Planar biaxial creep and stress relaxation of the mitral valve anterior leaflet

A Mathematical Model for Postimplant Collagen Remodeling in an Autologous Engineered Pulmonary Arterial Conduit

This study was undertaken to develop a mathematical model of the long-term in vivo remodeling processes in postimplanted pulmonary artery (PA) conduits. Experimental results from two extant ovine in vivo studies, wherein polyglycolic-acid (PGA)/poly-L-lactic acid tubular conduits were constructed, cell seeded, incubated for 4 weeks, and then implanted in mature sheep to obtain the remodeling data for up to two years. Explanted conduit analysis included detailed novel structural and mechanical studies. Results in both studies indicated that the in vivo conduits remained dimensionally stable up to 80 weeks, so that the conduits maintained a constant in vivo stress and deformation state. In contrast, continued remodeling of the constituent collagen fiber network as evidenced by an increase in effective tissue uniaxial tangent modulus, which then stabilized by one year postimplant. A mesostructural constitute model was then applied to extant planar biaxial mechanical data and revealed several interesting features, including an initial pronounced increase in effective collagen fiber modulus, paralleled by a simultaneous shift toward longer, more uniformly length-distributed collagen fibers. Thus, while the conduit remained dimensionally stable, its internal collagen fibrous structure and resultant mechanical behaviors underwent continued remodeling that stabilized by one year. A time-evolving structural mixture-based mathematical model specialized for this unique form of tissue remodeling was developed, with a focus on time-evolving collagen fiber stiffness as the driver for tissue-level remodeling. The remodeling model was able to fully reproduce (1) the observed tissue-level increases in stiffness by time-evolving simultaneous increases in collagen fiber modulus and lengths, (2) maintenance of the constant collagen fiber angular dispersion, and (3) stabilization of the remodeling processes at one year. Collagen fiber remodeling geometry was directly verified experimentally by histological analysis of the time-evolving collagen fiber crimp, which matches model predictions very closely. Interestingly, the remodeling model indicated that the basis for tissue homeostasis was maintenance of the collagen fiber ensemble stress for all orientations, and not individual collagen fiber stresses. Unlike other growth and remodeling models that traditionally treat changes in the external boundary conditions (e.g., changes in blood pressure) as the primary input stimuli, the driver herein is changes to the internal constituent collagen fiber themselves due to cellular mediated cross-linking.

A Computational Pipeline for Patient-Specific Prediction of the Postoperative Mitral Valve Functional State

While mitral valve (MV) repair remains the preferred clinical option for mitral regurgitation (MR) treatment, long-term outcomes remain suboptimal and difficult to predict. Furthermore, pre-operative optimization is complicated by the heterogeneity of MR presentations and the multiplicity of potential repair configurations. In the present work, we established a patient-specific MV computational pipeline based strictly on standard-of-care pre-operative imaging data to quantitatively predict the post-repair MV functional state. First, we established human mitral valve chordae tendinae (MVCT) geometric characteristics obtained from five CT-imaged excised human hearts. From these data, we developed a finite-element model of the full patient-specific MV apparatus that included MVCT papillary muscle origins obtained from both the in vitro study and the pre-operative three-dimensional echocardiography images. To functionally tune the patient-specific MV mechanical behavior, we simulated pre-operative MV closure and iteratively updated the leaflet and MVCT prestrains to minimize the mismatch between the simulated and target end-systolic geometries. Using the resultant fully calibrated MV model, we simulated undersized ring annuloplasty (URA) by defining the annular geometry directly from the ring geometry. In three human cases, the postoperative geometries were predicted to 1 mm of the target, and the MV leaflet strain fields demonstrated close agreement with noninvasive strain estimation technique targets. Interestingly, our model predicted increased posterior leaflet tethering after URA in two recurrent patients, which is the likely driver of long-term MV repair failure. In summary, the present pipeline was able to predict postoperative outcomes from pre-operative clinical data alone. This approach can thus lay the foundation for optimal tailored surgical planning for more durable repair, as well as development of mitral valve digital twins.

Functional mechanical behavior of the murine pulmonary heart valve

Genetically modified mouse models provide a versatile and efficient platform to extend our understanding of the underlying disease processes and evaluate potential treatments for congenital heart valve diseases. However, applications have been limited to the gene and molecular levels due to the small size of murine heart valves, which prohibits the use of standard mechanical evaluation and in vivo imaging methods. We have developed an integrated imaging/computational mechanics approach to evaluate, for the first time, the functional mechanical behavior of the murine pulmonary heart valve (mPV). We utilized extant mPV high resolution µCT images of 1-year-old healthy C57BL/6J mice, with mPVs loaded to 0, 10, 20 or 30 mmHg then chemically fixed to preserve their shape. Individual mPV leaflets and annular boundaries were segmented and key geometric quantities of interest defined and quantified. The resulting observed inter-valve variations were small and consistent at each TVP level. This allowed us to develop a high fidelity NURBS-based geometric model. From the resultant individual mPV geometries, we developed a mPV shape-evolving geometric model (SEGM) that accurately represented mPV shape changes as a continuous function of transvalvular pressure. The SEGM was then integrated into an isogeometric finite element based inverse model that estimated the individual leaflet and regional mPV mechanical behaviors. We demonstrated that the mPV leaflet mechanical behaviors were highly anisotropic and nonlinear, with substantial leaflet and regional variations. We also observed the presence of strong axial mechanical coupling, suggesting the important role of the underlying collagen fiber architecture in the mPV. When compared to larger mammalian species, the mPV exhibited substantially different mechanical behaviors. Thus, while qualitatively similar, the mPV exhibited important functional differences that will need to accounted for in murine heart valve studies. The results of this novel study will allow detailed murine tissue and organ level investigations of semi-lunar heart valve diseases.

Engineering Heart Valve Interfaces Using Melt Electrowriting: Biomimetic Design Strategies from Multi-Modal Imaging

Interfaces within biological tissues not only connect different regions but also contribute to the overall functionality of the tissue. This is especially true in the case of the aortic heart valve. Here, melt electrowriting (MEW) is used to engineer complex, user-defined, interfaces for heart valve scaffolds. First, a multi-modal imaging investigation into the interfacial regions of the valve reveals differences in collagen orientation, density, and recruitment in previously unexplored regions including the commissure and inter-leaflet triangle. Overlapping, suturing, and continuous printing methods for interfacing MEW scaffolds are then investigated for their morphological, tensile, and flexural properties, demonstrating the superior performance of continuous interfaces. G-codes for MEW scaffolds with complex interfaces are designed and generated using a novel software and graphical user interface. Finally, a singular MEW scaffold for the interfacial region of the aortic heart valve is presented incorporating continuous interfaces, gradient porosities, variable layer numbers across regions, and tailored fiber orientations inspired by the collagen distribution and orientation from the multi-modal imaging study. The scaffold exhibits similar yield strain, hysteresis, and relaxation behavior to porcine heart valves. This work demonstrates the ability of a bioinspired approach for MEW scaffold design to address the functional complexity of biological tissues.

Simultaneous Wide-Field Planar Strain-Fiber Orientation Distribution Measurement Using Polarized Spatial Domain Imaging

In the present study, we demonstrate that soft tissue fiber architectural maps captured using polarized spatial frequency domain imaging (pSFDI) can be utilized as an effective texture source for DIC-based planar surface strain analyses. Experimental planar biaxial mechanical studies were conducted using pericardium as the exemplar tissue, with simultaneous pSFDI measurements taken. From these measurements, the collagen fiber preferred direction [Formula: see text] was determined at the pixel level over the entire strain range using established methods ( https://doi.org/10.1007/s10439-019-02233-0 ). We then utilized these pixel-level [Formula: see text] maps as a texture source to quantify the deformation gradient tensor [Formula: see text] as a function of spatial position [Formula: see text] within the specimen at time t. Results indicted that that the pSFDI approach produced accurate deformation maps, as validated using both physical markers and conventional particle based method derived from the DIC analysis of the same specimens. We then extended the pSFDI technique to extract the fiber orientation distribution [Formula: see text] as a function of [Formula: see text] from the pSFDI intensity signal. This was accomplished by developing a calibration procedure to account for the optical behavior of the constituent fibers for the soft tissue being studied. We then demonstrated that the extracted [Formula: see text] was accurately computed in both the referential (i.e. unloaded) and deformed states. Moreover, we noted that the measured [Formula: see text] agreed well with affine kinematic deformation predictions. We also demonstrated this calibration approach could also be effectively used on electrospun biomaterials, underscoring the general utility of the approach. In a final step, using the ability to simultaneously quantify [Formula: see text] and [Formula: see text], we examined the effect of deformation and collagen structural measurements on the measurement region size. For pericardial tissues, we determined a critical length of [Formula: see text] 8 mm wherein the regional variations sufficiently dissipated. This result has immediate potential in the identification of optimal length scales for meso-scale strain measurement in soft tissues and fibrous biomaterials.

Crosslinking porcine aortic valve by radical polymerization for the preparation of BHVs with improved cytocompatibility, mild immune response, and reduced calcification

Over one million artificial heart valve transplantations are performed each year due to valvular stenosis or regurgitation. Among them, bioprosthetic heart valves (BHVs) are increasingly being used because of the absence of the need for lifelong anticoagulation. Almost all of the commercial BHVs are treated with Glutaraldehyde (GLUT). As GLUT-treated BHVs are prone to calcification and structural degradation, their durability is greatly reduced with a service life of only 12-15 years. The physiological structure and mechanical properties of the porcine aortic valve (PAV) are closer to that of a human heart valve, so in this study, PAV is used as the model to explore the comprehensive properties of the prepared BHVs by radical polymerization crosslinking method. We found that PAV treated by radical polymerization crosslinking method showed similar ECM stability and biaxial mechanical properties with GLUT-treated PAV. However, radical polymerization crosslinked PAV exhibited better cytocompatibility and endothelialization potential in vitro cell experiment as better anticalcification potential and reduced immune response than GLUT-treated PAV through subcutaneous animal experiments in rats. To conclude, a novel crosslinking method of non-glutaraldehyde fixation of xenogeneic tissues for the preparation of BHVs is expected.

A versatile biaxial testing platform for soft tissues

Uniaxial testing remains the most common modality of mechanical analysis for biological and other soft materials; however, biaxial testing enables a more comprehensive understanding of these materials' mechanical behavior. In recent years, a number of commercially available biaxial testing systems designed for biological materials have been produced; however, there are common limitations that are often associated with using these systems. For example, the range of allowable sample geometries are relatively constrained, the clamping systems are relatively limited with respect to allowable configurations, the load and displacement ranges are relatively small, and the software and control elements offer relatively limited options. Due to these constraints, there are significant benefits associated with designing custom biaxial testing systems that meet the technical requirements for testing a broad range of materials. Herein we present a design for a biaxial testing system with capabilities that extend beyond those associated with typical commercially available systems. Our design is capable of performing uniaxial tests, traditional biaxial tests, and double lap shear (simple shear) tests, in either a displacement or load control mode. Testing protocols have been developed and proof-of-concept experiments have been performed on commercially available silicone membranes and rat abdominal skin samples.

Influence of multi-axial dynamic constraint on cell alignment and contractility in engineered tissues

In this study an experimental rig is developed to investigate the influence of tissue constraint and cyclic loading on cell alignment and active cell force generation in uniaxial and biaxial engineered tissues constructs. Addition of contractile cells to collagen hydrogels dramatically increases the measured forces in uniaxial and biaxial constructs under dynamic loading. This increase in measured force is due to active cell contractility, as is evident from the decreased force after treatment with cytochalasin D. Prior to dynamic loading, cells are highly aligned in uniaxially constrained tissues but are uniformly distributed in biaxially constrained tissues, demonstrating the importance of tissue constraints on cell alignment. Dynamic uniaxial stretching resulted in a slight increase in cell alignment in the centre of the tissue, whereas dynamic biaxial stretching had no significant effect on cell alignment. Our active modelling framework accurately predicts our experimental trends and suggests that a slightly higher (3%) total SF formation occurs at the centre of a biaxial tissue compared to the uniaxial tissue. However, high alignment of SFs and lateral compaction in the case of the uniaxially constrained tissue results in a significantly higher (75%) actively generated cell contractile stress, compared to the biaxially constrained tissue. These findings have significant implications for engineering of contractile tissue constructs.

The time has come to extend the expiration limit of cryopreserved allograft heart valves

Despite the wide choice of commercial heart valve prostheses, cryopreserved semilunar allograft heart valves (C-AHV) are required, and successfully transplanted in selected groups of patients. The expiration limit (EL) criteria have not been defined yet. Most Tissue Establishments (TE) use the EL of 5 years. From physiological, functional, and surgical point of view, the morphology and mechanical properties of aortic and pulmonary roots represent basic features limiting the EL of C-AHV. The aim of this work was to review methods of AHV tissue structural analysis and mechanical testing from the perspective of suitability for EL validation studies. Microscopic structure analysis of great arterial wall and semilunar leaflets tissue should clearly demonstrate cells as well as the extracellular matrix components by highly reproducible and specific histological staining procedures. Quantitative morphometry using stereological grids has proved to be effective, as the exact statistics was feasible. From mechanical testing methods, tensile test was the most suitable. Young's moduli of elasticity, ultimate stress and strain were shown to represent most important AHV tissue mechanical characteristics, suitable for exact statistical analysis. C-AHV are prepared by many different protocols, so as each TE has to work out own EL for C-AHV.

Mitral valve leaflet response to ischaemic mitral regurgitation: from gene expression to tissue remodelling

Ischaemic mitral regurgitation (IMR), a frequent complication following myocardial infarction (MI), leads to higher mortality and poor clinical prognosis if untreated. Accumulating evidence suggests that mitral valve (MV) leaflets actively remodel post MI, and this remodelling increases both the severity of IMR and the occurrence of MV repair failures. However, the mechanisms of extracellular matrix maintenance and modulation by MV interstitial cells (MVICs) and their impact on MV leaflet tissue integrity and repair failure remain largely unknown. Herein, we sought to elucidate the multiscale behaviour of IMR-induced MV remodelling using an established ovine model. Leaflet tissue at eight weeks post MI exhibited significant permanent plastic radial deformation, eliminating mechanical anisotropy, accompanied by altered leaflet composition. Interestingly, no changes in effective collagen fibre modulus were observed, with MVICs slightly rounder, at eight weeks post MI. RNA sequencing indicated that YAP-induced genes were elevated at four weeks post MI, indicating elevated mechanotransduction. Genes related to extracellular matrix organization were downregulated at four weeks post MI when IMR occurred. Transcriptomic changes returned to baseline by eight weeks post MI. This multiscale study suggests that IMR induces plastic deformation of the MV with no functional damage to the collagen fibres, providing crucial information for computational simulations of the MV in IMR.

Mechanical considerations for polymeric heart valve development: Biomechanics, materials, design and manufacturing

The native human heart valve leaflet contains a layered microstructure comprising a hierarchical arrangement of collagen, elastin, proteoglycans and various cell types. Here, we review the various experimental methods that have been employed to probe this intricate microstructure and which attempt to elucidate the mechanisms that govern the leaflet's mechanical properties. These methods include uniaxial, biaxial, and flexural tests, coupled with microstructural characterization techniques such as small angle X-ray scattering (SAXS), small angle light scattering (SALS), and polarized light microscopy. These experiments have revealed complex elastic and viscoelastic mechanisms that are highly directional and dependent upon loading conditions and biochemistry. Of all engineering materials, polymers and polymer-based composites are best able to mimic the tissue-level mechanical behavior of the native leaflet. This similarity to native tissue permits the fabrication of polymeric valves with physiological flow patterns, reducing the risk of thrombosis compared to mechanical valves and in some cases surpassing the in vivo durability of bioprosthetic valves. Earlier work on polymeric valves simply assumed the mechanical properties of the polymer material to be linear elastic, while more recent studies have considered the full hyperelastic stress-strain response. These material models have been incorporated into computational models for the optimization of valve geometry, with the goal of minimizing internal stresses and improving durability. The latter portion of this review recounts these developments in polymeric heart valves, with a focus on mechanical testing of polymers, valve geometry, and manufacturing methods.

Finite elastic wrinkling deformations of incompressible fiber-reinforced plates

A two-dimensional plate theory, valid for finite elastic deformations with small strains, is derived for incompressible, fiber-reinforced materials. Single-layer plates and two-layer laminates are considered. Numerical simulations illustrate the substantial effect that fiber reinforcement has on wrinkling patterns in the sheet.

Quantification of Material Constants for a Phenomenological Constitutive Model of Porcine Tricuspid Valve Leaflets for Simulation Applications

The tricuspid valve is a one-way valve on the pulmonary side of the heart, which prevents backflow of blood during ventricular contractions. Development of computational models of the tricuspid valve is important both in understanding the normal valvular function and in the development/improvement of surgical procedures and medical devices. A key step in the development of such models is quantification of the mechanical properties of the tricuspid valve leaflets. In this study, after examining previously measured five-loading-protocol biaxial stress-strain response of porcine tricuspid valves, a phenomenological constitutive framework was chosen to represent this response. The material constants were quantified for all three leaflets, which were shown to be highly anisotropic with average anisotropy indices of less than 0.5 (an anisotropy index value of 1 indicates a perfectly isotropic response, whereas a smaller value of the anisotropy index indicates an anisotropic response). To obtain mean values of material constants, stress-strain responses of the leaflet samples were averaged and then fitted to the constitutive model (average R2 over 0.9). Since the sample thicknesses were not hugely different, averaging the data using the same tension levels and stress levels produced similar average material constants for each leaflet.

An investigation of the effect of freezing storage on the biaxial mechanical properties of excised porcine tricuspid valve anterior leaflets

The atrioventricular heart valve (AHV) leaflets are critical to the facilitation of proper unidirectional blood flow through the heart. Previously, studies have been conducted to understand the tissue mechanics of healthy AHV leaflets to inform the development of valve-specific computational models and replacement materials for use in diagnosing and treating valvular heart disease. Generally, these studies involved biaxial mechanical testing of the AHV leaflet tissue specimens to extract relevant mechanical properties. Most of those studies considered freezing-based storage systems based on previous findings for other connective tissues such as aortic tissue or skin. However, there remains no study that specifically examines the effects of freezing storage on the characterized mechanical properties of the AHV leaflets. In this study, we aimed to address this gap in knowledge by performing biaxial mechanical characterizations of the tricuspid valve anterior leaflet (TVAL) tissue both before and after a 48-h freezing period. Primary findings of this study include: (i) a statistically insignificant change in the tissue extensibilities, with the frozen tissues being slightly stiffer and more anisotropic than the fresh tissues; and (ii) minimal variations in the stress relaxation behaviors between the fresh and frozen tissues, with the frozen tissues demonstrating slightly lessened relaxation. The findings from this study suggested that freezing-based storage does not significantly impact the observed mechanical properties of one of the five AHV leaflets-the TVAL. The results from this study are useful for reaffirming the experimental methodologies in the previous studies, as well as informing the tissue preservation methods of future investigations of AHV leaflet mechanics.

An investigation of layer-specific tissue biomechanics of porcine atrioventricular valve anterior leaflets

Atrioventricular heart valves (AHVs) are composed of structurally complex and morphologically heterogeneous leaflets. The coaptation of these leaflets during the cardiac cycle facilitates unidirectional blood flow. Valve regurgitation is treated preferably by surgical repair if possible or replacement based on the disease state of the valve tissue. A comprehensive understanding of valvular morphology and mechanical properties is crucial to refining computational models, serving as a patient-specific diagnostic and surgical tool for preoperative planning. Previous studies have modeled the stress distribution throughout the leaflet's thickness, but validations with layer-specific biaxial mechanical experiments are missing. In this study, we sought to fill this gap in literature by investigating the impact of microstructure constituents on mechanical behavior throughout the thickness of the AHVs' anterior leaflets. Porcine mitral valve anterior leaflets (MVAL) and tricuspid valve anterior leaflets (TVAL) were micro-dissected into three layers (atrialis/spongiosa, fibrosa, and ventricular) and two layers (atrialis/spongiosa and fibrosa/ventricularis), respectively, based on their relative distributions of extracellular matrix components as quantified by histological analyses: collagen, elastin, and glycosaminoglycans. Our results suggest that (i) for both valves, the atrialis/spongiosa layer is the most extensible and anisotropic layer, possibly due to its relatively low collagen content as compared to other layers, (ii) the intact TVAL response is stiffer than the atrialis/spongiosa layer but more compliant than the fibrosa/ventricularis layer, and (iii) the MVAL fibrosa and ventricularis layers behave nearly isotropic. These novel findings emphasize the biomechanical variances throughout the AHV leaflets, and our results could better inform future AHV computational model developments. STATEMENT OF SIGNIFICANCE: This study, which is the first of its kind for atrioventricular heart valve (AHV) leaflet tissue layers, rendered a mechanical characterization of the biaxial mechanical properties and distributions of extracellular matrix components (collagen, elastin, and glycosaminoglycans) of the mitral and tricuspid valve anterior leaflet layers. The novel findings from the present study emphasize the biomechanical variances throughout the thickness of AHV leaflets, and our results indicate that the previously-adopted homogenous leaflet in the AHV biomechanical modeling may be an oversimplification of the complex leaflet anatomy. Such improvement in the understanding of valvular morphology and tissue mechanics is crucial to future refinement of AHV computational models, serving as a patient-specific diagnostic and surgical tool, at the preoperative stage, for treating valvular heart diseases.

A computational multi-scale approach to investigate mechanically-induced changes in tricuspid valve anterior leaflet microstructure

The tricuspid valve is an atrioventricular valve that prevents blood backflow from the right ventricle into the right atrium during ventricular contractions. It is important to study mechanically induced microstructural alterations in the tricuspid valve leaflets, as this aids both in understanding valvular diseases and in the development of new engineered tissue replacements. The structure and composition of the extracellular matrix (ECM) fiber networks are closely tied to an overall biomechanical function of the tricuspid valve. In this study, we conducted experiments and implemented a multiscale modeling approach to predict ECM microstructural changes to tissue-level mechanical responses in a controlled loading environment. In particular, we characterized a sample of a porcine anterior leaflet at a macroscale using a biaxial mechanical testing method. We then generated a three-dimensional finite element model, to which computational representations of corresponding fiber networks were incorporated based on properties of the microstructural architecture obtained from small angle light scattering. Using five different biaxial boundary conditions, we performed iterative simulations to obtain model parameters with an overall R² value of 0.93. We observed that mechanical loading could markedly alter the underlying ECM architecture. For example, a relatively isotropic fiber network (with an anisotropy index value α of 28%) became noticeably more anisotropic (with an α of 40%) when it underwent mechanical loading. We also observed that the mechanical strain was distributed in a different manner at the ECM/fiber level as compared to the tissue level. The approach presented in this study has the potential to be implemented in pathophysiologically altered biomechanical and structural conditions and to bring insights into the mechanobiology of the tricuspid valve. STATEMENT OF SIGNIFICANCE: Quantifying abnormal cellar/ECM-level deformation of tricuspid valve leaflets subjected to a modified loading environment is of great importance, as it is believed to be linked to valvular remodeling responses. For example, developing surgical procedures or engineered tissue replacements that maintain/mimic ECM-level mechanical homeostasis could lead to more durable outcomes. To quantify leaflet deformation, we built a multiscale framework encompassing the contributions of disorganized ECM components and organized fibers, which can predict the behavior of the tricuspid valve leaflets under physiological loading conditions both at the tissue level and at the ECM level. In addition to future in-depth studies of tricuspid valve pathologies, our model can be used to characterize tissues in other valves of the heart.

An investigation of the glycosaminoglycan contribution to biaxial mechanical behaviours of porcine atrioventricular heart valve leaflets

The atrioventricular heart valve (AHV) leaflets have a complex microstructure composed of four distinct layers: atrialis, ventricularis, fibrosa and spongiosa. Specifically, the spongiosa layer is primarily proteoglycans and glycosaminoglycans (GAGs). Quantification of the GAGs' mechanical contribution to the overall leaflet function has been of recent focus for aortic valve leaflets, but this characterization has not been reported for the AHV leaflets. This study seeks to expand current GAG literature through novel mechanical characterizations of GAGs in AHV leaflets. For this characterization, mitral and tricuspid valve anterior leaflets (MVAL and TVAL, respectively) were: (i) tested by biaxial mechanical loading at varying loading ratios and by stress-relaxation procedures, (ii) enzymatically treated for removal of the GAGs and (iii) biaxially mechanically tested again under the same protocols as in step (i). Removal of the GAG contents from the leaflet was conducted using a 100 min enzyme treatment to achieve approximate 74.87% and 61.24% reductions of all GAGs from the MVAL and TVAL, respectively. Our main findings demonstrated that biaxial mechanical testing yielded a statistically significant difference in tissue extensibility after GAG removal and that stress-relaxation testing revealed a statistically significant smaller stress decay of the enzyme-treated tissue than untreated tissues. These novel findings illustrate the importance of GAGs in AHV leaflet behaviour, which can be employed to better inform heart valve therapeutics and computational models.

Biaxial Mechanical Characterizations of Atrioventricular Heart Valves

Extensive biaxial mechanical testing of the atrioventricular heart valve leaflets can be utilized to derive optimal parameters used in constitutive models, which provide a mathematical representation of the mechanical function of those structures. This presented biaxial mechanical testing protocol involves (i) tissue acquisition, (ii) the preparation of tissue specimens, (iii) biaxial mechanical testing, and (iv) postprocessing of the acquired data. First, tissue acquisition requires obtaining porcine or ovine hearts from a local Food and Drug Administration-approved abattoir for later dissection to retrieve the valve leaflets. Second, tissue preparation requires using tissue specimen cutters on the leaflet tissue to extract a clear zone for testing. Third, biaxial mechanical testing of the leaflet specimen requires the use of a commercial biaxial mechanical tester, which consists of force-controlled, displacement-controlled, and stress-relaxation testing protocols to characterize the leaflet tissue's mechanical properties. Finally, post-processing requires the use of data image correlation techniques and force and displacement readings to summarize the tissue's mechanical behaviors in response to external loading. In general, results from biaxial testing demonstrate that the leaflet tissues yield a nonlinear, anisotropic mechanical response. The presented biaxial testing procedure is advantageous to other methods since the method presented here allows for a more comprehensive characterization of the valve leaflet tissue under one unified testing scheme, as opposed to separate testing protocols on different tissue specimens. The proposed testing method has its limitations in that shear stress is potentially present in the tissue sample. However, any potential shear is presumed negligible.

Comparative mechanical, morphological, and microstructural characterization of porcine mitral and tricuspid leaflets and chordae tendineae

BACKGROUND

Healthy function of tricuspid valve (TV) structures is essential to avoid tricuspid regurgitation (TR) and may significantly improve disease prognosis. Mitral valve (MV) structures have been extensively studied, but little is known about the TV and right-sided heart diseases. Therefore, clinical decisions and finite element (FE) simulations often rely heavily on MV data for TV applications, despite fundamentally different mechanical and physiological environments.

METHOD/RESULTS

To bridge this gap, we performed a rigorous mechanical, morphological, and microstructural characterization of the MV and TV leaflets and chordae in a porcine model. Planar biaxial testing, uniaxial testing, second harmonic generation imaging and Verhoeff Van Gieson staining were performed. Morphological parameters, tissue moduli, extensibility, and anisotropy were quantified and compared. No major differences in leaflet mechanics or structure were found between TV and MV; chordal mechanics, morphology, and structure were found to compensate for anatomical and physiological loading differences between the valves. No differences in chordal mechanics were observed by insertion point within a leaflet; the septal tricuspid leaflet (STL) and posterior mitral leaflet (PML) did not have distinguishable strut chords, and the STL had the shortest chords. Within a valve, chords from septally-located leaflets were more extensible. MV chords were stiffer.

CONCLUSIONS

This study presents the first rigorous comparative mechanical and structural dataset of MV and TV structures. Valve type and anatomical location may be stronger predictors of chordal mechanics. Chords from septally-located leaflets differ from each other and from their intravalvular counterparts; they merit special consideration in surgical and computational applications.

STATEMENT OF SIGNIFICANCE

A better understanding of the tricuspid valve (TV) and its associated structures is important for making advancements towards the repair of tricuspid regurgitation. Mitral valve structures have been extensively studied, but little is known about the TV and right-sided heart diseases. Clinical decisions and computational simulations often rely heavily on MV data for TV applications, despite fundamentally different environments. We therefore performed a rigorous mechanical, morphological, and microstructural characterization of atrioventricular leaflets and chordae tendineae in a porcine model. Finding that valve type and anatomical location may be strong predictors of chordal mechanics, chords from septally-located leaflets differ from each other and from their intravalvular counterparts; they merit special consideration in surgical and computational applications.

An investigation of regional variations in the biaxial mechanical properties and stress relaxation behaviors of porcine atrioventricular heart valve leaflets

The facilitation of proper blood flow through the heart depends on proper function of heart valve components, and alterations to any component can lead to heart disease or failure. Comprehension of these valvular diseases is reliant on thorough characterization of healthy heart valve structures for use in computational models. Previously, computational models have treated these leaflet structures as a structurally and mechanically homogenous material, which may not be an accurate description of leaflet mechanical response. In this study, we aimed to characterize the mechanics of the heart valve leaflet as a structurally heterogenous material. Specifically, porcine mitral valve and tricuspid valve anterior leaflets were sectioned into six regions and biaxial mechanical tests with various loading ratios and stress-relaxation test were performed on each regional tissue sample. Three main findings from this study were summarized as follows: (i) the central regions of the leaflet had a more anisotropic nature than edge regions, (ii) the mitral valve anterior leaflet was more extensible in regions closer to the annulus, and (iii) there was variance in the stress-relaxation behavior among all six regions, with mitral valve leaflet tissue regions exhibiting a greater decay than the tricuspid valve regions. This study presents a novel investigation of the regional variations in the heart valve biomechanics that has not been comprehensively examined. Our results thus allow for a refinement of computational models for more accurately predicting diseased or surgically-intervened condition, where tissue heterogeneity plays an essential role in the heart valve function.

Biomechanical properties and microstructure of neonatal porcine ventricles

Neonatal heart disorders represent a major clinical challenge, with congenital heart disease alone affecting 36,000 new-borns annually within the European Union. Surgical intervention to restore normal function includes the implantation of synthetic and biological materials; however, a lack of experimental data describing the mechanical behaviour of neonatal cardiac tissue is likely to contribute to the relatively poor short- and long-term outcome of these implants. This study focused on characterising the mechanical behaviour of neonatal cardiac tissue using a porcine model, to enhance the understanding of how this differs to the equivalent mature tissue. The biomechanical properties of neonatal porcine cardiac tissue were characterised by uniaxial tensile, biaxial tensile, and simple shear loading modes, using samples collected from the anterior and posterior walls of the right and left ventricles. Histological images were prepared using Masson's trichrome staining, to enable assessment of the microstructure and correlation with tissue behaviour. The mechanical tests demonstrated that the neonatal cardiac tissue is non-linear, anisotropic, viscoelastic and heterogeneous. Our data provide a baseline describing the biomechanical behaviour of immature porcine cardiac tissue. Comparison with published data also indicated that the neonatal porcine cardiac tissue exhibits one-half the stiffness of mature porcine tissue in uniaxial extension testing, one-third in biaxial extension testing, and one-fourth stiffness in simple shear testing; hence, it provides an indication as to the relative change in characteristics associated with tissue maturation. These data may prove valuable to researchers investigating neonatal cardiac mechanics.

Soft mechanical metamaterials with unusual swelling behavior and tunable stress-strain curves

Soft adaptable materials that change their shapes, volumes, and properties in response to changes under ambient conditions have important applications in tissue engineering, soft robotics, biosensing, and flexible displays. Upon water absorption, most existing soft materials, such as hydrogels, show a positive volume change, corresponding to a positive swelling. By contrast, the negative swelling represents a relatively unusual phenomenon that does not exist in most natural materials. The development of material systems capable of large or anisotropic negative swelling remains a challenge. We combine analytic modeling, finite element analyses, and experiments to design a type of soft mechanical metamaterials that can achieve large effective negative swelling ratios and tunable stress-strain curves, with desired isotropic/anisotropic features. This material system exploits horseshoe-shaped composite microstructures of hydrogel and passive materials as the building blocks, which extend into a periodic network, following the lattice constructions. The building block structure leverages a sandwiched configuration to convert the hydraulic swelling deformations of hydrogel into bending deformations, thereby resulting in an effective shrinkage (up to around -47% linear strain) of the entire network. By introducing spatially heterogeneous designs, we demonstrated a range of unusual, anisotropic swelling responses, including those with expansion in one direction and, simultaneously, shrinkage along the perpendicular direction. The design approach, as validated by experiments, allows the determination of tailored microstructure geometries to yield desired length/area changes. These design concepts expand the capabilities of existing soft materials and hold promising potential for applications in a diverse range of areas.

Regulation of valve interstitial cell homeostasis by mechanical deformation: implications for heart valve disease and surgical repair

Mechanical stress is one of the major aetiological factors underlying soft-tissue remodelling, especially for the mitral valve (MV). It has been hypothesized that altered MV tissue stress states lead to deviations from cellular homeostasis, resulting in subsequent cellular activation and extracellular matrix (ECM) remodelling. However, a quantitative link between alterations in the organ-level in vivo state and in vitro-based mechanobiology studies has yet to be made. We thus developed an integrated experimental-computational approach to elucidate MV tissue and interstitial cell responses to varying tissue strain levels. Comprehensive results at different length scales revealed that normal responses are observed only within a defined range of tissue deformations, whereas deformations outside of this range lead to hypo- and hyper-synthetic responses, evidenced by changes in α-smooth muscle actin, type I collagen, and other ECM and cell adhesion molecule regulation. We identified MV interstitial cell deformation as a key player in leaflet tissue homeostatic regulation and, as such, used it as the metric that makes the critical link between in vitro responses to simulated equivalent in vivo behaviour. Results indicated that cell responses have a delimited range of in vivo deformations that maintain a homeostatic response, suggesting that deviations from this range may lead to deleterious tissue remodelling and failure.

Quantification and comparison of the mechanical properties of four human cardiac valves

OBJECTIVE

Although having the same ability to permit unidirectional flow within the heart, the four main valves-the mitral valve (MV), aortic (AV), tricuspid (TV) and pulmonary (PV) valves-experience different loading conditions; thus, they exhibit different structural integrity from one another. Most research on heart valve mechanics have been conducted mainly on MV and AV or an individual valve, but none quantify and compare the mechanical and structural properties among the four valves from the same aged patient population whose death was unrelated to cardiovascular disease.

METHODS

A total of 114 valve leaflet samples were excised from 12 human cadavers whose death was unrelated to cardiovascular disease (70.1±3.7years old). Tissue mechanical and structural properties were characterized by planar biaxial mechanical testing and histological methods. The experimental data were then fitted with a Fung-type constitutive model.

RESULTS

The four valves differed substantially in thickness, degree of anisotropy, and stiffness. The leaflets of the left heart (the AV leaflets and the anterior mitral leaflets, AML) were significantly stiffer and less compliant than their counterparts in the right heart. TV leaflets were the most extensible and isotropic, while AML and AV leaflets were the least extensible and the most anisotropic. Age plays a significant role in the reduction of leaflet stiffness and extensibility with nearly straightened collagen fibers observed in the leaflet samples from elderly groups (65years and older).

CONCLUSIONS

Results from 114 human leaflet samples not only provided a baseline quantification of the mechanical properties of aged human cardiac valves, but also offered a better understanding of the age-dependent differences among the four valves. It is hoped that the experimental data collected and the associated constitutive models in this study can facilitate future studies of valve diseases, treatments and the development of interventional devices.

STATEMENT OF SIGNIFICANCE

Most research on heart valve mechanics have been conducted mainly on mitral and aortic valves or an individual valve, but none quantify and compare the mechanical and structural properties among the four valves from the same relatively healthy elderly patient population. In this study, the mechanical and microstructural properties of 114 leaflets of aortic, mitral, pulmonary and tricuspid valves from 12 human cadaver hearts were mechanically tested, analyzed and compared. Our results not only provided a baseline quantification of the mechanical properties of aged human valves, but a age range between patients (51-87years) also offers a better understanding of the age-dependent differences among the four valves. It is hoped that the obtained experimental data and associated constitutive parameters can facilitate studies of valve diseases, treatments and the development of interventional devices.

On the in vivo function of the mitral heart valve leaflet: insights into tissue-interstitial cell biomechanical coupling

There continues to be a critical need for developing data-informed computational modeling techniques that enable systematic evaluations of mitral valve (MV) function. This is important for a better understanding of MV organ-level biomechanical performance, in vivo functional tissue stresses, and the biosynthetic responses of MV interstitial cells (MVICs) in the normal, pathophysiological, and surgically repaired states. In the present study, we utilized extant ovine MV population-averaged 3D fiducial marker data to quantify the MV anterior leaflet (MVAL) deformations in various kinematic states. This approach allowed us to make the critical connection between the in vivo functional and the in vitro experimental configurations. Moreover, we incorporated the in vivo MVAL deformations and pre-strains into an enhanced inverse finite element modeling framework (Path 1) to estimate the resulting in vivo tissue prestresses [Formula: see text] and the in vivo peak functional tissue stresses [Formula: see text]. These in vivo stress estimates were then cross-verified with the results obtained from an alternative forward modeling method (Path 2), by taking account of the changes in the in vitro and in vivo reference configurations. Moreover, by integrating the tissue-level kinematic results into a downscale MVIC microenvironment FE model, we were able to estimate, for the first time, the in vivo layer-specific MVIC deformations and deformation rates of the normal and surgically repaired MVALs. From these simulations, we determined that the placement of annuloplasty ring greatly reduces the peak MVIC deformation levels in a layer-specific manner. This suggests that the associated reductions in MVIC deformation may down-regulate MV extracellular matrix maintenance, ultimately leading to reduction in tissue mechanical integrity. These simulations provide valuable insight into MV cellular mechanobiology in response to organ- and tissue-level alternations induced by MV disease or surgical repair. They will also assist in the future development of computer simulation tools for guiding MV surgery procedure with enhanced durability and improved long-term surgical outcomes.

Biaxial stress relaxation of semilunar heart valve leaflets during simulated collagen catabolism: Effects of collagenase concentration and equibiaxial strain state

Heart valve leaflet collagen turnover and remodeling are innate to physiological homeostasis; valvular interstitial cells routinely catabolize damaged collagen and affect repair. Moreover, evidence indicates that leaflets can adapt to altered physiological (e.g. pregnancy) and pathological (e.g. hypertension) mechanical load states, tuning collagen structure and composition to changes in pressure and flow. However, while valvular interstitial cell-secreted matrix metalloproteinases are considered the primary effectors of collagen catabolism, the mechanisms by which damaged collagen fibers are selectively degraded remain unclear. Growing evidence suggests that the collagen fiber strain state plays a key role, with the strain-dependent configuration of the collagen molecules either masking or presenting proteolytic sites, thereby protecting or accelerating collagen proteolysis. In this study, the effects of equibiaxial strain state on collagen catabolism were investigated in porcine aortic valve and pulmonary valve tissues. Bacterial collagenase (0.2 and 0.5 mg/mL) was utilized to simulate endogenous matrix metalloproteinases, and biaxial stress relaxation and biochemical collagen concentration served as functional and compositional measures of collagen catabolism, respectively. At a collagenase concentration of 0.5 mg/mL, increasing the equibiaxial strain imposed during stress relaxation (0%, 37.5%, and 50%) yielded significantly lower median collagen concentrations in the aortic valve (p = 0.0231) and pulmonary valve (p = 0.0183), suggesting that relatively large strain magnitudes may enhance collagen catabolism. Collagen concentration decreases were paralleled by trends of accelerated normalized stress relaxation rate with equibiaxial strain in aortic valve tissues. Collectively, these in vitro results indicate that biaxial strain state is capable of affecting the susceptibility of valvular collagens to catabolism, providing a basis for further investigation of how such phenomena may manifest at different strain magnitudes or in vivo.

Heart Valve Biomechanics and Underlying Mechanobiology

Heart valves control unidirectional blood flow within the heart during the cardiac cycle. They have a remarkable ability to withstand the demanding mechanical environment of the heart, achieving lifetime durability by processes involving the ongoing remodeling of the extracellular matrix. The focus of this review is on heart valve functional physiology, with insights into the link between disease-induced alterations in valve geometry, tissue stress, and the subsequent cell mechanobiological responses and tissue remodeling. We begin with an overview of the fundamentals of heart valve physiology and the characteristics and functions of valve interstitial cells (VICs). We then provide an overview of current experimental and computational approaches that connect VIC mechanobiological response to organ- and tissue-level deformations and improve our understanding of the underlying functional physiology of heart valves. We conclude with a summary of future trends and offer an outlook for the future of heart valve mechanobiology, specifically, multiscale modeling approaches, and the potential directions and possible challenges of research development. © 2016 American Physiological Society. Compr Physiol 6:1743-1780, 2016.

On the Biaxial Mechanical Response of Porcine Tricuspid Valve Leaflets

Located on the right side of the heart, the tricuspid valve (TV) prevents blood backflow from the right ventricle to the right atrium. Similar to other cardiac valves, quantification of TV biaxial mechanical properties is essential in developing accurate computational models. In the current study, for the first time, the biaxial stress–strain behavior of porcine TV was measured ex vivo under different loading protocols using biaxial tensile testing equipment. The results showed a highly nonlinear response including a compliant region followed by a rapid transition to a stiff region for all of the TV leaflets both in the circumferential and in the radial directions. Based on the data analysis, all three leaflets were found to be anisotropic, and they were stiffer in the circumferential direction in comparison to the radial direction. It was also concluded that the posterior leaflet was the most anisotropic leaflet.

Biomechanical Behavior of Bioprosthetic Heart Valve Heterograft Tissues: Characterization, Simulation, and Performance

The use of replacement heart valves continues to grow due to the increased prevalence of valvular heart disease resulting from an ageing population. Since bioprosthetic heart valves (BHVs) continue to be the preferred replacement valve, there continues to be a strong need to develop better and more reliable BHVs through and improved the general understanding of BHV failure mechanisms. The major technological hurdle for the lifespan of the BHV implant continues to be the durability of the constituent leaflet biomaterials, which if improved can lead to substantial clinical impact. In order to develop improved solutions for BHV biomaterials, it is critical to have a better understanding of the inherent biomechanical behaviors of the leaflet biomaterials, including chemical treatment technologies, the impact of repetitive mechanical loading, and the inherent failure modes. This review seeks to provide a comprehensive overview of these issues, with a focus on developing insight on the mechanisms of BHV function and failure. Additionally, this review provides a detailed summary of the computational biomechanical simulations that have been used to inform and develop a higher level of understanding of BHV tissues and their failure modes. Collectively, this information should serve as a tool not only to infer reliable and dependable prosthesis function, but also to instigate and facilitate the design of future bioprosthetic valves and clinically impact cardiology.

Mechanical Characteristics of Bovine Glisson's Capsule as a Model Tissue for Soft Collagenous Membranes

An extensive multiaxial experimental campaign on the monotonic, time- and history-dependent mechanical response of bovine Glisson's capsule (GC) is presented. Reproducible characteristics were observed such as J-shaped curves in uniaxial and biaxial configurations, large lateral contraction, cyclic tension softening, large tension relaxation, and moderate creep strain accumulation. The substantial influence of the reference state selection on the kinematic response and the tension versus stretch curves is demonstrated and discussed. The parameters of a large-strain viscoelastic constitutive model were determined based on the data of uniaxial tension relaxation experiments. The model is shown to well predict the uniaxial and biaxial viscoelastic responses in all other configurations. GC, the corresponding model, and the experimental protocols are proposed as a useful basis for future studies on the relation between microstructure and tissue functionality and on the factors influencing the mechanical response of soft collagenous membranes.

Micro-structural and Biaxial Creep Properties of the Swine Uterosacral-Cardinal Ligament Complex

The uterosacral ligament and cardinal ligament (USL/CL) complex is the major suspensory tissue of the uterus, cervix, and vagina. This tissue is subjected primarily to bi-axial forces in-vivo that significantly alter its structure and dimension over time, compromising its support function and leading to pelvic floor disorders. In this study, we present the first rigorous characterization of the collagen fiber microstructure and creep properties of the swine USL/CL complex by using scanning electron microscopy and planar biaxial testing in combination with three-dimensional digital image correlation. Collagen fiber bundles were found to be arranged into layers. Although the fiber bundles were oriented in multiple directions, 80.8% of them were aligned within ±45[Formula: see text] to the main in-vivo loading direction. The straightness parameter, defined as the ratio of the end-to-end distance of a fiber bundle to its length, varied from 0.28 to 1.00, with 95.2% fiber bundles having a straightness parameter between 0.60 and 1.00. Under constant equi-biaxial loads of 2 and 4 N, the USL/CL complex exhibited significant creep both along the main in-vivo loading direction (the parallel direction) and along the direction perpendicular to it (the perpendicular direction). Specifically, over a 120-min period, the mean strain increased by 20-34[Formula: see text] in the parallel direction and 33-41[Formula: see text] in the perpendicular direction. However, there was no statistically significant difference in creep strains observed after 120 min between the parallel and perpendicular directions for either the 2 or 4 N load case. Creep proceeded slightly faster in the perpendicular direction under the equi-biaxial load of 2 N than under the equi-biaxial load of 4 N ([Formula: see text]). It proceeded significantly faster in the parallel direction under the equi-biaxial loads of 2 N than under the equi-biaxial loads of 4 N ([Formula: see text]). Overall, our findings contribute to a greater understanding of the biomaterial properties of the USL/CL complex that is needed for the development of new surgical reconstruction methods and mesh materials for pelvic floor disorders.

A meso-scale layer-specific structural constitutive model of the mitral heart valve leaflets

Fundamental to developing a deeper understanding of pathophysiological remodeling in mitral valve (MV) disease is the development of an accurate tissue-level constitutive model. In the present work, we developed a novel meso-scale (i.e. at the level of the fiber, 10-100 μm in length scale) structural constitutive model (MSSCM) for MV leaflet tissues. Due to its four-layer structure, we focused on the contributions from the distinct collagen and elastin fiber networks within each tissue layer. Requisite collagen and elastin fibrous structural information for each layer were quantified using second harmonic generation microscopy and conventional histology. A comprehensive mechanical dataset was also used to guide model formulation and parameter estimation. Furthermore, novel to tissue-level structural constitutive modeling approaches, we allowed the collagen fiber recruitment function to vary with orientation. Results indicated that the MSSCM predicted a surprisingly consistent mean effective collagen fiber modulus of 162.72 MPa, and demonstrated excellent predictive capability for extra-physiological loading regimes. There were also anterior-posterior leaflet-specific differences, such as tighter collagen and elastin fiber orientation distributions (ODF) in the anterior leaflet, and a thicker and stiffer atrialis in the posterior leaflet. While a degree of angular variance was observed, the tight valvular tissue ODF also left little room for any physically meaningful angular variance in fiber mechanical responses. Finally, a novel fibril-level (0.1-1 μm) validation approach was used to compare the predicted collagen fiber/fibril mechanical behavior with extant MV small angle X-ray scattering data. Results demonstrated excellent agreement, indicating that the MSSCM fully captures the tissue-level function. Future utilization of the MSSCM in computational models of the MV will aid in producing highly accurate simulations in non-physiological loading states that can occur in repair situations, as well as guide the form of simplified models for real-time simulation tools.

A novel fibre-ensemble level constitutive model for exogenous cross-linked collagenous tissues

Exogenous cross-linking of soft collagenous tissues is a common method for biomaterial development and medical therapies. To enable improved applications through computational methods, physically realistic constitutive models are required. Yet, despite decades of research, development and clinical use, no such model exists. In this study, we develop the first rigorous full structural model (i.e. explicitly incorporating various features of the collagen fibre architecture) for exogenously cross-linked soft tissues. This was made possible, in-part, with the use of native to cross-linked matched experimental datasets and an extension to the collagenous structural constitutive model so that the uncross-linked collagen fibre responses could be mapped to the cross-linked configuration. This allowed us to separate the effects of cross-linking from kinematic changes induced in the cross-linking process, which in turn allowed the non-fibrous tissue matrix component and the interaction effects to be identified. It was determined that the matrix could be modelled as an isotropic material using a modified Yeoh model. The most novel findings of this study were that: (i) the effective collagen fibre modulus was unaffected by cross-linking and (ii) fibre-ensemble interactions played a large role in stress development, often dominating the total tissue response (depending on the stress component and loading path considered). An important utility of the present model is its ability to separate the effects of exogenous cross-linking on the fibres from changes due to the matrix. Applications of this approach include the utilization in the design of novel chemical treatments to produce specific mechanical responses and the study of fatigue damage in bioprosthetic heart valve biomaterials.

Regional biomechanical and histological characterization of the mitral valve apparatus: Implications for mitral repair strategies

The aim of this study was to investigate the regional and directional differences in the biomechanics and histoarchitecture of the porcine mitral valve (MV) apparatus, with a view to tailoring tissue-engineered constructs for MV repair. The anterior leaflet displayed the largest directional anisotropy with significantly higher strength in the circumferential direction compared to the posterior leaflet. The histological results indicated that this was due to the circumferential alignment of the collagen fibers. The posterior leaflet demonstrated no significant directional anisotropy in the mechanical properties, and there was no significant directionality of the collagen fibers in the main body of the leaflet. The thinner commissural chordae were found to be significantly stiffer and less extensible than the strut chordae. Histological staining demonstrated a tighter knit of the collagen fibers in the commissural chordae than the strut chordae. By elucidating the inhomogeneity of the histoarchitecture and biomechanics of the MV apparatus, the results from this study will aid the regional differentiation of MV repair strategies, with tailored mitral-component-specific biomaterials or tissue-engineered constructs.

Mitral valve disease--morphology and mechanisms

Mitral valve disease is a frequent cause of heart failure and death. Emerging evidence indicates that the mitral valve is not a passive structure, but--even in adult life--remains dynamic and accessible for treatment. This concept motivates efforts to reduce the clinical progression of mitral valve disease through early detection and modification of underlying mechanisms. Discoveries of genetic mutations causing mitral valve elongation and prolapse have revealed that growth factor signalling and cell migration pathways are regulated by structural molecules in ways that can be modified to limit progression from developmental defects to valve degeneration with clinical complications. Mitral valve enlargement can determine left ventricular outflow tract obstruction in hypertrophic cardiomyopathy, and might be stimulated by potentially modifiable biological valvular-ventricular interactions. Mitral valve plasticity also allows adaptive growth in response to ventricular remodelling. However, adverse cellular and mechanobiological processes create relative leaflet deficiency in the ischaemic setting, leading to mitral regurgitation with increased heart failure and mortality. Our approach, which bridges clinicians and basic scientists, enables the correlation of observed disease with cellular and molecular mechanisms, leading to the discovery of new opportunities for improving the natural history of mitral valve disease.

Heterogeneity of Mitral Leaflet Matrix Composition and Turnover Correlates with Regional Leaflet Strain

To determine how extracellular matrix and contractile valvular cells contribute to the heterogeneous motion and strain across the mitral valve (MV) during the cardiac cycle, regional MV material properties, matrix composition, matrix turnover, and cell phenotype were related to regional leaflet strain. Radiopaque markers were implanted into 14 sheep to delineate the septal (SEPT), lateral (LAT), and anterior and posterior commissural leaflets (ANT-C, POST-C). Videofluoroscopy imaging was used to calculate radial and circumferential strains. Mechanical properties were assessed using uniaxial tensile testing and micropipette aspiration. Matrix composition and cell phenotypes were immunohistochemically evaluated within each leaflet region [basal leaflet (BL), mid-leaflet (ML), and free edge]. SEPT-BL segments were stiffer and stronger than other valve tissues, while LAT segments demonstrated more extensibility and strain. Collagens I and III in SEPT were greater than in LAT, although LAT showed greater collagen turnover [matrix metalloprotease (MMP)-13, lysyl oxidase] and cell activation [smooth muscle alpha-actin (SMaA), and non-muscle myosin (NMM)]. MMP13, NMM, and SMaA were strongly correlated with each other, as well as with radial and circumferential strains in both SEPT and LAT. SMaA and MMP13 in POST-C ML was greater than ANT-C, corresponding to greater radial strains in POST-C. This work directly relates leaflet strain, material properties, and matrix turnover, and suggests a role for myofibroblasts in the heterogeneity of leaflet composition and strain. New approaches to MV repair techniques and ring design should preserve this normal coupling between leaflet composition and motion.

A novel crosslinking method for improved tear resistance and biocompatibility of tissue based biomaterials

Over 300,000 heart valve replacements are performed annually to replace stenotic and regurgitant heart valves. Bioprosthetic heart valves (BHVs), derived from glutaraldehyde crosslinked (GLUT) porcine aortic valve leaflets or bovine pericardium are often used. However, valve failure can occur within 12-15 years due to calcification and/or progressive degeneration. In this study, we have developed a novel fabrication method that utilizes carbodiimide, neomycin trisulfate, and pentagalloyl glucose crosslinking chemistry (TRI) to better stabilize the extracellular matrix of porcine aortic valve leaflets. We demonstrate that TRI treated leaflets show similar biomechanics to GLUT crosslinked leaflets. TRI treated leaflets had better resistance to enzymatic degradation in vitro and demonstrated better tearing toughness after challenged with enzymatic degradation. When implanted subcutaneously in rats for up to 90 days, GLUT control leaflets calcified heavily while TRI treated leaflets resisted calcification, retained more ECM components, and showed better biocompatibility.

Coupled Simulation of Heart Valves: Applications to Clinical Practice

The last few decades have seen great advances in the understanding of heart valves, and consequently, in the development of novel treatment modalities and surgical procedures for valves afflicted by disease. This is due in part to the profound advancements in computing technology and noninvasive medical imaging techniques that have made it possible to numerically model the complex heart valve systems characterized by distinct features at different length scales and various interacting processes. In this article, we highlight the importance of explicitly coupling these multiple scales and diverse processes to accurately simulate the true behavior of the heart valves, in health and disease. We examine some of the computational modeling studies that have a direct consequence on clinical practice.

On the presence of affine fibril and fiber kinematics in the mitral valve anterior leaflet

In this study, we evaluated the hypothesis that the constituent fibers follow an affine deformation kinematic model for planar collagenous tissues. Results from two experimental datasets were utilized, taken at two scales (nanometer and micrometer), using mitral valve anterior leaflet (MVAL) tissues as the representative tissue. We simulated MVAL collagen fiber network as an ensemble of undulated fibers under a generalized two-dimensional deformation state, by representing the collagen fibrils based on a planar sinusoidally shaped geometric model. The proposed approach accounted for collagen fibril amplitude, crimp period, and rotation with applied macroscopic tissue-level deformation. When compared to the small angle x-ray scattering measurements, the model fit the data well, with an r(2) = 0.976. This important finding suggests that, at the homogenized tissue-level scale of ∼1 mm, the collagen fiber network in the MVAL deforms according to an affine kinematics model. Moreover, with respect to understanding its function, affine kinematics suggests that the constituent fibers are largely noninteracting and deform in accordance with the bulk tissue. It also suggests that the collagen fibrils are tightly bounded and deform as a single fiber-level unit. This greatly simplifies the modeling efforts at the tissue and organ levels, because affine kinematics allows a straightforward connection between the macroscopic and local fiber strains. It also suggests that the collagen and elastin fiber networks act independently of each other, with the collagen and elastin forming long fiber networks that allow for free rotations. Such freedom of rotation can greatly facilitate the observed high degree of mechanical anisotropy in the MVAL and other heart valves, which is essential to heart valve function. These apparently novel findings support modeling efforts directed toward improving our fundamental understanding of tissue biomechanics in healthy and diseased conditions.

Time-dependent mechanical behavior of human amnion: macroscopic and microscopic characterization

Characterizing the mechanical response of the human amnion is essential to understand and to eventually prevent premature rupture of fetal membranes. In this study, a large set of macroscopic and microscopic mechanical tests have been carried out on fresh unfixed amnion to gain insight into the time-dependent material response and the underlying mechanisms. Creep and relaxation responses of amnion were characterized in macroscopic uniaxial tension, biaxial tension and inflation configurations. For the first time, these experiments were complemented by microstructural information from nonlinear laser scanning microscopy performed during in situ uniaxial relaxation tests. The amnion showed large tension reduction during relaxation and small inelastic strain accumulation in creep. The short-term relaxation response was related to a concomitant in-plane and out-of-plane contraction, and was dependent on the testing configuration. The microscopic investigation revealed a large volume reduction at the beginning, but no change of volume was measured long-term during relaxation. Tension-strain curves normalized with respect to the maximum strain were highly repeatable in all configurations and allowed the quantification of corresponding characteristic parameters. The present data indicate that dissipative behavior of human amnion is related to two mechanisms: (i) volume reduction due to water outflow (up to ∼20 s) and (ii) long-term dissipative behavior without macroscopic deformation and no systematic global reorientation of collagen fibers.

Biaxial mechanical properties of swine uterosacral and cardinal ligaments

Mechanical alterations to pelvic floor ligaments may contribute to the development and progression of pelvic floor disorders. In this study, the first biaxial elastic and viscoelastic properties were determined for uterosacral ligament (USL) and cardinal ligament (CL) complexes harvested from adult female swine. Biaxial stress-stretch data revealed that the ligaments undergo large strains. They are orthotropic, being typically stiffer along their main physiological loading direction (i.e., normal to the upper vaginal wall). Biaxial stress relaxation data showed that the ligaments relax equally in both loading directions and more when they are less stretched. In order to describe the experimental findings, a three-dimensional constitutive law based on the Pipkin-Rogers integral series was formulated. The model accounts for incompressibility, large deformations, nonlinear elasticity, orthotropy, and stretch-dependent stress relaxation. This combined theoretical and experimental study provides new knowledge about the mechanical properties of USLs and CLs that could lead to the development of new preventive and treatment methods for pelvic floor disorders.

An inverse modeling approach for stress estimation in mitral valve anterior leaflet valvuloplasty for in-vivo valvular biomaterial assessment

Estimation of regional tissue stresses in the functioning heart valve remains an important goal in our understanding of normal valve function and in developing novel engineered tissue strategies for valvular repair and replacement. Methods to accurately estimate regional tissue stresses are thus needed for this purpose, and in particular to develop accurate, statistically informed means to validate computational models of valve function. Moreover, there exists no currently accepted method to evaluate engineered heart valve tissues and replacement heart valve biomaterials undergoing valvular stresses in blood contact. While we have utilized mitral valve anterior leaflet valvuloplasty as an experimental approach to address this limitation, robust computational techniques to estimate implant stresses are required. In the present study, we developed a novel numerical analysis approach for estimation of the in-vivo stresses of the central region of the mitral valve anterior leaflet (MVAL) delimited by a sonocrystal transducer array. The in-vivo material properties of the MVAL were simulated using an inverse FE modeling approach based on three pseudo-hyperelastic constitutive models: the neo-Hookean, exponential-type isotropic, and full collagen-fiber mapped transversely isotropic models. A series of numerical replications with varying structural configurations were developed by incorporating measured statistical variations in MVAL local preferred fiber directions and fiber splay. These model replications were then used to investigate how known variations in the valve tissue microstructure influence the estimated ROI stresses and its variation at each time point during a cardiac cycle. Simulations were also able to include estimates of the variation in tissue stresses for an individual specimen dataset over the cardiac cycle. Of the three material models, the transversely anisotropic model produced the most accurate results, with ROI averaged stresses at the fully-loaded state of 432.6±46.5 kPa and 241.4±40.5 kPa in the radial and circumferential directions, respectively. We conclude that the present approach can provide robust instantaneous mean and variation estimates of tissue stresses of the central regions of the MVAL.

Effects of stretch and shortening on gene expression in intact myocardium

Multiple cues have been suggested as the mechanical stimulus for the heart's hypertrophic response. Our work has previously suggested that the amount of cyclic shortening in cardiomyocytes controls myocyte shape and the amount of stretch controls myocyte size. To identify gene expression changes that occur in response to these mechanical perturbations, we used microarray analysis of papillary muscles cultured for 12 h at physiological or reduced levels of cyclic shortening and physiological or reduced mean stretch. Overall, genes related to extracellular matrix (ECM) were surprisingly prominent in our analysis. Connective tissue growth factor was among a small group of genes regulated by the amount of cyclic shortening regardless of the level of mean stretch, and many more ECM genes were regulated by shortening with reduced amounts of stretch. When we compared our results to gene expression data from an in vivo model of pressure overload (PO), which also decreases myocyte shortening, we found the genes that were commonly regulated in PO and our decreased shortening groups were most significantly enriched for ontology terms related to the ECM, followed by genes associated with mechanosensing and the cytoskeleton. The list of genes regulated in PO and our decreased shortening groups also includes genes known to change early in hypertrophy, such as myosin heavy chain 7, brain natriuretic peptide, and myosin binding protein C. We conclude that in intact myocardium, the amount of cyclic shortening may be an important regulator not only of myocyte genes classically associated with hypertrophy but also of ECM genes.

Interlayer micromechanics of the aortic heart valve leaflet

While the mechanical behaviors of the fibrosa and ventricularis layers of the aortic valve (AV) leaflet are understood, little information exists on their mechanical interactions mediated by the GAG-rich central spongiosa layer. Parametric simulations of the interlayer interactions of the AV leaflets in flexure utilized a tri-layered finite element (FE) model of circumferentially oriented tissue sections to investigate inter-layer sliding hypothesized to occur. Simulation results indicated that the leaflet tissue functions as a tightly bonded structure when the spongiosa effective modulus was at least 25 % that of the fibrosa and ventricularis layers. