \u0026plusmn; 2.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.005\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePerimeter, mm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e79.5 \u0026plusmn; 8.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e85.4 \u0026plusmn; 7.7\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e80.0 \u0026plusmn; 8.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.02\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eArea, mm\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e481.8 \u0026plusmn; 102.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e554.8 \u0026plusmn; 101.0\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e489.5 \u0026plusmn; 99.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSinus of Valsalva, mm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36.6 \u0026plusmn; 4.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38.4 \u0026plusmn; 4.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e36.8 \u0026plusmn; 5.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.25\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eST junction, mm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30.9 \u0026plusmn; 4.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31.7 \u0026plusmn; 3.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31.5 \u0026plusmn; 5.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.58\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAscending aorta tubular portion, mm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40.7 \u0026plusmn; 6.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38.4 \u0026plusmn; 4.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e40.4 \u0026plusmn; 7.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.31\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNormalized to BSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAVA\u003csub\u003eCT\u003c/sub\u003e, mm\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e51.7 \u0026plusmn; 13.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60.7 \u0026plusmn; 15.8\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e58.0 \u0026plusmn; 15.6\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAVA\u003csub\u003eplani\u003c/sub\u003e, mm\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e52.6 \u0026plusmn; 13.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e59.5 \u0026plusmn; 17.5\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e57.8 \u0026plusmn; 15.2\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.005\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAortic annulus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaximal dimeter, mm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16.8 \u0026plusmn; 2.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18.2 \u0026plusmn; 2.6\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16.9 \u0026plusmn; 1.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean diameter, mm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15.2 \u0026plusmn; 1.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16.1 \u0026plusmn; 1.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15.4 \u0026plusmn; 1.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.06\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePerimeter, mm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e48.7 \u0026plusmn; 5.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e51.1 \u0026plusmn; 5.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e49.2 \u0026plusmn; 5.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eArea, mm\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e293.4 \u0026plusmn; 55.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e331.0 \u0026plusmn; 56.6\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e299.7 \u0026plusmn; 55.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.02\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSinus of Valsalva, mm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22.4 \u0026plusmn; 2.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23.0 \u0026plusmn; 2.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22.6 \u0026plusmn; 2.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.65\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eST junction diameter, mm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18.9 \u0026plusmn; 2.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18.9 \u0026plusmn; 2.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19.3 \u0026plusmn; 3.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.69\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAscending aorta tubular portion, mm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25.0 \u0026plusmn; 4.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23.0 \u0026plusmn; 2.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24.8 \u0026plusmn; 4.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.15\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgical valve size, mm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22.1 \u0026plusmn; 2.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23.0 \u0026plusmn; 2.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22.3 \u0026plusmn; 2.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.18\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgical valve type\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCE Magna\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e144\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eATSAP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHancock\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSt. Jude Regent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperator\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.47\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperator 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e170\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperator 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperator 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperator 4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperator 5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMACCE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34 (7.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (27.8) \u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (7.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOverall mortality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e57 (13.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (33.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8 (14.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFollow-up duration, d\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1517.5 (1188.8 \u0026ndash; 2026.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1134.0 (26.0 \u0026ndash; 1682.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1455.0 (1112.0 \u0026ndash; 1944.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.007\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eValues are means \u0026plusmn; standard deviations or numbers and percentages in parentheses. \u003csup\u003e*\u003c/sup\u003eSignificant difference between patients with severe aortic stenosis and patients with classic low-flow, low-gradient, severe aortic stenosis (classic LF-LG AS) groups. \u003csup\u003e\u0026dagger;\u003c/sup\u003eSignificant difference between severe aortic stenosis and paradoxical LF-LG AS groups. AS, aortic stenosis; AVA, aortic valve area; AVC, aortic valve calcium score; BNP, B-type natriuretic peptide; EDVI, end-diastolic volume index; ESVI, end-systolic volume index; LF-LG, low-flow and low-gradient; lnBNP, log-transformed B-type natriuretic peptide; LVEF, left ventricular ejection fraction; LVMI, left ventricular mass index; LVOT, left ventricular outflow tract; MACCE, major adverse cardiac and cerebrovascular event; N/A, not available; PG, pressure gradient; SAC, systemic arterial compliance; VTI, velocity time integral; Zva, valvulo-arterial impedance.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eEchocardiography\u003c/h2\u003e \u003cp\u003eLVEF, transaortic peak velocity and PG were lower in the classic LF-LG AS group and reflected the characteristics of LF-LG AS (P\u0026lt;0.001, for all) (Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The ESVI (63.4 vs. 27.7 mL/m\u003csup\u003e2\u003c/sup\u003e, P\u0026lt;0.001) and EDVI (96.3 vs. 66.8 mL/m\u003csup\u003e2\u003c/sup\u003e, P\u0026lt;0.001) were significantly larger in classic LF-LG AS, compared to the high-gradient severe AS group. SAC was not different among the groups (P=0.28), although Zva was lower in paradoxical LF-LG AS compared to others (P\u0026lt;0.001).