Personne : Dahou, Abdellaziz
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Université Laval. Faculté de médecine
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- PublicationAccès libreNouveaux marqueurs pronostiques dans la sténose aortique à bas débit(2017) Dahou, Abdellaziz; Beaudoin, Jonathan; Pibarot, Philippe; Clavel, Marie-AnnickLa sténose aortique (SA) est la valvulopathie la plus fréquente dans les pays industrialisés. La SA avec bas débit cardiaque n’est pas une condition rare. Environ 5-10% des patients ayant une SA sévère présentent un état de bas débit cardiaque avec fraction d’éjection ventriculaire gauche (FEVG) diminuée (< 50%; c.-à-d. bas débit classique), et environ 10-25% présentent une SA à bas débit (SABD) malgré la présence d’une FEVG préservée (> 50%; c.-à-d. bas débit paradoxal). La présence d’un faible débit cardiaque s’accompagne souvent d’un bas gradient avec une petite aire valvulaire aortique (AVA) ce qui peut fausser l’évaluation de la sévérité de la sténose et conduire à une mauvaise décision thérapeutique. Deux principaux défis se posent chez ces patients afin de guider le traitement : le premier est de différentier une SA vraiment sévère (SAVS) d’une SA pseudo-sévère (SAPS) et le deuxième est de quantifier avec précision les dommages myocardiques pour mieux stratifier le risque. Malheureusement, les paramètres traditionnels dérivés de l’échocardiographie de repos ou de stress qui sont utilisés pour évaluer la sévérité de la SA et la fonction cardiaque sont loin d’être optimaux. Par conséquent, la quantification de la sévérité de la maladie et la prise en charge thérapeutique peuvent être inappropriées dans une proportion non négligeable de ces patients. L’objectif général de ce projet de doctorat est de déterminer quels sont, parmi les facteurs échocardiographiques, électrocardiographiques, et sanguins ceux qui permettent de mieux préciser la sévérité de la SA et l’atteinte myocardique et prédire de façon indépendante la survenue de morbidité et mortalité. Le but ultime est d’améliorer les algorithmes de stratification du risque et de décision thérapeutique chez ces patients.
- PublicationRestreintAssociation between plasma lipoprotein levels and bioprosthetic valve structural degeneration(BMJ, 2016-07-04) Dahou, Abdellaziz; Bouchareb, Rihab; Arsenault, Benoit; Larose, Éric; Mahjoub, Haïfa; Boulanger, Marie-Chloé; Bossé, Yohan; Mahmut, Ablajan; Pibarot, Philippe; Després, Jean-Pierre; Nsaibia, Mohamed Jalloul; Mathieu, PatrickIntroduction: Structural valve degeneration (SVD) leads to the failure of aortic valve bioprostheses. It is suspected that lipid-derived factors could play a role in SVD. We hypothesised that oxidised low-density lipoprotein (OxLDL), OxLDL/LDL, OxLDL/high-density lipoprotein (OxLDL/HDL) and proprotein convertase subtilisin/kexin 9 (PCSK9) may be associated with SVD. Methods: We included 199 patients who underwent an aortic valve replacement with a bioprosthesis and had an echocardiography follow-up to evaluate the function of the prosthesis. SVD was defined as an increase in mean transprosthetic gradient (=10 mm Hg) or a worsening of transprosthetic regurgitation (=1/3) during the follow-up. Results: After a mean follow-up of 8±3.5 years, 41(21%) patients developed SVD. The univariate predictors of SVD were LDL (p=0.03), apolipoprotein B (p=0.01), OxLDL (p=0.02), OxLDL/HDL (p=0.009) and LDL associated with small, dense particles (LDL-C<255Å) (p=0.02). In a model adjusted for covariates, only OxLDL/HDL (OR 1.49, 95%CI 1.08 to 2.07 per 10 units, p=0.01) remained associated with SVD. There was a significant interaction between OxLDL/HDL and PCSK9 on SVD (p=0.05). After adjustment, compared with patients with low OxLDL/HDL (median, <25.4) and low PCSK9 (median, <298 ng/mL) (referent), patients with both an elevated OxLDL/HDL ratio and PCSK9 had a higher risk of SVD (OR 2.93, 95% CI 1.02 to 9.29, p=0.04). Conclusions: OxLDL/HDL ratio is independently associated with SVD.
- PublicationRestreintCardiovascular magnetic resonance to evaluate aortic regurgitation after transcatheter aortic valve replacement(Elsevier, 2016-08-09) Campelo-Parada, Francisco; Orwat, Stefan; Dahou, Abdellaziz; Hayek, Salim; Abdul-Jawad Altisent, Omar; Larose, Éric; Babaliaros, Vasilis; Rodés-Cabau, Josep; Le Ven, Florent; Ribeiro, Henrique Barbosa; Pasian, Sergio; Pibarot, Philippe; Clavel, Marie-Annick; Puri, Rishi; Lerakis, Stamatios A.; Baumgartner, HelmutBackground: Residual aortic regurgitation (AR) following transcatheter aortic valve replacement (TAVR) is associated with greater mortality; yet, determining AR severity post-TAVR using Doppler echocardiography remains challenging. Cardiovascular magnetic resonance (CMR) is purported as a more accurate means of quantifying AR; however, no data exist regarding the prognostic value of AR as assessed by CMR post-TAVR. Objectives: This study sought to evaluate the effect of AR assessed with CMR on clinical outcomes post-TAVR. Methods We included 135 patients from 3 centers. AR was quantified using regurgitant fraction (RF) measured by phase-contrast velocity mapping CMR at a median of 40 days post-TAVR, and using Doppler echocardiography at a median of 6 days post-TAVR. Median follow-up was 26 months. Clinical outcomes included mortality and rehospitalization for heart failure. Results: Moderate-severe AR occurred in 17.1% and 12.8% of patients as measured by echocardiography and CMR, respectively. Higher RF post-TAVR was associated with increased mortality (hazard ratio: 1.18 for each 5% increase in RF [95% confidence interval: 1.08 to 1.30]; p < 0.001) and the combined endpoint of mortality and rehospitalization for heart failure (hazard ratio: 1.19 for each 5% increase in RF; 95% confidence interval: 1.15 to 1.23; p < 0.001). Prediction models yielded significant incremental predictive value; CMR performed a median of 40 days post-TAVR had a greater association with post-TAVR clinical events compared with early echocardiography (p < 0.01). RF =30% best predicted poorer clinical outcomes (p < 0.001 for either mortality or the combined endpoint of mortality and heart failure rehospitalization). Conclusions: Worse CMR-quantified AR was associated with increased mortality and poorer clinical outcomes following TAVR. Quantifying AR with CMR may identify patients with AR who could benefit from additional treatment measures.
- PublicationRestreintClinical value of stress transaortic flow rate during dobutamine echocardiography in reduced left ventricular ejection fraction(Lippincott Williams & Wilkins, 2021-11-08) Vamvakidou, Anastasia; Dahou, Abdellaziz; Guzzetti, Ezequiel; Annabi, Mohamed Salah; Plonska-Gosciniak, Edyta; Pibarot, Philippe; Almeida, Ana G.; Clavel, Marie-Annick; Burwash, Ian G.; Koschutnik, Matthias; Bartko, Philipp E.; Bergler-Klein, Jutta; Mascherbauer, Julia; Orwat, Stefan; Baumgartner, Helmut; Cavalcante, João L.; Pinto, Fausto J.; Kukulski, Tomasz; Kasprzak, Jaroslaw D.; Flachskampf, Frank A.; Senior, RoxyBackground: Low rest transaortic flow rate (FR) has been shown previously to predict mortality in low-gradient aortic stenosis. However limited prognostic data exists on stress FR during low-dose dobutamine stress echocardiography. We aimed to assess the value of stress FR for the detection of aortic valve stenosis (AS) severity and the prediction of mortality. Methods: This is a multicenter cohort study of patients with reduced left ventricular ejection fraction and low-gradient aortic stenosis (aortic valve area <1 cm2 and mean gradient <40 mm Hg) who underwent low-dose dobutamine stress echocardiography to identify the AS severity and presence of flow reserve. The outcome assessed was all-cause mortality. Results: Of the 287 patients (mean age, 75±10 years; males, 71%; left ventricular ejection fraction, 31±10%) over a mean follow-up of 24±30 months there were 127 (44.3%) deaths and 147 (51.2%) patients underwent aortic valve intervention. Higher stress FR was independently associated with reduced risk of mortality (hazard ratio, 0.97 [95% CI, 0.94–0.99]; P=0.01) after adjusting for age, chronic kidney disease, heart failure symptoms, aortic valve intervention, and rest left ventricular ejection fraction. The minimum cutoff for prediction of mortality was stress FR 210 mL/s. Following adjustment to the same important clinical and echocardiographic parameters, among the three criteria of AS severity during stress, ie, the guideline definition of aortic valve area <1cm2 and aortic valve mean gradient ≥40 mm Hg, or aortic valve mean gradient ≥40 mm Hg, or the novel definition of aortic valve area <1 cm2 at stress FR ≥210 mL/s, only the latter was independently associated with mortality (hazard ratio, 1.72 [95% CI, 1.05–2.82]; P=0.03). Furthermore aortic valve area <1cm2 at stress FR ≥210 mL/s was the only severe aortic stenosis criterion that was associated with improved outcome following aortic valve intervention (P<0.001). Guideline-defined stroke volume flow reserve did not predict mortality. Conclusions: Stress FR during low-dose dobutamine stress echocardiography was useful for the detection of both AS severity and flow reserve and was associated with improved prediction of outcome following aortic valve intervention.
