Incidence and outcome of prosthetic valve endocarditis after transcatheter aortic valve replacement in the Netherlands

Background

Transcatheter aortic valve replacement (TAVR) is increasingly being used as an alternative to conventional surgical valve replacement. Prosthetic valve endocarditis (PVE) is a rare but feared complication after TAVR, with reported first-year incidences varying from 0.57 to 3.1%. This study was performed to gain insight into the incidence and outcome of PVE after TAVR in the Netherlands.

Methods

A multicentre retrospective registry study was performed. All patients who underwent TAVR in the period 2010–2017 were screened for the diagnosis of infective endocarditis in the insurance database and checked for the presence of PVE before analysis of general characteristics, PVE parameters and outcome.

Results

A total of 3968 patients who underwent TAVR were screened for PVE. During a median follow-up of 33.5 months (interquartile range (IQR) 22.8–45.8), 16 patients suffered from PVE (0.4%), with a median time to onset of 177 days (IQR 67.8–721.3). First-year incidence was 0.24%, and the overall incidence rate was 0.14 events per 1000 person-years. Overall mortality during follow-up in our study was 31%, of which 25% occurred in hospital. All patients were treated conservatively with intravenous antibiotics alone, and none underwent a re-intervention. Other complications of PVE occurred in 5 patients (31%) and included aortic abscess (2), decompensated heart failure (2) and cerebral embolisation (1).

Conclusion

PVE in patients receiving TAVR is a relatively rare complication and has a high mortality rate.

     

Pre-procedural elevated cardiac troponin predict risk of long-term all-cause mortality after transcatheter aortic valve replacement: a meta-analysis of prospective studies

Abstract

Background: The purpose of this meta-analysis was to evaluate the relationship between elevated cardiac troponin pre-transcatheter aortic valve replacement (TAVR) and long-term all-cause mortality.

Methods: Prospective studies with the endpoint of all-cause mortality were included. We primarily used the fixed-effect model weighted by inverse variance. Meta-regression and subgroup analyses were conducted to explore the potential sources of heterogeneity by specified study characteristics.

Results: Seven prospective studies comprising of 3049 subjects were included in our meta-analysis. Pre-procedural elevated cardiac troponin was associated with increased risk of long-term mortality post TAVR [hazard ratio (HR) 2.25, 95% CI 1.83–2.78, p?=?0.000, I² = 30.3%, p for heterogeneity 0.197]. In addition, subgroup analyses have shown that the group with an younger age (<82?y) seemed to have a higher risk of all-cause mortality than the group with older age (≥82?y) [HR 4.08 (2.41 to 6.89) VS 2.01 (1.60 to 2.53), p?=?0.016 for subgroup difference].

Conclusions: Pre-procedural elevated cardiac troponin was associated with increased long-term all-cause mortality in patients undergoing TAVR.     

Three-Dimensional Computational Modeling of an Extra-Descending Aortic Assist Device Using Fluid-Structure Interaction

BackgroundThe incidence of heart failure is anticipated to rise by 2030, resulting in more than 8 million adults with this condition in US. Despite the advancement in pharmacological and surgical treatments, some patients progress to severe forms of cardiac dysfunction requiring cardiac transplantation as a last-resort treatment. Cardiac assist devices play an essential role in the recovery of normal cardiac performance through reversible remodeling or in assisting the weak organ to prolong survival rate. However, these devices need to be monitored carefully, as prolonged use may lead to physiological maladaptation and further cardiac complications. The optimization of such devices has done through the development and use of numerical simulations that allow the analysis of in-vivo hemodynamic patterns of blood flow. This study aims to investigate the performance of a model of extra-aortic assist device surrounding the descending aorta through three-dimensional patient-specific modeling.MethodsA three-dimensional model of the aorta was constructed from patient-specific cardiac CT images of a 60-year-old male diagnosed with left ventricular failure at the Tehran Heart Center (THC). Numerical simulation was conducted for two complete cardiac cycles using fluid-structure interaction (FSI) analysis under the assumption that the balloon and the aortic vessel behave as linear elastic materials, and that blood is a Newtonian and incompressible fluid.ResultsThe numerical simulation demonstrated a high correlation between the FSI analysis and clinical data of the patient-specific anatomical and physiological conditions. Blood velocity, pressure, deformation, and strain contours were simulated and analyzed through three-dimensional modeling. Compared to the unassisted aorta, the device provided an increase in blood flow displacement of an additional 15 ml of blood in the descending aorta, brachiocephalic, carotid, and subclavian arteries. The maximum von Mises stress distribution across the aortic vessel was higher than the stress imposed on the system in the unassisted heart, with values of 3.3 MPa and 0.28 MPa, respectively. Numerical investigation of structural responses revealed that no remarkable force was exerted on the aortic valve by the device at the descending aorta.ConclusionWe present the numerical investigation of a counterpulsation device around the descending aorta that has not previously been tested on human or animal models. While this extra-aortic balloon pump (EABP) did not show a significant improvement in coronary perfusion, there is room for improvement in further studies to optimize the geometry of the balloon. Additional investigations are required to determine the efficacy of this device and its safety before in-vivo experimental studies are pursued. This simulation has clinical relevance when choosing an appropriate cardiac assist device to address patient-specific physiological and pathological conditions.     