\u003c/p\u003e \u003cp\u003eWe found that AVA\u003csub\u003eCT\u003c/sub\u003e \u0026ge;1.2 cm\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e was noted in 27.8% (5/18) of the patients with classic LF-LG AS (Figure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). In classic LF-LG AS, AVA\u003csub\u003eecho\u003c/sub\u003e was larger in patients with AVA\u003csub\u003eCT\u003c/sub\u003e\u0026ge;1.2 cm\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e than those with AVA\u003csub\u003eCT\u003c/sub\u003e\u0026lt;1.2cm\u003csup\u003e2\u003c/sup\u003e (61.1 vs. 81.9 mm\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e, P=0.005) (Supplementary Table 2). However, other echocardiography parameters such as LVEF, peak velocity, and PG were not statistically different between subgroups with AVA\u003csub\u003eCT\u003c/sub\u003e\u0026lt;1.2cm\u003csup\u003e2\u003c/sup\u003e and AVA\u003csub\u003eCT\u003c/sub\u003e\u0026ge;1.2 cm\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e (P\u0026gt;0.05, for all). In patients with paradoxical LF-LG AS, AVA\u003csub\u003eecho\u003c/sub\u003e was larger in AVA\u003csub\u003eCT\u003c/sub\u003e\u0026ge;1.2cm\u003csup\u003e2\u003c/sup\u003e group (68.2 vs. 77.3 mm\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e, P=0.08), but without statistical significance.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eComputed tomography\u003c/h2\u003e \u003cp\u003eInterobserver agreements for aortic root measurement on CT are high with the range of ICC from 89.2~97.0. (Supplementary Table 3). The pearson correlation coefficient for AVA\u003csub\u003eecho\u003c/sub\u003e and AVA\u003csub\u003eCT\u003c/sub\u003e was good (r=0.73, P\u0026lt;0.001). AVA\u003csub\u003eCT\u003c/sub\u003e is larger than AVA\u003csub\u003eecho\u003c/sub\u003e and the mean difference between AVA\u003csub\u003eecho\u003c/sub\u003e and AVA\u003csub\u003eCT\u003c/sub\u003e was 24.1 mm\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e (95% CI, \u0026minus;8.3 to 56.4 mm\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e, P\u0026lt;0.001) (Figure \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eA and \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eB). Comparison of AVA\u003csub\u003eecho\u003c/sub\u003e and AVA\u003csub\u003eplani\u003c/sub\u003e is presented in Supplementary Figure 2. AVC was highest in patients with high-gradient severe S, and statistically lower in paradoxical LF-LG AS and moderate AS groups (P=0.0.04). LVOT dimeter measured on CT was longer in classic LF-LG AS group compared to that in high-gradient severe AS (24.8 vs. 27.1 mm, P=0.003). The mean AVA\u003csub\u003eCT\u003c/sub\u003e was larger in the classic LF-LG AS group, compared to the high-gradient severe AS group (100.8 vs. 84.9 mm\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e, P=0.001). Normalized aortic annulus maximal diameter was longer (16.8 mm vs. 18.2 mm, P=0.01) and aortic annulus area was larger (293.4 mm\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e vs. 331.0 mm\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e, P=0.02) in classic LF-LG AS group compared to those in high-gradient severe AS.\u003c/p\u003e \u003cp\u003eIn classic LF-LG AS group, mean AVC was higher in AVA\u003csub\u003eCT\u003c/sub\u003e\u0026lt;1.2cm\u003csup\u003e2\u003c/sup\u003e group compared to that in AVA\u003csub\u003eCT\u003c/sub\u003e\u0026ge;1.2 cm\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e (3912.2 vs. 1360.1, P=0.002) (Table \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). AVA\u003csub\u003eplani\u003c/sub\u003e was also smaller in AVA\u003csub\u003eCT\u003c/sub\u003e\u0026lt;1.2cm\u003csup\u003e2\u003c/sup\u003e group compared to that in AVA\u003csub\u003eCT\u003c/sub\u003e\u0026ge;1.2 cm\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e (88.2 vs. 129.9 mm\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e, P\u0026lt;0.001). The normalized annulus sizes and aortic root diameters on CT were not statistically different between AVA\u003csub\u003eCT\u003c/sub\u003e\u0026lt;1.2cm\u003csup\u003e2\u003c/sup\u003e and AVA\u003csub\u003eCT\u003c/sub\u003e\u0026ge;1.2 cm\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e groups (P\u0026lt;0.05, for all). In paradoxical LF-LG AS patients, LVOT area normalized to BSA (289.3 vs. 345.5 mm\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e, P=0.01), normalized sizes of aortic annulus area (292.7 vs. 341.4 mm\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e, P=0.02), sinus of Valsalva (22.1 vs. 25.2 mm, P=0.003) and ST junction (30.6 vs. 36.7 mm, P=0.006) were larger in AVA\u003csub\u003eCT\u003c/sub\u003e\u0026ge;1.2 cm\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e group, compared to those measured in patients with AVA\u003csub\u003eCT\u003c/sub\u003e\u0026lt;1.2cm\u003csup\u003e2\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSubgroups of LF-LG AS according to AVA\u003csub\u003eCT\u003c/sub\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eClassic LF-LG AS (n = 18)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003eParadoxical LF-LG AS (n = 55)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAVA\u003csub\u003eCT\u003c/sub\u003e\u0026lt;1.2cm\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAVA\u003csub\u003eCT\u003c/sub\u003e\u0026ge;1.2 cm\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAVA\u003csub\u003eCT\u003c/sub\u003e \u0026lt;1.2 cm\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAVA\u003csub\u003eCT\u003c/sub\u003e\u0026ge;1.2 cm\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo. of patients (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (72.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (27.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e47 (85.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e8 (14.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e66.1 \u0026plusmn; 5.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e68.6 \u0026plusmn; 7.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e67.3 \u0026plusmn; 9.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e67.3 \u0026plusmn; 10.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.99\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (69.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (80.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e25 (53.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e6 (75.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.72\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBSA, m\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.7 \u0026plusmn; 0.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.6 \u0026plusmn; 0.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.6 \u0026plusmn; 0.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.7 \u0026plusmn; 0.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.34\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypertension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (53.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (100.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e26 (55.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4 (50.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAtrial fibrillation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (23.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (20.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2 (4.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2 (25.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePCI or CABG\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (46.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (60.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e14 (25.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRheumatic valvular disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (15.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6 (12.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2 (25.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.33\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eB-type natriuretic peptide, pg/mL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1118.0 (304.8 \u0026ndash; 3066.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e738.5 (239.3 \u0026ndash; 3227.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e59.0 (32.5 \u0026ndash; 180.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e200.5 (59.0 \u0026ndash; 305.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.38\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003elnBNP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.0 (5.7 \u0026ndash; 8.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.6 (5.0 \u0026ndash; 7.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.1 (3.5 \u0026ndash; 5.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5.2 (4.1 \u0026ndash; 5.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlood urea nitrogen, mg/dL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25.2 \u0026plusmn; 16.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18.6 \u0026plusmn; 4.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e18.8 \u0026plusmn; 8.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e18.0 \u0026plusmn; 4.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.81\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCreatinine, mg/dL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.1 \u0026plusmn; 2.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.9 \u0026plusmn; 1.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.0 \u0026plusmn; 0.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.9 \u0026plusmn; 0.