- PublicationAccès libreComparison of early surgical or transcatheter aortic valve replacement versus conservative management in low-flow, low-gradient aortic stenosis sing Inverse Probability of Treatment Weighting: Results From the TOPAS Prospective Observational Cohort Study(John Wiley & Sons, 2020-12-08) Dahou, Abdellaziz; Côté, Nancy; Rodés-Cabau, Josep; Annabi, Mohamed Salah; Pibarot, Philippe; Clavel, Marie-AnnickBACKGROUND: No randomized comparison of early (ie, ≤3 months) aortic valve replacement (AVR) versus conservative management or of transcatheter AVR (TAVR) versus surgical AVR has been conducted in patients with low-flow, low-gradient (LFLG) aortic stenosis (AS). METHODS AND RESULTS: A total of 481 consecutive patients (75±10 years; 71% men) with LFLG AS (aortic valve area ≤0.6 cm2/m2 and mean gradient <40 mm Hg), 72% with classic LFLG and 28% with paradoxical LFLG, were prospectively recruited in the multicenter TOPAS (True or Pseudo Severe Aortic Stenosis) study. True-severe AS or pseudo-severe AS was adjudicated by flow-independent criteria. During follow-up (median [IQR] 36 [11–60] months), 220 patients died. Using inverse probability of treatment weighting to address the bias of nonrandom treatment assignment, early AVR (n=272) was associated with a major overall survival benefit (hazard ratio [HR], 0.34 [95% CI, 0.24–0.50]; P<0.001). This benefit was observed in patients with true-severe AS but also with pseudo-severe AS (HR, 0.38 [95% CI, 0.18–0.81]; P=0.01), and in classic (HR, 0.33 [95% CI, 0.22–0.49]; P<0.001) and paradoxical LFLG AS (HR, 0.42 [95% CI, 0.20–0.92]; P=0.03). Compared with conservative management in the conventional multivariate model, trans femoral TAVR was associated with the best survival (HR, 0.23 [95% CI, 0.12–0.43]; P<0.001), followed by surgical AVR (HR, 0.36 [95% CI, 0.23–0.56]; P<0.001) and alternative-access TAVR (HR, 0.51 [95% CI, 0.31–0.82]; P=0.007). In the inverse probability of treatment weighting model, trans femoral TAVR appeared to be superior to surgical AVR (HR [95% CI] 0.28 [0.11–0.72]; P=0.008) with regard to survival. CONCLUSIONS: In this large prospective observational study of LFLG AS, early AVR appeared to confer a major survival benefit in both classic and paradoxical LFLG AS. This benefit seems to extend to the subgroup with pseudo-severe AS. Our findings suggest that TAVR using femoral access might be the best strategy in these patients.
