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Visual scoring of aortic valve calcifications on low-dose CT in lung cancer screening



To evaluate risk factors for prevalence and progression of aortic valve calcification (AVC) in lung cancer screening participants and also to assess the sensitivity and reliability of visual AVCs on low-dose CT (LDCT) for predicting aortic stenosis (AS) in high-risk smokers.


We reviewed 1225 consecutive participants in annual LDCT screening for lung cancer at the Mount Sinai Hospital between 2010 and 2017. Sensitivity and specificity of moderate/severe AVC score on LDCT to identify AS on echocardiogram were calculated for 126 participants who had both 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 visual AVC scores (1) with standard-dose, electrocardiography (ECG)-gated CT for 31 participants who had both within 12 months and (2) with Agatston scores of 1225 participants and by determining (3) the intra-reader agreement of 1225 participants.


Visual AVC scores on LDCT had substantial agreement with the severity of AS on echocardiography and substantial inter-observer and excellent intra-observer agreement. Sensitivity and specificity of moderate/severe visual AVC scores for moderate/severe AS on echocardiogram were 100% and 94%, respectively. Significant predictors for baseline AVC were male sex (OR = 2.52), age (OR10 years = 2.87), and coronary artery calcification score (OR = 1.18), the significant predictor for AVC progression after baseline was pack-years of smoking (HR10 packyears = 1.14), and significant predictors for new AVC on annual LDCT were male sex (HR = 1.51), age (HR10 years = 2.17), CAC (HR = 1.09)  and BMI (HR = 1.06).


AVC scores on LDCT should be documented, especially in lung cancer screening program.

Key Points

LDCT screening for lung cancer provides an opportunity to identify lung cancer and cardiovascular disease in asymptomatic smokers.

Visual aortic valve calcification scores could be reliably evaluated on LDCT and had substantial agreement with the severity of aortic valve stenosis on echocardiography.

Sensitivity and specificity of moderate/severe visual AVC scores on LDCT for moderate/severe AS on echocardiogram were 100% and 94%, respectively.

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Fig. 1



American Heart Association/American College of Cardiology


Aortic stenosis


Aortic valve calcification


Aortic valve replacement


Body mass index


Coronary artery calcification


Confidence interval


Chronic obstructive pulmonary disease




Early Lung Cancer Action Program


Health Insurance Portability and Accountability Act


Hazard ratio


Hounsfield unit


Interquartile range


Institutional review board


Low-dose computed tomography


Multiplanar reconstruction


Mount Sinai Early Lung Cancer Action Program


Odds ratio


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This study was partially funded by the Flight Attendants Medical Research Institute, and Y.Z. was funded by the China Scholarship Council (CSC).

Author information

Correspondence to Claudia I. Henschke.

Ethics declarations


The scientific guarantor of this publication is Dr. Claudia Henschke.

Conflict of interest

The authors of this manuscript declare relationships with the following companies:

Dr. Yankelevitz is a named inventor on a number of patents and patent applications relating to the evaluation of diseases of the chest including measurement of nodules. Some of these, which are owned by Cornell Research Foundation (CRF), are non-exclusively licensed to General Electric. As an inventor of these patents, Dr. Yankelevitz is entitled to a share of any compensation which CRF may receive from its commercialization of these patents. He is also an equity owner in Accumetra, a privately held technology company committed to improving the science and practice of image-based decision making. Dr. Yankelevitz also serves on the advisory board of GRAIL.

Dr. Henschke is the President and serves on the board of the Early Diagnosis and Treatment Research Foundation. She receives no compensation from the Foundation. The Foundation is established to provide grants for projects, conferences, and public databases for research on early diagnosis and treatment of diseases. Dr. Claudia Henschke is also a named inventor on a number of patents and patent applications relating to the evaluation of pulmonary nodules on CT scans of the chest which are owned by Cornell Research Foundation (CRF). Since 2009, Dr. Henschke does not accept any financial benefit from these patents including royalties and any other proceeds related to the patents or patent applications owned by CRF.

The other authors of this manuscript declare no relationships with any companies, whose products or services may be related to the subject matter of the article.

Statistics and biometry

Two of the authors have significant statistical expertise (Claudia Henschke and Rowena Yip).

Informed consent

Written informed consent was obtained from all subjects (patients) in this study.

Ethical approval

Institutional review board approval was obtained.

Study subjects or cohorts overlap

Some study subjects have been previously reported for lung findings, but results of aortic valve calcification have never been reported.


• Retrospective

• Observational

• Performed at one institution

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Zhu, Y., Wang, Y., Gioia, W.E. et al. Visual scoring of aortic valve calcifications on low-dose CT in lung cancer screening. Eur Radiol (2020). https://doi.org/10.1007/s00330-019-06614-w

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  • Cardiovascular diseases
  • Aortic valve stenosis
  • Echocardiography
  • Aortic valve calcification