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.46\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEchocardiography\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLVEF, %\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36.9 \u0026plusmn; 11.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33.8 \u0026plusmn; 8.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e62.8 \u0026plusmn; 5.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e61.5 \u0026plusmn; 4.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.53\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePeak velocity, m/s\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.6 \u0026plusmn; 0.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.4 \u0026plusmn; 0.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.5 \u0026plusmn; 0.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.6 \u0026plusmn; 0.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.67\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePeak PG, mmHg\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e53.5 \u0026plusmn; 11.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48.0 \u0026plusmn; 17.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e49.5 \u0026plusmn; 16.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e53.4 \u0026plusmn; 16.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.53\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean PG, mmHg\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30.8 \u0026plusmn; 6.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27.2 \u0026plusmn; 10.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e27.7 \u0026plusmn; 9.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e29.8 \u0026plusmn; 10.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.59\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLVMI, gm/ m\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e151.5 \u0026plusmn; 33.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e144.7 \u0026plusmn; 26.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e121.5 \u0026plusmn; 32.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e144.6 \u0026plusmn; 50.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAV TVI, cm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e101.3 \u0026plusmn; 34.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e78.2 \u0026plusmn; 26.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e114.2 \u0026plusmn; 28.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e98.9 \u0026plusmn; 21.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.15\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLVOT TVI, cm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16.0 \u0026plusmn; 4.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16.2 \u0026plusmn; 3.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e21.4 \u0026plusmn; 3.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e19.7 \u0026plusmn; 3.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.24\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLVOT diameter, mm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22.1 \u0026plusmn; 2.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21.2 \u0026plusmn; 0.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e21.0 \u0026plusmn; 1.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e22.2 \u0026plusmn; 2.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.18\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLVOT diameter/BSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12.9 \u0026plusmn; 1.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13.6 \u0026plusmn; 1.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13.0 \u0026plusmn; 1.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e13.2 \u0026plusmn; 1.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.75\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAVA\u003csub\u003eecho\u003c/sub\u003e, mm\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e61.1 \u0026plusmn; 12.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e81.9 \u0026plusmn; 9.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.005\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e68.2 \u0026plusmn; 13.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e77.3 \u0026plusmn; 12.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.08\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eESVI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e63.0 \u0026plusmn; 30.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e64.4 \u0026plusmn; 20.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e23.4 \u0026plusmn; 10.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e30.7 \u0026plusmn; 14.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEDVI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e96.4 \u0026plusmn; 32.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95.9 \u0026plusmn; 21.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e62.0 \u0026plusmn; 22.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e78.4 \u0026plusmn; 31.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.08\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSAC, mL/m\u003csup\u003e2\u003c/sup\u003e/mmHg\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.7 \u0026plusmn; 0.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.6 \u0026plusmn; 0.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.7 \u0026plusmn; 0.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.0 \u0026plusmn; 0.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.21\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eZva, mmHg/mL/m\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.7 \u0026plusmn; 1.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.8 \u0026plusmn; 2.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.5 \u0026plusmn; 1.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.8 \u0026plusmn; 1.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.21\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCT findings\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eValve morphology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTricuspid\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (69.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (100.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e26 (55.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2 (25.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBicuspid\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (30.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e21 (44.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e6 (75.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAVC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3912.2 (2247.0 \u0026ndash; 4496.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1360.1 (960.1 \u0026ndash; 2108.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2002.4 (1192.2 \u0026ndash; 2841.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2584.3 (1306.5 \u0026ndash; 5172.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAVA\u003csub\u003eCT\u003c/sub\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e92.4 \u0026plusmn; 15.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e122.7 \u0026plusmn; 25.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.007\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e90.2 \u0026plusmn; 22.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e117.7 \u0026plusmn; 27.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAVA\u003csub\u003eplani\u003c/sub\u003e, mm\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e88.2 \u0026plusmn; 20.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e129.9 \u0026plusmn; 5.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e90.1 \u0026plusmn; 21.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e140.9 \u0026plusmn; 13.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLVOT area\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e587.5 \u0026plusmn; 129.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e572.3 \u0026plusmn; 79.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e468.9 \u0026plusmn; 94.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e581.3 \u0026plusmn; 94.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAortic annulus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaximum diameter, mm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30.6 \u0026plusmn; 3.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30.0 \u0026plusmn; 2.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e27.1 \u0026plusmn; 2.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e29.0 \u0026plusmn; 3.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCircularity, %\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e77.6 \u0026plusmn; 7.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e76.9 \u0026plusmn; 4.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e82.0 \u0026plusmn; 5.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e83.8 \u0026plusmn; 7.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.18\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean diameter, mm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27.1 \u0026plusmn; 2.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26.5 \u0026plusmn; 1.