- PublicationAccès libreIntérêt de la déformation longitudinale globale du ventricule gauche chez les patients atteints de sténose aortique à bas débit et bas gradient avec basse fraction d'éjection(2014) Dahou, Abdellaziz; Rodés-Cabau, Josep; Pibarot, PhilippeLa sténose aortique est la valvulopathie la plus fréquente dans les pays industrialisés. Environ 5 à 10% des patients ayant une sténose aortique sévère présentent un état de bas débit cardiaque avec altération de la fraction d’éjection du ventricule gauche (FEVG). La présence d’un faible débit cardiaque s’accompagne souvent d’un bas gradient, ce qui peut fausser l’évaluation de la sévérité de la sténose et par conséquent conduire à une mauvaise décision thérapeutique. Deux principaux défis se posent chez ces patients. Le premier est de différentier une SA vraiment sévère d’une SA pseudo-sévère, c.à.d. un ventricule gauche défaillant qui est incapable d’ouvrir complètement une valve légèrement ou modérément sténosée. Cette distinction est cruciale car le remplacement valvulaire est bénéfique seulement dans le cas de SA vraiment sévère. Le deuxième défi est de quantifier précisément les dommages myocardiques. À cet effet, l’évaluation de la réserve contractile est importante car les patients qui n’ont pas ou peu de réserve contractile ont un haut risque de mortalité opératoire lors du remplacement valvulaire. Malheureusement, les paramètres traditionnels dérivés de l’échocardiographie de repos ou de stress qui sont utilisés pour évaluer la sévérité de la SA et la dysfonction du myocardique sont loin d’être optimaux. Par conséquent, la quantification de la sévérité de la maladie et la prise en charge thérapeutique peuvent ne pas être appropriées dans une proportion non négligeable de ces patients. Le principal objectif de ce projet de maîtrise est de déterminer l’utilité de la déformation longitudinale globale du ventricule gauche (DLG) mesurée au repos et lors d’une échocardiographie de stress à la dobutamine pour la stratification du risque et son impact sur le pronostic et la prise en charge des patients ayant une SA à bas débit et bas gradient (SABD) avec basse FEVG. Notre hypothèse est la suivante: la DLG du ventricule gauche est supérieure à la FEVG pour prédire la mortalité chez les patients avec SABD et basse FEVG inclus dans l’étude TOPAS.
- PublicationRestreintAssociation of aortic valve leaflet calcification on hemodynamic and clinical outcomes(Elsevier Biomedical, 2020-10-05) Zhang, Bin; Dahou, Abdellaziz; Clisson, Marine; Mahjoub, Haïfa; Côté, Nancy; Zenses, Anne-Sophie; Pibarot, Philippe; Clavel, Marie-Annick; Mathieu, Patrick; Salaun, ErwanBackground: The prognostic value of aortic valve calcification (AVC) measured by using multidetector computed tomography imaging has been well validated in native aortic stenosis, and sex-specific thresholds have been proposed. However, few data are available regarding the impact of leaflet calcification on outcomes after biological aortic valve replacement (AVR). Objectives: The goal of this study was to analyze the association of quantitative bioprosthetic leaflet AVC with hemodynamic and clinical outcomes, as well as its possible interaction with sex. Methods: From 2008 to 2010, a total of 204 patients were prospectively enrolled with a median of 7.0 years (interquartile range: 5.1 to 9.2 years) after biological surgical AVR. AVC measured by using the Agatston method was indexed to the cross-sectional area of aortic annulus measured by echocardiography to calculate the AVC density (AVCd). Presence of hemodynamic valve deterioration (HVD; increase in mean gradient [MG] ≥10 mm Hg and/or increase in transprosthetic regurgitation ≥1) was assessed by echocardiography in 137 patients at the 3-year follow-up. The primary clinical endpoint was mortality or aortic valve re-intervention. Results: There was no significant sex-related difference in the relationship between bioprosthetic AVCd and the progression of MG. Baseline AVCd showed an independent association with HVD at 3 years. During follow-up, there were 134 (65.7%) deaths (n = 100) or valve re-interventions (n = 47). AVCd ≥58 AU/cm2 was independently associated with an increased risk of mortality or aortic valve re-intervention (adjusted hazard ratio: 2.23; 95% confidence interval: 1.44 to 3.35; p < 0.001). The AVCd threshold combined with an MG progression threshold of 10 mm Hg amplified the stratification of patients at risk (log-rank, p < 0.001). The addition of AVCd threshold into the prediction model including traditional risk factors improved outcome prediction (net classification improvement: 0.25, p = 0.04; likelihood ratio test, p < 0.001). Conclusions: Aortic bioprosthetic leaflet calcification is strongly and independently associated with HVD and the risk of death or aortic valve re-intervention. As opposed to native aortic stenosis, there is no sex-related differences in the relationship between AVCd and hemodynamic or clinical outcomes.
