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This single-center retrospective cohort included 63 consecutive pre-TAVI patients with trileaflet, classical high-flow\/high-gradient severe AS. CT-AVC was quantified on non-contrast ECG-gated CT at 130, 200, 500, 800, and 1000 HU within a manually defined leaflet\/annulus region of interest, excluding left ventricular outflow tract and mitral annular calcification. Associations with peak gradient, mean gradient, and aortic valve area were assessed using correlation and multivariable linear regression.Exploratory ROC analysis assessed discrimination of very severe hemodynamic burden, defined as a mean gradient\u2009\u2265\u200960 mmHg, within the established severe-AS cohort, with ROC areas compared using DeLong testing. CT-AVC at all HU thresholds was independently associated with higher peak gradient (\u03b2, 0.010 at 130 HU to 0.144 at 1000 HU; all\n                    <jats:italic>P<\/jats:italic>\n                    \u2009\u2264\u20090.005) and higher mean gradient (\u03b2, 0.0059 at 130 HU to 0.073 at 1000 HU; all\n                    <jats:italic>P<\/jats:italic>\n                    \u2009\u2264\u20090.024). Associations with aortic valve area were not statistically significant. Within-cohort discrimination of very severe hemodynamic burden was modest and comparable across thresholds (AUC 0.65\u20130.67), with no statistically significant difference by DeLong testing (\n                    <jats:italic>P<\/jats:italic>\n                    \u2009=\u20090.68). In classical high-flow\/high-gradient severe AS, CT-AVC demonstrated consistent associations with transvalvular gradients across HU thresholds. Higher HU thresholds did not outperform conventional 130-HU scoring and showed only modest, comparable performance for within-severity hemodynamic stratification. These thresholds should be interpreted as complementary densitometric analyses rather than alternative diagnostic cut-offs.\n                  <\/jats:p>","DOI":"10.1007\/s10554-026-03800-y","type":"journal-article","created":{"date-parts":[[2026,8,14]],"date-time":"2026-08-14T06:11:34Z","timestamp":1786687894000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["CT-based multi-threshold calcium scoring for aortic valve assessment: comparable predictive performance across HU thresholds in a pre-TAVI cohort"],"prefix":"10.1007","author":[{"given":"Michael","family":"Welt","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mohammad","family":"Alnees","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yazan","family":"Hamdan","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Khaled","family":"khalilia","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tamar","family":"Shalmon","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jebrin","family":"Alkrinawi","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ramon","family":"Cohen","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mustafa Abu","family":"Teer","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Elias","family":"Hellou","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nizar","family":"Abu Hamdeh","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Amir","family":"Haim","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Omar","family":"Ayyad","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Adam","family":"Hasan","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mohammad","family":"Masu\u2019d","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Duha","family":"Najajra","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alex","family":"Blatt","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Haitham","family":"Abu Khadija","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2026,8,14]]},"reference":[{"issue":"5","key":"3800_CR1","first-page":"e35","volume":"143","author":"CM Otto","year":"2021","unstructured":"Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP 3rd, Gentile F et al (2021) 2020 ACC\/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology\/American Heart Association Joint Committee on Clinical Practice Guidelines. 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The study was conducted in accordance with the ethical principles of the Declaration of Helsinki. All data used for analysis were anonymized, and patient confidentiality was maintained throughout all stages of data collection, analysis, and reporting.","order":2,"name":"Ethics","label":"Ethics approval","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"The requirement for informed consent was waived by the local Helsinki Committee at Kaplan Medical Center because of the retrospective observational design of the study, the use of anonymized data, and the absence of any intervention or change in patient management.","order":3,"name":"Ethics","label":"Consent to participate","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"Not applicable. This manuscript does not contain identifiable individual patient data, images, or personal clinical details requiring consent for publication.","order":4,"name":"Ethics","label":"Consent to publish","group":{"name":"EthicsHeading","label":"Declarations"}}]}}