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e24.7 \u0026plusmn; 2.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e27.0 \u0026plusmn; 3.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePerimeter, mm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e86.0 \u0026plusmn; 8.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e83.8 \u0026plusmn; 3.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e78.7 \u0026plusmn; 7.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e87.3 \u0026plusmn; 10.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eArea, mm\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e563.3 \u0026plusmn; 116.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e532.8 \u0026plusmn; 45.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e475.2 \u0026plusmn; 91.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e572.9 \u0026plusmn; 113.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.009\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSinus of Valsalva, mm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e39.3 \u0026plusmn; 4.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36.1 \u0026plusmn; 3.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e35.9 \u0026plusmn; 4.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e42.0 \u0026plusmn; 4.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eST junction, mm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32.1 \u0026plusmn; 3.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30.7 \u0026plusmn; 2.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e30.6 \u0026plusmn; 5.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e36.7 \u0026plusmn; 7.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.006\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAscending aorta, mm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e39.5 \u0026plusmn; 4.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35.5 \u0026plusmn; 4.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e39.6 \u0026plusmn; 7.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e45.1 \u0026plusmn; 9.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.06\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNormalized to BSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAVA\u003csub\u003eCT\u003c/sub\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e53.9 \u0026plusmn; 9.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e78.3 \u0026plusmn; 16.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e55.9 \u0026plusmn; 14.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e70.3 \u0026plusmn; 17.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAVA\u003csub\u003eplani\u003c/sub\u003e, mm\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e51.5 \u0026plusmn; 12.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e82.7 \u0026plusmn; 6.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e55.7 \u0026plusmn; 12.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e84.1 \u0026plusmn; 10.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLVOT area, mm\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e341.2 \u0026plusmn; 69.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e365.5 \u0026plusmn; 54.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e289.3 \u0026plusmn; 55.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e345.5 \u0026plusmn; 54.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAortic annulus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaximal dimeter, mm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17.9 \u0026plusmn; 2.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19.2 \u0026plusmn; 2.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e16.8 \u0026plusmn; 1.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e17.4 \u0026plusmn; 1.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.37\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean diameter, mm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15.8 \u0026plusmn; 2.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17.0 \u0026plusmn; 1.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e15.3 \u0026plusmn; 1.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e16.1 \u0026plusmn; 1.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.20\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePerimeter, mm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50.2 \u0026plusmn; 6.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e53.6 \u0026plusmn; 5.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e48.7 \u0026plusmn; 4.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e52.0 \u0026plusmn; 6.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eArea, mm\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e327.6 \u0026plusmn; 65.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e339.7 \u0026plusmn; 26.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e292.7 \u0026plusmn; 50.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e341.4 \u0026plusmn; 71.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.02\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSinus of Valsalva\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22.9 \u0026plusmn; 3.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23.0 \u0026plusmn; 2.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e22.1 \u0026plusmn; 2.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e25.1 \u0026plusmn; 3.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.007\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eST junction diameter\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18.7 \u0026plusmn; 1.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19.6 \u0026plusmn; 2.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e18.9 \u0026plusmn; 2.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e21.9 \u0026plusmn; 5.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAscending aorta tubular portion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23.1 \u0026plusmn; 3.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22.6 \u0026plusmn; 2.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e24.5 \u0026plusmn; 4.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e26.9 \u0026plusmn; 5.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.18\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgical valve size, mm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23.2 \u0026plusmn; 2.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22.6 \u0026plusmn; 1.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e22.1 \u0026plusmn; 2.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e23.3 \u0026plusmn; 1.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMACCE (cardiovascular death)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (15.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (60.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4 (8.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOverall mortality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (30.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (40.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7 (14.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1 (12.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003eAS, aortic stenosis; AVA, aortic valve area; AVA\u003csub\u003eCT\u003c/sub\u003e, AVA measured on CT; AVC, aortic valve calcium score; BSA, body surface area; EDVI, end-diastolic volume index; ESVI, end-systolic volume index; LF-LG, low-flow and low-gradient; lnBNP, log-transformed B-type natriuretic peptide; LVEF, left ventricular ejection fraction; LVMI, left ventricular mass index; LVOT, left ventricular outflow tract; MACCE, major adverse cardiac and cerebrovascular event; VTI, velocity time integral.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eOutcome analysis\u003c/h2\u003e \u003cp\u003eMACCE were composed of arrhythmia (n=6), nonfatal cerebrovascular accident (CVA) (n=10), nonfatal myocardial infarction (n=4), heart failure (n=4), reoperation (n=1), and cardiovascular death (n=18). To identify clinical and radiological factors that affect MACCE, cox-proportional hazard regression analysis was performed (Table \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). In univariate analysis, older age, high BNP, high blood urea nitrogen and creatinine, presence of preoperative AF, tricuspid AV, classic LF-LG AS, small AV VTI and LVOT VTI, and small aortic annulus were factors significantly associated with MACCE (P\u0026lt;0.05, for all).