Numerical modeling of arterial pulse wave propagation to characterize aortic hemodynamic: Validation using magnetic resonance data

ObjectivesArterial stiffness, which is caused by aging and other cardiovascular risk factors and primarily affects the aorta, is associated with cardiac and cerebral morbidity and mortality. The objective of our study was to non-invasively estimate local biomechanical and hemodynamic biomarkers related to proximal aortic stiffness, by combining cardiovascular magnetic resonance (CMR) data and numerical simulations.Materials and methodsTo achieve this aim, we used a numerical 1D fluid-structure model to simulate blood flow in the descending aorta, and we combined this model with clinical data (areas and velocities in three levels of the descending aorta, carotid pressures) acquired in two healthy subjects using CMR and applanation tonometry.ResultsFirst, we studied the sensibility of our model on an idealized aorta and showed that our model was able to characterize age-related arterial alterations, when compared to established physiological knowledge. Furthermore, while comparisons of simulations against clinical data revealed low errors (< 20%) in terms of aortic areas and velocities for the two subjects, more important errors were found for pulse pressures (up to 20%). Importantly, errors in terms of velocity and area were lower than their variations occurring with aging.ConclusionsThus, our fast method could enable the non-invasive estimation of aortic functional parameters and a more realistic version of our numerical model could also provide a reliable estimation of central pressure.     

A calcified polymeric valve for valve-in-valve applications

The prevalence of aortic valve stenosis (AS) is increasing in the aging society. More recently, novel treatments and devices for AS, especially transcatheter aortic valve replacement (TAVR) have significantly changed the therapeutic approach to this disease. Research and development related to TAVR require testing these devices in the calcified heart valves that closely mimic a native calcific valve. However, no animal model of AS has yet been available. Alternatively, animals with normal aortic valve that are currently used for TAVR experiments do not closely replicate the aortic valve pathology required for proper testing of these devices. To solve this limitation, for the first time, we developed a novel polymeric valve whose leaflets possess calcium hydroxyapatite inclusions immersed in them. This study reports the characteristics and feasibility of these valves. Two types of the polymeric valve, i.e., moderate and severe calcified AS models were developed and tested by deploying a transcatheter valve in those and measuring the related hemodynamics. The valves were tested in a heart flow simulator, and were studied using echocardiography. Our results showed high echogenicity of the polymeric valve, that was correlated to the severity of the calcification. Aortic valve area of the polymeric valves was measured, and the severity of stenosis was defined according to the clinical guidelines. Accordingly, we showed that these novel polymeric valves closely mimic AS, and can be a desired cost-saving solution for testing the performance of the transcatheter aortic valve systems in vitro.     

A method for the measurement of left ventricular overload for aortic valve insufficiency

BackgroundThe degree of left ventricular overload in patients with aortic valve insufficiency (AI) plays an important role in determining the need and timing of surgical intervention. Because hemodynamic evaluation of AI may potentially predict the effects of an insufficient valve on the ventricle before they occur, it would be useful to guide valve surgery with such a diagnostic tool. The purpose of this study was to test the performance of a new hemodynamic index based on mechanical energy loss for the measurement of the effects of insufficiency on ventricular workload.Methods and resultsAn intact and subsequently perforated aortic bioprosthesis was tested within an in vitro model of the left heart, varying cardiac output, diastolic aortic pressure, and the size of perforation. Regurgitant orifice area (ROA), regurgitant volume (RV), regurgitant fraction (RF), and energy loss index (ELI) were measured for each experimental condition and plotted against the increase in workload per unit volume net forward flow (ΔWPV) due to perforation. ROA, RV, and RF showed good correlations with ΔWPV, but the relationship between these variables and ΔWPV became ambiguous as their magnitudes increased. ELI had a near perfect linear relationship with ΔWPV (slope=1.00, r²=0.98) independent of the experimental condition.ConclusionsRV, RF, and ROA do not by themselves fully describe the increase in difficulty the ventricle has in moving the blood across an insufficient valve. ELI, in contrast, was found to be a very good measure of the decrease in pump efficiency due to aortic valve insufficiency.     

Numerical Models for the Simulation of Flexible Artificial Heart Valves: Part II - Valve Studies

Abstract

Using a coupled Lagrangian dynamic leaflet model and an unsteady potential flow solver the motion of a polyurethane type heart valve is simulated in the aortic position. The simulations incorporate two flow domains; the first comprises only the leaflets which are embedded within an unsteady flow of infinite expanse, and the second incorporates the influence of the aortic geometry via a conformal mapping. Simulations are performed for a cardiac output of 51itres/min and a beat period of 72 b.p.m. corresponding to a typical aortic pulse. Resulting valve motions are computed for various leaflet bending stiffnesses in both flow domains. In addition both the bending stress and strain and their time rate of change are evaluated. Valve motion displays the characteristic rapid opening, stable opening and slow closing phases as detailed in the literature. The computed stress values along the leaflet surface are of the order of those found experimentally.     

Transcatheter aortic valve replacement: impact of pre-procedural FEops HEARTguide assessment on device size selection in borderline annulus size cases

ObjectivesThe aim of this study is to evaluate device size selection in patients within the borderline annulus size range undergoing transcatheter aortic valve replacement (TAVR) and to assess if pre-procedural patient-specific computer simulation will lead to the selection of a different device size than standard of care.BackgroundIn TAVR, appropriate device sizing is imperative. In borderline annulus size cases no standardised technique for tailored device size selection is currently available. Pre-procedural patient-specific computer simulation can be used, predicting the risk for paravalvular leakage (PVL) and need for permanent pacemaker implantation (PPI).MethodsIn this multicentre retrospective study, 140 patients in the borderline annulus size range were included. Hereafter, device size selection was left to the discretion of the operator. After TAVR, in 24 of the 140 patients, patient-specific computer simulation calculated the most appropriate device size expected to give the lowest risk for PVL and need for PPI. In these 24 patients, device size selection based on patient-specific computer simulation was compared with standard-of-care device size selection relying on a standardised matrix (Medtronic).ResultsIn a significant proportion of the 140 patients (26.4%) a different device size than recommended by the matrix was implanted. In 10 of the 24 patients (41.7%) in whom a computer simulation was performed, a different device size was recommended than by means of the matrix.ConclusionsDevice size selection in patients within the borderline annulus size range is still ambiguous. In these patients, patient-specific computer simulation is feasible and can contribute to a more tailored device size selection.     

Effect of turbulent models on left ventricle diastolic flow patterns simulation

Abstract

Vortex structures, as one of the most important features of cardiac flow, have a crucial impact on the left ventricle function and pathological conditions. These swirling flows are closely related to the presence of turbulence in left ventricle which is investigated in the current study. Using an extended model of the left heart, including a fluid-structure interaction (FSI) model of the mitral valve with a realistic geometry, the effect of using two numerical turbulent models, k-ε and Spalart-Allmaras (SA), on diastolic flow patterns is studied and compared with results from laminar flow model. As a result of the higher dissipation rate in turbulent models (k-ε and SA), vortices are larger and stronger in the laminar flow model. Comparing E/A ratio in the three models (Laminar, k-ε, and SA) with experimental data from healthy subjects, it is concluded that the results from k-ε model are more accurate.     

Intracardiac echocardiographic guidance for hemodynamic assessment in a patient with congenital abnormalities and a prosthetic aortic valve

In this case report, we present the use of intracardiac echocardiography (ICE) for guiding the cardiac catheterization and subsequent hemodynamic investigation in an unusual patient case with multiple congenital abnormalities (bicuspid aortic valve, left cervical aortic arch, two aortic coarctations) and two aortic valve replacement operations in the past. The ICE catheter (AcuNav) permitted us to accurately and safely puncture the interatrial septum and place the Swan-Ganz catheter in the left ventricle; additionally, visualization of the aortic coarctation in the ascending aorta was also achieved.     

Comparison of Manual and Automated Preprocedural Segmentation Tools to Predict the Annulus Plane Angulation and C-Arm Positioning for Transcatheter Aortic Valve Replacement

BackgroundPreprocedural manual multi-slice-CT-segmentation tools (MSCT-ST) define the gold standard for planning transcatheter aortic valve replacement (TAVR). They are able to predict the perpendicular line of the aortic annulus (PPL) and to indicate the corresponding C-arm angulation (CAA). Fully automated planning-tools and their clinical relevance have not been systematically evaluated in a real world setting so far.ConclusionsA-MSCT-analysis provides precise preprocedural information on CAA for optimal visualization of the aortic annulus compared to the M-MSCT gold standard. Intraprocedural application of this information during TAVR significantly reduces the levels of contrast and radiation exposure.

Trial Registration

ClinicalTrials.gov {"type":"clinical-trial","attrs":{"text":"NCT01805739","term_id":"NCT01805739"}}NCT01805739     

Multi-biomarker analysis in patients after transcatheter aortic valve implantation (TAVI)

Abstract

Background: In this study we sought to examine whether transcatheter aortic valve implantation (TAVI) is followed by a change in the plasma levels of novel cardiovascular biomarkers.

Methods: We collected blood samples of 79 patients with severe aortic valve stenosis undergoing TAVI before and at 7 days, 1 month, 3 months and 6 months post TAVI and analyzed the plasma concentrations of GDF-15, H-FABP, fetuin-A, galectin 3, sST2 and suPAR by means of ELISA.

Results: There was a significant increase in the concentration of fetuin-A (median: 52.44 mg/ml to 113.2 mg/ml, p?<?0.001) and a significant decrease of H–FABP after TAVI (median: 4.835 ng/ml to 2.534 ng/ml, p?<?0.001). The concentrations of suPAR and sST2 showed an initial increase (suPAR median: 2755 pg/ml 3489 pg/ml, p?<?0.001; sST2 median: 5832 pg/ml to 7137 pq/ml, p?<?0.001) and subsequently decreased significantly.

Conclusion: We hypothesize that the decrease of H-FABP and the increase of fetuin-A could be due to a hemodynamic improvement after valve replacement. The initial increase of suPAR could indicate an inflammatory stimulus and the significant increase in sST2 could be due to the mechanical strain caused by implantation of the valve.     

Prognostic analysis of Behçet’s disease with aortic regurgitation or involvement

Background

Aortic regurgitation is the most common cardiovascular damage in Chinese patients with Behçet’s disease (BD) and is usually associated with aortic disease. These patients are easily misdiagnosed, and their prognosis is poor, even after surgical treatment. This study aimed to analyse potential factors that can improve the prognosis of BD patients with aortic regurgitation and/or aortic involvement.

Methods

Twenty-two patients with diagnosed or suspected BD as well as aortic regurgitation and/or aortic involvement in our hospital from 2012 through 2017 were collected in this study. Their clinical characteristics were listed, and the diagnosis of BD was evaluated by two different criteria sets. The influences of surgical treatment and immunosuppressive therapy (IST) on their prognosis were also explored.

Results

The diagnostic positive rate of the International Criteria for Behçet’s Disease was higher than that of the International Study Group criteria (kappa value 0.31, p?<?0.05), indicating that the diagnostic consistency between the criteria sets was poor. There was no significant difference in survival between patients who had undergone ≤?1 operation and those with ≥?2 operations. Aortic valve replacement alone or in combination with aortic root replacement had no significant effect on the incidence of reoperation or death, but IST did significantly reduce this incidence (p?<?0.05). However, there was no significant difference in the occurrence of reoperation or death between preoperative and postoperative IST versus postoperative IST only.

Conclusion

IST significantly improved the prognosis of BD patients with aortic regurgitation and/or aortic involvement.

     

A parametric geometry model of the aortic valve for subject-specific blood flow simulations using a resistive approach

Cardiac valves simulation is one of the most complex tasks in cardiovascular modeling. Fluid–structure interaction is not only highly computationally demanding but also requires knowledge of the mechanical properties of the tissue. Therefore, an alternative is to include valves as resistive flow obstacles, prescribing the geometry (and its possible changes) in a simple way, but, at the same time, with a geometry complex enough to reproduce both healthy and pathological configurations. In this work, we present a generalized parametric model of the aortic valve to obtain patient-specific geometries that can be included into blood flow simulations using a resistive immersed implicit surface (RIIS) approach. Numerical tests are presented for geometry generation and flow simulations in aortic stenosis patients whose parameters are extracted from ECG-gated CT images.

     

Coupling between MRI-assessed regional aortic pulse wave velocity and diameters in patients with thoracic aortic aneurysm: a feasibility study

Aims

Thoracic aortic aneurysm (TAA) is potentially life-threatening and requires close follow-up to prevent aortic dissection. Aortic stiffness and size are considered to be coupled. Regional aortic stiffness in patients with TAA is unknown. We aimed to evaluate coupling between regional pulse wave velocity (PWV), a marker of vascular stiffness, and aortic diameter in TAA patients.

Methods

In 40 TAA patients (59 ± 13 years, 28 male), regional aortic diameters and regional PWV were assessed by 1.5 T MRI. The incidence of increased diameter and PWV were determined for five aortic segments (S1, ascending aorta; S2, aortic arch; S3, thoracic descending aorta; S4, suprarenal and S5, infrarenal abdominal aorta). In addition, coupling between regional PWV testing and aortic dilatation was evaluated and specificity and sensitivity were assessed.

Results

Aortic diameter was 44 ± 5 mm for the aortic root and 39 ± 5 mm for the ascending aorta. PWV was increased in 36 (19 %) aortic segments. Aortic diameter was increased in 28 (14 %) segments. Specificity of regional PWV testing for the prediction of increased regional diameter was ≥ 84 % in the descending thoracic to abdominal aorta and ≥ 68 % in the ascending aorta and aortic arch.

Conclusion

Normal regional PWV is related to absence of increased diameter, with high specificity in the descending thoracic to abdominal aorta and moderate results in the ascending aorta and aortic arch.     

Supra-annular Valve-in-Valve implantation reduces blood stasis on the transcatheter aortic valve leaflets

Leaflet thrombosis following transcatheter aortic valve replacement (TAVR) and Valve-in-Valve (ViV) procedures has been increasingly recognized. This study aimed to investigate the effect of positioning of the transcatheter aortic valve (TAV) in ViV setting on the flow dynamics aspect of post-ViV thrombosis by quantifying the blood stasis in the intra-annular and supra-annular settings. To that end, two idealized computational models, representing ViV intra-annular and supra-annular positioning of a TAV were developed in a patient-specific geometry. Three-dimensional flow fields were then obtained via fluid-solid interaction modeling to study the difference in blood residence time (BRT) on the TAV leaflets in the two settings. At the end of diastole, a strip of high BRT ($⩾1.2s$) region was observed on the TAV leaflets in the ViV intra-annular positioning at the fixed boundary where the leaflets are attached to the frame. Such a high BRT region was absent on the TAV leaflets in the supra-annular positioning. The maximum value of BRT on the surface of non-, right, and left coronary leaflets of the TAV in the supra-annular positioning were 53%, 11%, and 27% smaller compared to the intra-annular positioning, respectively. It was concluded that the geometric confinement of TAV by the leaflets of the failed bioprosthetic valve in ViV intra-annular positioning increases the BRT on the leaflets and may act as a permissive factor in valvular thrombosis. The absence of such a geometric confinement in the ViV supra-annular positioning leads to smaller BRT and subsequently less likelihood of leaflet thrombosis.     

Determinants of elevated carbohydrate antigen 125 in patients with severe symptomatic aortic valve stenosis referred for transcatheter aortic valve implantation

Purpose: Elevated carbohydrate antigen 125 (CA125) predicts adverse outcome after transcatheter aortic valve implantation (TAVI). While known underlying pathophysiological mechanisms of elevated CA125 include serosal effusions and inflammatory stimuli, clinical determinants associated with elevated CA125 in patients referred for TAVI remain unknown. Therefore, we investigated clinical, laboratory and echocardiographic determinants of elevated CA125 in patients with severe aortic valve stenosis referred for TAVI.

Methods: This study includes 650 patients with severe aortic stenosis referred for TAVI. Baseline CA125 was determined by an immunoassay and dichotomized (elevated versus normal) based on the manufacturer cutoff value (>35?U/mL).

