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Micheal Chung

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    MS10 - Lung Cancer Screening, Opportunistic Evaluation of Findings (ID 73)

    • Event: WCLC 2019
    • Type: Mini Symposium
    • Track: Screening and Early Detection
    • Presentations: 1
    • Now Available
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      MS10.03 - Aortic Valve Calcifications (Now Available) (ID 3494)

      15:45 - 17:15  |  Author(s): Micheal Chung

      • Abstract
      • Presentation
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      INTRODUTION: Smoking is a major risk factor for both cardiovascular disease and lung cancer. Low-dose computed tomography (LDCT) screening for lung cancer provides an opportunity to identify both diseases in asymptomatic smokers (1). The extent of aortic valve calcification (AVC) is the predominant driver of degenerative aortic valve stenosis (AS) (2), which is an underdiagnosed and undertreated disease. Cardiovascular morbidity and mortality is higher for people with moderate/severe AVC as compared to those with none or mild AVC as demonstrated on echocardiography (3). Our study aimed to assess sensitivity and reliability of visual AVC scoring on LDCT for predicting AS in older smokers. In addition, we aimed to determine the frequency of any AVC and its significant predictors in a program of LDCT screening for lung cancer, separately on baseline and annual repeat screenings.

      MOTHODS: We reviewed 1225 consecutive participants in annual LDCT screening for lung cancer at the Mount Sinai Hospital before July 2018, who had at least two LDCTs without aortic valve replacement (AVR) before enrolled. The baseline LDCT was the first scan obtained at the time of enrollment and the most recent LDCT was the last LDCT obtained before July 2018, unless the participant had either AVR or had died before July 2018; for these cases, the last LDCT scan before surgery or death was used. Sensitivity and specificity of moderate/severe visual AVC score on LDCT to identify AS on echocardiogram was calculated for 126 participants who had both tests within 12 months. Using regression analyses, risk factors for AVC at baseline, for progression, and for new AVC on annual rounds of screening were identified. Reliability of AVC assessment on LDCT was assessed by comparing AVC visual scores with 1) standard-dose, electrocardiography (ECG)-gated CT for 31 participants who had both tests within 12 months, 2) with Agatston scores of 1225 participants on the most recent follow-up LDCT, and 3) by determining the intra-reader agreement on baseline LDCTs and separately for the most recent LDCTs of all participants.

      RESULTS: Among these 126 participants who had LDCT and echocardiography within 12 months, 7 (5.6%) were diagnosed with moderate/severe AS, 3 (2.4%) were diagnosed with mild AS, 37 (29.4%) with aortic sclerosis, and 79 (62.7%) with no sclerosis or AS (Table 1). Of the 3 diagnosed as severe AS on echocardiography, all 3 had severe (grade 3) AVC on LDCT and of the 4 diagnosed as moderate AS on echocardiography, all 4 had moderate (grade 2) AVC on LDCT. Visual AVC scores on LDCT had substantial agreement with the severity of AS on echocardiography (weighted kappa=0.68, 95% CI: 0.56, 0.80). In addition, correlation was significant between the AVC visual scores on LDCT and both the echocardiographically determined mean pressure gradient (p = 0.02) and aortic valve area (p = 0.02) in these 10 participants with AS. Sensitivity and specificity of moderate/severe visual AVC scores for moderate/severe AS on echocardiogram was 100% and 94%, respectively.

      There is substantial inter- (total weighted kappa of 0.73) and excellent intra-observer agreement (Baseline LDCT: weighted Kappa=0.91, 95% CI: 0.88-0.95; The most recent LDCT: weighted Kappa=0.90, 95% CI: 0.88-0.92).

      Of the 1225 participants, no AVC was identified on the baseline LDCT in 1081 (88.2%), while 116 had mild AVC (grade 1), 26 moderate AVC (grade 2), and 2 severe AVC (grade 3). On the most recent LDCT, median follow-up time from baseline LDCT was 10.9 years (IQR: 4.2 to 15.1 yrs.), 865 (70.6%) had no AVC, 262 (21.4%) mild AVC, 80 (6.5%) moderate AVC, and 18 (1.5%) severe AVC. Multivariable logistic regression analysis showed significant predictors for baseline AVC were male sex (OR=3.39), age (OR=1.11) and CAC score (OR=1.28), for AVC progression after baseline, was pack-years of smoking (HR=1.01), and for new AVC on annual LDCT, were male sex (HR=1.65), age (HR=1.06), and BMI (HR=1.06).

      CONCLUSIONS: Our results suggest that moderate to severe AVC scores could be reliably obtained on LDCT, should also be reported on screening LDCTs and further workup by echocardiography should be recommended as finding moderate or severe AVC on LDCT was associated with a high probability of AS in asymptomatic smokers.


      1. Lu MT, Onuma OK, Massaro JM, D'Agostino RB, Sr., O'Donnell CJ, Hoffmann U. Lung Cancer Screening Eligibility in the Community: Cardiovascular Risk Factors, Coronary Artery Calcification, and Cardiovascular Events. Circulation. 2016;134(12):897-9.

      2. Nguyen V, Cimadevilla C, Estellat C, et al. Haemodynamic and anatomic progression of aortic stenosis. Heart. 2015;101(12):943-7.

      3. Otto CM, Lind BK, Kitzman DW, Gersh BJ, Siscovick DS. Association of aortic-valve sclerosis with cardiovascular mortality and morbidity in the elderly. The New England journal of medicine. 1999;341(3):142-7.

      TABLE 1. Agreement of AVC Score on LDCT by Extent of Aortic Stenosis on Echocardiogram Among Those Who Had Both Tests Within 12 Months.

      Aortic stenosis categories based on Echocardiography*

      No Aortic Stenosis

      Aortic Stenosis



      Aortic sclerosis




      Visual AVC scores

      None (0)







      Mild (1)







      Moderate (2)







      Severe (3)














      Weighted Kappa=0.68 (95% CI: 0.56, 0.80).

      FIGURE 1. Visual and Agatston AVC Scoring.

      figure 1.jpg

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