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCox proportional hazard regression model for prediction of MACCE\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eUnivariate\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eMultivariable\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParameter\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHR (95% CI)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHR (95% CI)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.06 (1.02\u0026ndash;1.10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.005\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.04 (1.00\u0026ndash;1.09)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.049\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBody surface area, m\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.49 (0.08\u0026ndash;3.15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eB-type natriuretic peptide, 10 pg/mL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.01 (1.003\u0026ndash;1.01)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.005 (1.003\u0026ndash;1.01)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003elnBNP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.42 (1.13\u0026ndash;1.77)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAtrial fibrillation, (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.22 (1.70\u0026ndash;6.11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.75 (1.40\u0026ndash;5.40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLVEF, %\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.98 (0.96\u0026ndash;1.01)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePeak velocity, m/s\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.80 (0.57\u0026ndash;1.12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean PG, mmHg\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.99 (0.98\u0026ndash;1.01)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLVMI, gm/ m\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.99 (0.99\u0026ndash;1.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eESVI, mL/m\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.01 (0.99\u0026ndash;1.02)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEDVI, mL/m\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.00 (0.99\u0026ndash;1.01)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSAC, mL/m\u003csup\u003e2\u003c/sup\u003e/mmHg\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.57 (0.21\u0026ndash;1.53)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eZva, mmHg/mL/m\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.00 (0.83\u0026ndash;1.20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBicuspid aortic valve\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.40 (0.21\u0026ndash;0.77)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.006\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClassic LF-LG AS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.04 (1.98\u0026ndash;12.84)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.53 (1.74\u0026ndash;17.56)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.004\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAVA\u003csub\u003eecho\u003c/sub\u003e, m\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.01 (0.99\u0026ndash;1.03)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAV VTI, cm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.98 (0.96\u0026ndash;0.99)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLVOT VTI, cm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.92 (0.86\u0026ndash;0.99)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003elnAVC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.89 (0.71\u0026ndash;1.09)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNormalized AVA\u003csub\u003eplani\u003c/sub\u003e, mm\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.00 (0.98\u0026ndash;1.03)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNormalized AVA\u003csub\u003eCT\u003c/sub\u003e, mm\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.02 (1.00\u0026ndash;1.04)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnnulus circularity, %\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.34 (0.01\u0026ndash;18.69)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAortic annulus area, cm\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.73 (0.53 \u0026ndash; 1.01)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.57 (0.40 \u0026ndash; 0.81)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgical valve size, mm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.89 (0.77\u0026ndash;1.04)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgical valve type\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCE Magna\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eATSAP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.55 (0.20 \u0026ndash; 1.48)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHancock\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.09 (0.50 \u0026ndash; 2.38)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSt. Jude Regent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.63 (0.25 \u0026ndash; 1.59)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.85 (0.31 \u0026ndash; 2.31)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperator\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperator 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperator 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.63 (0.78 \u0026ndash; 3.38)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperator 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.37 (0.05 \u0026ndash; 2. 76)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperator 4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.94 (0.37 \u0026ndash; 2.41)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperator 5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.73 (0.30 \u0026ndash; 1.78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eAS, aortic stenosis; AVA, aortic valve area; AVC, aortic valve calcium score; EDVI, end-diastolic volume index; ESVI, end-systolic volume index; HR, hazard ratio; LF-LG, low-flow and low-gradient; lnBNP, log-transformed B-type natriuretic peptide;LVEF, left ventricular ejection fraction; LVMI, left ventricular mass index; LVOT, left ventricular outflow tract; MACCE, major adverse cardiac and cerebrovascular event; PG, Pressure gradient; SAC, systemic arterial compliance; VTI, velocity time integral; Zva, valvulo-arterial impedance.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eOn multivariable analysis, old age (hazard ratio [HR], 1.04, 95%CI, 1.00\u0026ndash;1.09; P=0.049), high BNP (HR, 1.005; 95%CI, 1.003\u0026ndash;1.01 P\u0026lt;0.001), AF (HR, 2.75; 95% CI, 1.40\u0026ndash;5.40; P=0.003), classic LF LG AS (HR, 5.53; 95%CI, 1.74\u0026ndash;17.56; P=0.004), and small aortic annulus area (cm\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e), [HR, 0.57; 95%CI, 0.40\u0026ndash;0.81; P=0.002]) were factors significantly associated with MACCE (Table \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Normalized aortic annulus area (cm\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e) (HR, 0.40; 95%CI, 0.22\u0026ndash;0.74; P=0.004) was also a significantly associated factor when the parameter was substitute instead of aortic annulus area in multivariable analysis. When the normalized aortic sinus of Valsalva diameter instead of the aortic annulus size was substituted in the calculation, the weight of the other factors remained almost unchanged, while the normalized aortic sinus of Valsalva diameter (cm) (HR, 0.30; 95%CI, 0.09\u0026ndash;0.98; P=0.04) was also identified as a significant factor.\u003c/p\u003e \u003cp\u003eKaplan-Meier curves indicated significant mortality in the high BNP group (BNP\u0026gt;700 pg/mL) compared to the low BNP group (P=0.001) (Figure \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eA). Furthermore, preoperative AF was also associated with significant mortality (Figure \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eB) (P\u0026lt;0.001), and the outcome of classic LF-LG AS was worse in the cumulative survival curve (Figure \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eC) (P=0.001).\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study highlights the characteristics of LF-LG AS focusing on CT findings. The AVA\u003csub\u003eCT\u003c/sub\u003e and aortic annulus were larger in classic LF-LG AS compared to those in high-gradient severe AS and 27.8% of classic LF-LG AS patients presented AVA\u003csub\u003eCT\u003c/sub\u003e\u0026ge;1.2 cm\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. High BNP, preoperative AF, classic LF-LG AS, and smaller aortic root were associated with MACCE after AVR.\u003c/p\u003e \u003cp\u003eClassic LF-LG AS patients demonstrated higher ESVI and EDVI, lower LVEF, larger AVA\u003csub\u003eecho\u003c/sub\u003e and AVA\u003csub\u003eCT\u003c/sub\u003e, and larger aortic annulus compared to high-gradient severe AS. The key messages of this study are demonstrated in Figure \u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e. In a previous study, patients with severe AS had significantly larger aortic annulus and ST junction diameters compared with those measured in control groups.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e This could be attributed to aortic root remodelling: as severe AS progresses ESVI and EDVI increase to compensate, and dilated LV cavity may lead to dilatation of the aortic annulus. Failure to compensate may result in heart failure. Since the BNP was higher in classic LF-LG AS and the group presented poor outcome compared to high-gradient severe AS, classic LF-LG AS may be a compensation failure of high-gradient severe AS. Paradoxical LF-LG AS presented preserved ESVI, EDVI, and LVEF, although AVA\u003csub\u003eecho\u003c/sub\u003e and AVA\u003csub\u003eCT\u003c/sub\u003e were larger than in high-gradient severe AS.