Results: CA125 elevation was present in 28% (181/650). Patients with elevated CA125 had an overall worse clinical profile and were more symptomatic with a higher rate of NYHA class III/IV (80% versus 58%; p?Conclusion: Elevated CA125 levels in patients referred for TAVI summarize a subset of patients with an overall worse clinical profile who are more symptomatic.     

Analysis of cardiovascular mortality,bleeding, vascular and cerebrovascular events in patients with atrial fibrillation vs. sinus rhythm undergoing transfemoral Transcatheter Aortic Valve Implantation (TAVR)

Background

Transcatheter aortic valve replacement (TAVR) has been demonstrated to be an established therapy for high-risk, inoperable patients with severe symptomatic aortic valve stenosis. For patients with moderate surgical risk, TAVR is equivalent to conventional aortic valve surgery. However, atrial fibrillation (AF) is also present in many of these patients, thus requiring post-implantation oral anticoagulation therapy in addition to the inhibition of thrombocyte aggregation, which poses the risk of bleeding complications. The aim of our work was to investigate the influence of AF on mortality and the occurrence of bleeding, vascular and cerebrovascular complications related to TAVR according to the VARC-2 criteria.

Methods

Two hundred eighty-three patients who underwent TAVR between March 2010 and April 2016 were retrospectively examined. In total, 257 patients who underwent transfemoral access were included in this study. The mean patient age was 81?±?6 years, 54.1% of the patients were women, and 42.4% had pre-interventional AF.

Results

Compared to patients with sinus rhythm (SR, n?=?148), patients with AF (n?=?109) had an almost three-fold higher incidence of major vascular complications (AF 14.7% vs. SR 5.4%, p?=?0.016) and life-threatening bleeding (AF 11.9% vs. SR 4.1%, p?=?0.028) during the first 30 post-procedural days. However, the rate of cerebrovascular complications (AF 3.7% vs. SR 2.7%, p?=?0.726) did not significantly differ between the two groups. Overall mortality was significantly higher in patients with AF during the first month (AF 8.3% vs. SR 2.0%, p?=?0.032) and the first year (AF 28.4% vs. SR 15.3%; p?=?0.020) following TAVR.

Conclusion

Patients with AF had significantly more severe bleeding complications after TAVR, which were significantly related to mortality. Future prospective randomized studies must clarify the optimal anticoagulation therapy for patients with AF after TAVR.

Trial registration

DRKS00011798 on DRKS (Date 17.03.2017).

     

Earlier accumulation of calcium, phosphorus, and magnesium in the coronary artery in comparison with the ascending aorta, aortic valve, and mitral valve

To explore reasons for a high accumulation of Ca and P occurring in the coronary artery of Thai with aging, the authors investigated age-related changes of elements in the coronary artery, ascending aorta near the heart, and cardiac valves in single individuals, and the relationships in the elements between the coronary artery and either the ascending aorta or cardiac valves. After an ordinary dissection by medical students at Chiang Mai University was finished, the anterior descending arteries of the left coronary artery, ascending aortas, mitral valves, and aortic valves were resected from the subjects. The subjects consisted of 17 men and 9 women, ranging in age from 46 to 76 yr. The element content was analyzed by inductively coupled plasma-atomic emission spectrometry. The average content of Ca and P was the highest in the coronary artery and decreased in the order aortic valve, ascending aorta, and mitral valve. The Ca, P, and Mg content increased in the coronary artery in the fifties and in the ascending aorta, aortic valve, and mitral valve in the sixties. It should be noted that the accumulation of Ca, P, and Mg occurred earlier in the coronary artery than in the ascending aorta, aortic valve, and mitral valve. It was found that with respect to the Ca, P, Mg, and Na contents, the coronary artery correlated well with both the aortic valve and ascending aorta, especially with the aortic valve, but it did not correlate with the mitral valves. This finding suggests that the accumulation of Ca, P, Mg, and Na occurs in the coronary artery together with the aortic valve and ascending aorta, but not together with the mitral valve. Because regarding the accumulation of Ca, P, and Mg, the ascending aorta and aortic valve are preceded by the coronary artery, it is unlikely that the accumulation of Ca, P, and Mg spreads from the ascending aorta or aortic valve to the coronary artery.     

Numerical evaluation of transcatheter aortic valve performance during heart beating and its post-deployment fluid–structure interaction analysis

Biomechanics and Modeling in Mechanobiology - Transcatheter aortic valve replacement (TAVR) is a minimally invasive procedure that provides an effective alternative to open-heart surgical valve...