- PublicationRestreintImpact of left ventricular remodelling patterns on outcomes in patients with aortic stenosis(Oxford University Press, 2017-01-07) Dahou, Abdellaziz; O'Connor, Kim; Thébault, Christophe; Shen, Mylène; Le Ven, Florent; Bédard, Élisabeth; Capoulade, Romain; Beaudoin, Jonathan; Bernier, Mathieu; Pibarot, Philippe; Dumesnil, Jean G.; Clavel, Marie-Annick; Tastet, Lionel; Arsenault, MarieAims: The objective of this study was to examine the association between the different patterns of left ventricular (LV) remodelling/hypertrophy on all-cause and cardiovascular mortality in patients with aortic stenosis (AS). Methods and results: In total, 747 consecutive patients (69 ± 14 years, 57% men) with AS and preserved LV ejection fraction were included in this study. According to LV mass index and relative wall thickness, patients were classified into four LV patterns: normal, concentric remodelling (CR), concentric hypertrophy (CH), and eccentric hypertrophy (EH). One hundred and sixteen patients (15%) had normal pattern, 66 (9%) had EH, 169 (23%) had CR, and 396 (53%) had CH. During a median follow-up of 6.4 years, 339 patients died (242 from cardiovascular causes). CH was associated with higher risk of all-cause mortality compared with the three other LV patterns (all P < 0.05). After multivariable adjustment, CH remained associated with higher risk of mortality (HR = 1.27, 95% CI 1.01–1.61, P = 0.046). There was a significant interaction (P < 0.05) between sex and CH with regards to the impact on mortality: CH was associated with worse outcome in women (P = 0.0001) but not in men (P = 0.22). In multivariable analysis, CH remained associated with higher risk of worse outcome in women (HR = 1.56, 95% CI 1.08–2.24, P = 0.018). Conclusions: This study shows that CH was independently associated with increased risk of mortality in AS patients with preserved ejection fraction. This association was observed in women but not in men. The pattern of LV remodelling/hypertrophy should be integrated in the risk stratification process in patients with AS.
- PublicationAccès libreProsthesis-patient mismatch after aortic valve replacement in the PARTNER 2 trial and registry(Elsevier, 2021-07-05) Dahou, Abdellaziz; Guzzetti, Ezequiel; Herrmann, Howard C.; Beaudoin, Jonathan; Kodali, Susheel; Annabi, Mohamed Salah; Leipsic, Jonathon; Bernier, Mathieu; Blanke, Philipp; Pibarot, Philippe; Jaber, Wael; Clavel, Marie-Annick; Mack, Michael J.; Salaun, Erwan; Ternacle, Julien; Khalique, Omar K.; Weissman, Neil J.; Douglas, Pamela; Bax, Jeroen; Xu, Ke; Alu, Maria; Rogers, Erin; Leon, Martin; Thourani, Vinod H.; Abbas, Amr E.; Hahn, Rebecca T.Objectives This study aimed to compare incidence and impact of measured prosthesis-patient mismatch (PPMM) versus predicted PPM (PPMP) after surgical aortic valve replacement (SAVR) and transcatheter aortic valve replacement (TAVR). Background TAVR studies have used measured effective orifice area indexed (EOAi) to body surface area (BSA) to define PPM, but most SAVR series have used predicted EOAi. This difference may contribute to discrepancies in incidence and outcomes of PPM between series. Methods The study analyzed SAVR patients from the PARTNER (Placement of Aortic Transcatheter Valves) 2A trial and TAVR patients from the PARTNER 2 SAPIEN 3 Intermediate Risk registry. PPM was classified as moderate if EOAi ≤0.85 cm2/m2 (≤0.70 if obese: body mass index ≥30 kg/m2) and severe if EOAi ≤0.65 cm2/m2 (≤0.55 if obese). PPMM was determined by the core lab–measured EOAi on 30-day echocardiogram. PPMP was determined by 2 methods: 1) using normal EOA reference values previously reported for each valve model and size (PPMP1; n = 929 SAVR, 1,069 TAVR) indexed to BSA; and 2) using normal reference EOA predicted from aortic annulus size measured by computed tomography (PPMP2; n = 864 TAVR only) indexed to BSA. Primary endpoint was the composite of 5-year all-cause death and rehospitalization. Results The incidence of moderate and severe PPMP was much lower than PPMM in both SAVR (PPMP1: 28.4% and 1.2% vs. PPMM: 31.0% and 23.6%) and TAVR (PPMP1: 21.0% and 0.1% and PPMP2: 17.0% and 0% vs. PPMM: 27.9% and 5.7%). The incidence of severe PPMM and severe PPMP1 was lower in TAVR versus SAVR (P < 0.001). The presence of PPM by any method was associated with higher transprosthetic gradient. Severe PPMP1 was independently associated with events in SAVR after adjustment for sex and Society of Thoracic Surgeons score (hazard ratio: 3.18;95% CI: 1.69-5.96; P < 0.001), whereas no association was observed between PPM by any method and outcomes in TAVR. Conclusions EOAi measured by echocardiography results in a higher incidence of PPM following SAVR or TAVR than PPM based on predicted EOAi. Severe PPMP is rare (<1.5%), but is associated with increased all-cause death and rehospitalization after SAVR, whereas it is absent following TAVR.
- PublicationAccès libreHemodynamic deterioration of surgically implanted bioprosthetic aortic valves(Elsevier Biomedical, 2018-07-09) Dahou, Abdellaziz; Arsenault, Benoit; Larose, Éric; Mahjoub, Haïfa; Rodés-Cabau, Josep; Pibarot, Philippe; Clavel, Marie-Annick; Puri, Rishi; Després, Jean-Pierre; Mathieu, Patrick; Salaun, ErwanBACKGROUND: Dysmetabolic proﬁle has been associated with native aortic valve stenosis. However, there are imited data on the effects of an atherogenic milieu and its potential implications on the structural and hemodynamic deterio- ration of aortic bioprosthetic valves. OBJECTIVES: This prospective longitudinal study sought to determine the predictors and impact on outcomes of he- modynamic valve deterioration (HVD) of surgically implanted aortic bioprostheses. METHODS: A total of 137 patients with an aortic bioprosthesis implanted for a median time of 6.7 (interquartile range: 5.1 to 9.1) years prospectively underwent a ﬁrst (baseline) assessment with complete Doppler echocardiography, quantitation of bioprosthesis leaﬂet calciﬁcation by multidetector computed tomography (CT), and a fasting blood sample to assess cardiometabolic risk proﬁle. All patients underwent a second (follow-up) Doppler echocardiography examination at 3 (interquartile range: 2.9 to 3.3) years post-baseline visit. HVD was deﬁned by an annualized change in mean transprosthetic gradient $3 mm Hg/year and/or worsening or transprosthetic regurgitation by $1/3 class. The primary endpoint was a nonhierarchical composite of death from any cause or aortic reintervention procedure (redo surgical valve replacement or transcatheter valve-in-valve implantation) for bioprosthesis failure. RESULTS Thirty-four patients (25.6%) had leaﬂet calciﬁcation on baseline CT, and 18 patients (13.1%) developed an HVD between baseline and follow-up echocardiography. Fifty-two patients (38.0%) met the primary endpoint during subsequent follow-up after the second echocardiographic examination. Leaﬂet calciﬁcation (hazard ratio [HR]: 2.58; 95% conﬁdence interval [CI]: 1.35 to 4.82; p ¼ 0.005) and HVD (HR: 5.12; 95% CI: 2.57 to 9.71; p < 0.001) were independent predictors of the primary endpoint. Leaﬂet calciﬁcation, insulin resistance (homeostatic model assessment index $2.7), lipoprotein-associated phospholipase A2 activity (Lp-PLA2 per 0.1 nmol/min/ml increase), and high level of proprotein convertase subtilisin/kexin 9 (PCSK9) ($305 ng/ml) were associated with the development of HVD after adjusting for age, sex, and time interval since aortic valve replacement. CONCLUSIONS: HVD identiﬁed by Doppler echocardiography is independently associated with a marked increase in the risk of valve reintervention or mortality in patients with a surgical aortic bioprosthesis. A dysmetabolic proﬁle charac- terized by elevated plasma Lp-PLA2, PCSK9, and homeostatic model assessment index was associated with increased risk of HVD. The presence of leaﬂet calciﬁcation as detected by CT was a strong predictor of HVD, providing incremental risk- predictive capacity. (J Am Coll Cardiol 2018;72:241–51) © 2018 by the American College of Cardiology Foundation.