\u003c/p\u003e \u003cp\u003eIn this study, we used cut-off value of AVA\u003csub\u003eCT\u003c/sub\u003e\u0026lt;1.2 cm\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e as this value was suggested for severe AS in a previous study.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e However, in classic LF-LG AS group, approximately one third of the patients exhibited AVA\u003csub\u003eCT\u003c/sub\u003e\u0026ge;1.2 cm\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. AVC was lower in the AVA\u003csub\u003eCT\u003c/sub\u003e\u0026ge;1.2 cm\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e compared to that of AVA\u003csub\u003eCT\u003c/sub\u003e\u0026lt;1.2cm\u003csup\u003e2\u003c/sup\u003e group, and in this group, moderate AS patients might be misclassified as severe AS and vice versa. This can also be applied to paradoxical LF-LG patients, despite 14.5% of these patients presenting AVA\u003csub\u003eCT\u003c/sub\u003e\u0026ge;1.2 cm\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. Although we could not derive the role of AVA\u003csub\u003eCT\u003c/sub\u003e in diagnosing LF-LG AS patients, further studies whether AVA\u003csub\u003eCT\u003c/sub\u003e could be used to discriminate true LF-LG AS are would be of value.\u003c/p\u003e \u003cp\u003eThe outcome of AS after AVR was associated with preoperative high BNP levels, AF, classic LF-LG AS, and small aortic root. The plasma BNP level was associated with LV dysfunction in AS, and was a well-known predictor of poor outcome in patients with AS overall and after AVR.\u003csup\u003e\u003cspan additionalcitationids=\"CR18\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e AF is also a dominant predictor in both asymptomatic and symptomatic patients with moderate to severe AS, and after AVR.\u003csup\u003e\u003cspan additionalcitationids=\"CR21\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e Classic LF-LG AS was associated with worse outcomes after AVR compared those observed in high-gradient AS patients, although LF-LG AS patients have displayed survival benefits with AVR.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e Finally, small aortic root measured on CT was an independent prognostic factor. This finding should be interpreted cautiously. When AS severity progresses, the increased LV cavity volume may increase the size of the aortic annulus and sinus of Valsalva. However, a small aortic root has also been associated with increased ischemic cardiovascular events and mortality in patients with AS,\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e possibly reflecting impaired root remodelling process and atherosclerotic changes.\u003c/p\u003e \u003cp\u003eOur study has several limitations. Because this is a retrospective study using a patient cohort that underwent AVR, patients not indicated for surgery due to poor general conditions or comorbidities or who declined operation were not included. The selection bias may affect the outcome assessment, and AVR itself was not used as an outcome parameter. Instead, we used MACCE after AVR. Therefore, the outcomes of this study may not directly infer the outcomes of AS population managed with diverse treatment options. Further studies with AS managed by conservative treatment, surgical AVR, and transcatheter AVR could be of value to evaluate overall outcomes of AS patients. Second, because the small number of LF-LG AS patients, we could not observe the role of AVA\u003csub\u003eCT\u003c/sub\u003e for reclassification of LF-LG AS. However, we showed the CT characteristics of LF-LG AS: AVA\u003csub\u003eCT\u003c/sub\u003e and aortic annulus were larger in classic LF-LG AS compared to those in high-gradient severe AS. This finding may be explained by the aortic root remodelling which is associated with the dilated LV. Third, although classic LF-LG patients showed higher overall mortality and a large aortic annulus, a small aortic root was one of the factors associated with MACCE. Both decreased LV function in classic LF-LG AS and impaired aortic root remodelling may contribute to the outcome, respectively, but further studies are necessary to provide more evidences.\u003c/p\u003e \u003cp\u003eIn conclusion, classic LF-LG AS presented larger AVA\u003csub\u003eCT\u003c/sub\u003e and aortic annulus than high-gradient severe AS. Old age, high BNP, AF, classic LF-LG AS and small aortic root on CT were associated with MACCE after AVR. These findings suggest the potential role of cardiac CT in classification and outcome assessment of severe AS.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003ePatients\u003c/h2\u003e \u003cp\u003e This retrospective study was approved by the institutional review board committee of the Asan Medical Center, University of Ulsan College of Medicine (approval number: 2018-0233) and informed consent was waived by the institutional review board committee of the Asan Medical Center, University of Ulsan College of Medicine due to the retrospective nature of observational study. This study was performed in accordance with the Helsinki Declaration. Between June 2011 and Mar 2016, 781 patients underwent surgical AVR. The use of CT was determined mainly by clinician\u0026rsquo;s decision, but in our hospital, cardiac CT examination is generally performed in most of the patients who have performed planned surgical AVR for evaluation of AV and root morphology based on the guidelines for the appropriate use of cardiac CT\u003csup\u003e\u003cspan additionalcitationids=\"CR25 CR26\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e. After excluding patients with moderate AS (n=24), moderate degree of concomitant aortic regurgitation or other valvular heart disease (n=177), patients not subjected to preoperative cardiac CT (n=47) or CT without multiphase data (n=21), and a patient with quadricuspid AV (n=1), 511 patients were included. High-gradient severe AS was defined as AVA\u003csub\u003eecho\u003c/sub\u003e\u0026lt;1 cm\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e and a mean trans-valvular gradient \u0026ge;40 mmHg with LVEF \u0026lt; 50%. Classic LF-LG severe AS was defined as AVA\u003csub\u003eecho\u003c/sub\u003e\u0026lt;1 cm\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e, but with a low-gradient (\u0026lt;40 mmHg). Low-gradient severe AS with preserved LVEF was defined as paradoxical LF-LG AS. We classified patients with AS into three groups: 1) high-gradient severe; 2) classic LF-LG; and 3) paradoxical LF-LG AS. Clinical findings including age, body surface area (BSA), hypertension, atrial fibrillation (AF), B-type natriuretic peptide (BNP), echocardiography parameters, and cardiac CT data were collected. Postoperative echocardiography findings and reported clinical outcomes were comprehensively reviewed. Clinical outcomes included all-cause mortality and MACCE (composite of cardiac death, cerebrovascular accident or stroke, coronary artery revascularization or myocardial infarction, and redo-AVR) were evaluated.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eEchocardiography\u003c/h2\u003e \u003cp\u003ePreoperatively, all patients underwent transthoracic echocardiography using commercially available ultrasound machines with 3\u0026ndash;5 MHz real-time transducers (iE33, EPIC; Philips Medical Systems, Andover, MA; Vivid 7, E9, General Electric Healthcare, Waukesha, WI, USA). Comprehensive two-dimensional and Doppler images were obtained by expert cardiologists according to American Society of Echocardiography recommendations.\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e End-systolic volume, end-diastolic volume, and LVEF were obtained with the biplane Simpson method. The maximal aortic jet velocity was recorded with the apical, right parasternal, or suprasternal window that yielded the highest-velocity signal. The maximal and mean PG across the AV were estimated using a modified Bernoulli equation, and the AVA was calculated from the continuity equation. LV mass and LV mass indexed to body surface area calculated by LV cavity dimension and LV wall thickness at end-diastole. Systemic arterial compliance (SAC) was calculated as the ratio of SV index (SVI)/pulse pressure,\u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e and valvulo-arterial impedance (Zva), which is a parameter for global LV load, was defined as (systolic blood pressure + mean net aortic gradient)/SVI.\u003csup\u003e30\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eCardiac CT protocol and image analysis\u003c/h2\u003e \u003cp\u003ePreoperative cardiac CT was performed using a second-generation dual-source CT scanner (Somatom Definition Flash; Siemens Medical Solutions, Forchheim, Germany). Detailed CT protocol is described in supplementary file 1. Post-processing was conducted using an external workstation (AquariusNet; TeraRecon, Foster City, CA, USA) using multiphase CT data sets reconstructed by a 10% R-R interval. CT analysis methods are described in supplementary figure 1. CT characteristics such as AV morphology (tricuspid, bicuspid with raphe, and bicuspid without raphe), AVA\u003csub\u003eCT\u003c/sub\u003e, AVA obtained by planimetry (AVA\u003csub\u003eplani\u003c/sub\u003e), aortic annulus diameter, perimeter, and area, circularity (minimum annulus diameter/maximum annulus diameter\u0026times;100), and diameters of sinus of Valsalva, sinotubular (ST) junction, and ascending aorta tubular portion were measured by two experienced radiologists in consensus (BLINDED). AVA\u003csub\u003eCT\u003c/sub\u003e was calculated by using the LV outflow tract (LVOT) area measured on CT in the continuity equation with velocity time integrals (VTI) at LVOT and transaortic flow: AVA\u003csub\u003eCT\u003c/sub\u003e=LVOT\u003csub\u003eCT\u003c/sub\u003e\u0026times;VTI\u003csub\u003eLVOT\u003c/sub\u003e/VTI\u003csub\u003eAo\u003c/sub\u003e.\u003c/p\u003e \u003cp\u003eAVC was defined as a CT density of 130 Hounsfield units or greater confined to AV on non-enhanced cardiac gated images and measured using the methods suggested by Agatston et al. The AVC was measured using a commercially available software (Syngo.via Siemens Healthcare, Berlin, Germany).\u003csup\u003e\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eSystolic phase with largest AVA (20~30% RR) was selected and thick multiplanar reconstruction images were used to demarcate the tips of the aortic cusps for measuring AVA\u003csub\u003eplani\u003c/sub\u003e. To evaluate reliability of CT measurements, a third experienced radiologist (BLINDED) measured CT parameters in 100 randomly selected cases and interobserver agreement was determined. Observers were blinded to clinical data including echocardiography findings and operation records.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eStatistics\u003c/h2\u003e \u003cp\u003eContinuous variables were expressed as mean \u0026plusmn; standard deviation or median with interquartile range (IQR) and categorical variables are presented as numbers and percentages. Interobserver agreement of CT findings was determined using a two-way random model intra-class correlation coefficient (ICC) with consistency assumption. Comparison of AVA measured on echocardiography (AVA\u003csub\u003eecho\u003c/sub\u003e) and CT including AVA\u003csub\u003eCT\u003c/sub\u003e and AVA\u003csub\u003eplani\u003c/sub\u003e was performed using Pearson correlations and Bland-Altman plots were graphed. One way ANOVA with post-hoc (Tukey) test or Kruskall-Wallis test and Chi-square test were used to compare baseline clinical and radiological findings among high-gradient severe AS, classic LF-LG AS, paradoxical LF-LG AS, and moderate AS groups. Bonferroni correction was applied to control the type I error for multiple comparison, and P-value 0.05/4=0.0125 was used for comparing the three groups. Student t-test and Chi-square test were performed to compare two subgroups among the three groups. In LF-LG AS patients, clinical and CT findings for AVA\u003csub\u003eCT\u003c/sub\u003e\u0026lt;1.2 cm\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e and AVA\u003csub\u003eCT\u003c/sub\u003e\u0026ge;1.2 cm\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e were compared using the Student t-test and Chi-square test or Fisher\u0026rsquo;s exact test. For the stratification of risk factors for MACCE after AVR, cox proportional hazard models were used. Kaplan-Meier survival curves were drawn for statistically significant factors to predict MACCE. The 95% confidence intervals (CIs) were calculated and factors with P\u0026lt;0.10 were included for multivariable cox regression analysis with enter method. To avoid multicollinearity, one of the aortic root parameters was included in the multivariable analysis among the CT parameters significantly associated with MACCE in univariate analysis. For BNP analysis, a continuous parameter was used and a cut-off of 700 pg/mL\u003csup\u003e32\u003c/sup\u003e was set for outcome analysis using Kaplan-Meier curves.\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e P\u0026lt;0.05 was considered statistically significant, except for multiple dependant variable analyses. Statistical analysis was performed using commercial software (SPSS, version 20; SPSS, Chicago, IL, USA).\u003c/p\u003e "},{"header":"Declarations","content":"\u003cp\u003e\u003cb\u003eData availability\u003c/b\u003e\u003c/p\u003e \u003cp\u003eAll data used during the current study are included in this published article or are available from the corresponding author upon reasonable request.\u003c/p\u003e \n\u003cp\u003e\u003cstrong\u003eContributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConception: H.J.K. and D.K., Data curation: H.J.K., S.L., J.B.K. J-M.S. D-K.K, J-K. S., J-W. K., D.H.Y., Statistical analyses, H.J.K., and H.J.K, Manuscript writing: S.J.C., Y.A., H.J.K., Revising the manuscript: H.J.K. and D.K. All authors approved the final version of this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was supported by a grant (2021IT0006) from the Asan Institute for Life Sciences, Asan Medical Center, Seoul, Korea.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAdda, J. et al. Low-flow, low-gradient severe aortic stenosis despite normal ejection fraction is associated with severe left ventricular dysfunction as assessed by speckle-tracking echocardiography: a multicenter study. Circ Cardiovasc Imaging \u003cstrong\u003e5\u003c/strong\u003e, 27-35, doi:10.1161/CIRCIMAGING.111.967554 (2012).\u003c/li\u003e\n\u003cli\u003eAnnabi, M. S. et al. Dobutamine Stress Echocardiography for Management of Low-Flow, Low-Gradient Aortic Stenosis. Journal of the American College of Cardiology \u003cstrong\u003e71\u003c/strong\u003e, 475-485, doi:10.1016/j.jacc.2017.11.052 (2018).\u003c/li\u003e\n\u003cli\u003eClavel, M. A., Magne, J. \u0026amp; Pibarot, P. Low-gradient aortic stenosis. European heart journal \u003cstrong\u003e37\u003c/strong\u003e, 2645-2657, doi:10.1093/eurheartj/ehw096 (2016).\u003c/li\u003e\n\u003cli\u003eNishimura, R. A. et al. 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation \u003cstrong\u003e129\u003c/strong\u003e, 2440-2492, doi:10.1161/CIR.0000000000000029 (2014).\u003c/li\u003e\n\u003cli\u003ePibarot, P. \u0026amp; Dumesnil, J. G. Low-flow, low-gradient aortic stenosis with normal and depressed left ventricular ejection fraction. Journal of the American College of Cardiology \u003cstrong\u003e60\u003c/strong\u003e, 1845-1853, doi:10.1016/j.jacc.2012.06.051 (2012).\u003c/li\u003e\n\u003cli\u003eDumesnil, J. G. \u0026amp; Pibarot, P. Low gradient severe aortic stenosis with preserved ejection fraction: don\u0026apos;t forget the flow! Rev Esp Cardiol (Engl Ed) \u003cstrong\u003e66\u003c/strong\u003e, 245-247, doi:10.1016/j.rec.2012.10.019 (2013).\u003c/li\u003e\n\u003cli\u003eMinners, J. et al. Inconsistencies of echocardiographic criteria for the grading of aortic valve stenosis. European heart journal \u003cstrong\u003e29\u003c/strong\u003e, 1043-1048, doi:10.1093/eurheartj/ehm543 (2008).\u003c/li\u003e\n\u003cli\u003eMinners, J. et al. Inconsistent grading of aortic valve stenosis by current guidelines: haemodynamic studies in patients with apparently normal left ventricular function. Heart (British Cardiac Society) \u003cstrong\u003e96\u003c/strong\u003e, 1463-1468, doi:10.1136/hrt.2009.181982 (2010).\u003c/li\u003e\n\u003cli\u003eOh, J. K. et al. Prediction of the severity of aortic stenosis by Doppler aortic valve area determination: prospective Doppler-catheterization correlation in 100 patients. Journal of the American College of Cardiology \u003cstrong\u003e11\u003c/strong\u003e, 1227-1234 (1988).\u003c/li\u003e\n\u003cli\u003edeFilippi, C. R. et al. Usefulness of dobutamine echocardiography in distinguishing severe from nonsevere valvular aortic stenosis in patients with depressed left ventricular function and low transvalvular gradients. The American journal of cardiology \u003cstrong\u003e75\u003c/strong\u003e, 191-194 (1995).\u003c/li\u003e\n\u003cli\u003eKoos, R. et al. Aortic valve calcification as a marker for aortic stenosis severity: assessment on 16-MDCT. AJR. American journal of roentgenology \u003cstrong\u003e183\u003c/strong\u003e, 1813-1818, doi:10.2214/ajr.183.6.01831813 (2004).\u003c/li\u003e\n\u003cli\u003ePawade, T. et al. Computed Tomography Aortic Valve Calcium Scoring in Patients With Aortic Stenosis. Circ Cardiovasc Imaging \u003cstrong\u003e11\u003c/strong\u003e, e007146, doi:10.1161/circimaging.117.007146 (2018).\u003c/li\u003e\n\u003cli\u003eCueff, C. et al. Measurement of aortic valve calcification using multislice computed tomography: correlation with haemodynamic severity of aortic stenosis and clinical implication for patients with low ejection fraction. Heart (British Cardiac Society) \u003cstrong\u003e97\u003c/strong\u003e, 721-726, doi:10.1136/hrt.2010.198853 (2011).\u003c/li\u003e\n\u003cli\u003eClavel, M. A. et al. Aortic valve area calculation in aortic stenosis by CT and Doppler echocardiography. JACC. Cardiovascular imaging \u003cstrong\u003e8\u003c/strong\u003e, 248-257, doi:10.1016/j.jcmg.2015.01.009 (2015).\u003c/li\u003e\n\u003cli\u003eHalpern, E. J., Mallya, R., Sewell, M., Shulman, M. \u0026amp; Zwas, D. R. Differences in aortic valve area measured with CT planimetry and echocardiography (continuity equation) are related to divergent estimates of left ventricular outflow tract area. AJR. American journal of roentgenology \u003cstrong\u003e192\u003c/strong\u003e, 1668-1673, doi:10.2214/ajr.08.1986 (2009).\u003c/li\u003e\n\u003cli\u003eStolzmann, P. et al. Remodelling of the aortic root in severe tricuspid aortic stenosis: implications for transcatheter aortic valve implantation. European radiology \u003cstrong\u003e19\u003c/strong\u003e, 1316-1323, doi:10.1007/s00330-009-1302-0 (2009).\u003c/li\u003e\n\u003cli\u003eIwahashi, N., Nakatani, S., Umemura, S., Kimura, K. \u0026amp; Kitakaze, M. Usefulness of plasma B-type natriuretic peptide in the assessment of disease severity and prediction of outcome after aortic valve replacement in patients with severe aortic stenosis. Journal of the American Society of Echocardiography : official publication of the American Society of Echocardiography \u003cstrong\u003e24\u003c/strong\u003e, 984-991, doi:10.1016/j.echo.2011.03.012 (2011).\u003c/li\u003e\n\u003cli\u003eCapoulade, R. et al. Prognostic value of plasma B-type natriuretic peptide levels after exercise in patients with severe asymptomatic aortic stenosis. Heart (British Cardiac Society) \u003cstrong\u003e100\u003c/strong\u003e, 1606-1612, doi:10.1136/heartjnl-2014-305729 (2014).\u003c/li\u003e\n\u003cli\u003eDahou, A. et al. B-Type Natriuretic Peptide and High-Sensitivity Cardiac Troponin for Risk Stratification in Low-Flow, Low-Gradient Aortic Stenosis: A Substudy of the TOPAS Study. JACC. Cardiovascular imaging \u003cstrong\u003e11\u003c/strong\u003e, 939-947, doi:10.1016/j.jcmg.2017.06.018 (2018).\u003c/li\u003e\n\u003cli\u003eMinamino-Muta, E. et al. Causes of Death in Patients with Severe Aortic Stenosis: An Observational study. Scientific reports \u003cstrong\u003e7\u003c/strong\u003e, 14723, doi:10.1038/s41598-017-15316-6 (2017).\u003c/li\u003e\n\u003cli\u003eThourani, V. H. et al. Outcomes in 937 Intermediate-Risk Patients Undergoing Surgical Aortic Valve Replacement in PARTNER-2A. The Annals of thoracic surgery \u003cstrong\u003e105\u003c/strong\u003e, 1322-1329, doi:10.1016/j.athoracsur.2017.10.062 (2018).\u003c/li\u003e\n\u003cli\u003eBahler, R. C. et al. Predicting Outcomes in Patients With AsymptomaticModerate to Severe Aortic Stenosis. The American journal of cardiology \u003cstrong\u003e122\u003c/strong\u003e, 851-858, doi:10.1016/j.amjcard.2018.05.027 (2018).\u003c/li\u003e\n\u003cli\u003eBahlmann, E. et al. Small aortic root in aortic valve stenosis: clinical characteristics and prognostic implications. European heart journal cardiovascular Imaging \u003cstrong\u003e18\u003c/strong\u003e, 404-412, doi:10.1093/ehjci/jew159 (2017).\u003c/li\u003e\n\u003cli\u003eBeck KS, K. J., Choe YH, Hian SK, Hoe J, Hong YJ, et al. . 2017 Multimodality Appropriate Use Criteria for Noninvasive Cardiac Imaging: Expert Consensus of the Asian Society of Cardiovascular Imaging. Cardiovasc Imag Asia \u003cstrong\u003e1\u003c/strong\u003e, 156-165 (2017).\u003c/li\u003e\n\u003cli\u003eKim, Y. J. et al. Korean guidelines for the appropriate use of cardiac CT. Korean journal of radiology \u003cstrong\u003e16\u003c/strong\u003e, 251-285, doi:10.3348/kjr.2015.16.2.251 (2015).\u003c/li\u003e\n\u003cli\u003eTsai, I. C. et al. ASCI 2010 appropriateness criteria for cardiac computed tomography: a report of the Asian Society of Cardiovascular Imaging Cardiac Computed Tomography and Cardiac Magnetic Resonance Imaging Guideline Working Group. The international journal of cardiovascular imaging \u003cstrong\u003e26 Suppl 1\u003c/strong\u003e, 1-15, doi:10.1007/s10554-009-9577-4 (2010).\u003c/li\u003e\n\u003cli\u003eNishimura, R. A. et al. 2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Journal of the American College of Cardiology, doi:10.1016/j.jacc.2017.03.011 (2017).\u003c/li\u003e\n\u003cli\u003eMitchell, C. et al. Guidelines for Performing a Comprehensive Transthoracic Echocardiographic Examination in Adults: Recommendations from the American Society of Echocardiography. Journal of the American Society of Echocardiography : official publication of the American Society of Echocardiography \u003cstrong\u003e32\u003c/strong\u003e, 1-64, doi:10.1016/j.echo.2018.06.004 (2019).\u003c/li\u003e\n\u003cli\u003ede Simone, G. et al. Stroke volume/pulse pressure ratio and cardiovascular risk in arterial hypertension. Hypertension (Dallas, Tex. : 1979) \u003cstrong\u003e33\u003c/strong\u003e, 800-805 (1999).\u003c/li\u003e\n\u003cli\u003eBriand, M. et al. Reduced systemic arterial compliance impacts significantly on left ventricular afterload and function in aortic stenosis: implications for diagnosis and treatment. Journal of the American College of Cardiology \u003cstrong\u003e46\u003c/strong\u003e, 291-298, doi:10.1016/j.jacc.2004.10.081 (2005).\u003c/li\u003e\n\u003cli\u003eAgatston, A. S. et al. Quantification of coronary artery calcium using ultrafast computed tomography. Journal of the American College of Cardiology \u003cstrong\u003e15\u003c/strong\u003e, 827-832, doi:10.1016/0735-1097(90)90282-t (1990).\u003c/li\u003e\n\u003cli\u003eSakurai, S. et al. Brain natriuretic peptide facilitates severity classification of stable chronic heart failure with left ventricular dysfunction. Heart (British Cardiac Society) \u003cstrong\u003e89\u003c/strong\u003e, 661-662, doi:10.1136/heart.89.6.661 (2003).\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"cardiac computed tomographic, Aortic valve calcium, echocardiography, surgical AVR","lastPublishedDoi":"10.21203/rs.3.rs-1151439/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-1151439/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eAortic valve calcium scoring by cardiac computed tomographic (CT) has been recommended as an alternative to classify the AS severity, but it is unclear that whether CT findings can predict and have prognostic implication in low-flow, low-gradient aortic stenosis (LF-LG AS), which has fewer benefit from surgery among the AS subtypes. In this study, we examined the clinical and cardiac CT findings of LF-LG AS patients and evaluated factors affecting outcomes after surgical aortic valve replacement (AVR). This study included 511 (66.9±8.8 years, 55% men) consecutive patients with severe AS who underwent surgical AVR. Aortic valve area (AVA) was obtained by echocardiography (AVA\u003csub\u003eecho\u003c/sub\u003e) and by CT (AVA\u003csub\u003eCT\u003c/sub\u003e) using each modalities measurement of the left ventricular outflow tract. Patients with AS were classified as 1) high-gradient severe (n=438), 2) classic LF-LG (n=18), and 3) paradoxical LF-LG (n=55) based on echocardiography. Classic LF-LG AS patients had higher end-systolic and end-diastolic volume indices, lower left ventricular ejection fraction, larger AVA\u003csub\u003eecho\u003c/sub\u003e and AVA\u003csub\u003eCT\u003c/sub\u003e, and larger aortic annulus compared to high-gradient severe AS (P\u0026lt;0.05, for all). In classic LF-LG AS group, 27.8% of patients presented AVA\u003csub\u003eCT\u003c/sub\u003e≥1.2 cm\u003csup\u003e2\u003c/sup\u003e. After multivariable adjustment, old age (hazard ratio [HR], 1.04, P=0.049), high B-type natriuretic peptide (BNP) (HR, 1.005; P\u0026lt;0.001), preoperative atrial fibrillation (HR, 2.75; P=0.003), classic LF-LG AS (HR, 5.53, P=0.004), and small aortic annulus (HR, 0.57; P=0.002) were independently associated with major adverse cardiac and cerebrovascular events (MACCE). The classic LF-LG AS group presented larger AVA\u003csub\u003eCT\u003c/sub\u003e and aortic annulus than those in high-gradient severe AS group and one third of them had AVA\u003csub\u003eCT\u003c/sub\u003e ≥1.2 cm\u003csup\u003e2\u003c/sup\u003e. Old age, high BNP, atrial fibrillation, classic LF-LG AS, and small aortic annulus were associated with MACCE in severe AS patients after surgical AVR.\u003c/p\u003e","manuscriptTitle":"Low-Flow, Low-Gradient Severe Aortic Stenosis: Cardiac Computed Tomography Findings and Clinical Outcomes After Aortic Valve Replacement","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2021-12-17 14:18:05","doi":"10.21203/rs.3.rs-1151439/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2022-01-31T06:35:36+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2022-01-23T22:37:42+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"6f6e2dd6-54d9-4809-a8a3-ea4dda850818","date":"2022-01-17T20:50:02+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"475f0860-06e4-4be5-b1e4-4498e1205aca","date":"2022-01-03T19:50:10+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2021-12-22T10:05:16+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2021-12-21T13:54:29+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2021-12-15T12:26:06+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2021-12-15T12:11:56+00:00","index":"","fulltext":""},{"type":"submitted","content":"Scientific Reports","date":"2021-12-08T09:10:13+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c5eec7b4-f59a-4dfc-9728-70d01204b29b","owner":[],"postedDate":"December 17th, 2021","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[{"id":9214439,"name":"Cardiac \u0026 Cardiovascular Systems"}],"tags":[],"updatedAt":"2022-04-25T06:59:07+00:00","versionOfRecord":[],"versionCreatedAt":"2021-12-17 14:18:05","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-1151439","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-1151439","identity":"rs-1151439","version":["v1"]},"buildId":"cBFmMYwuxLRRLfASyISRj","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}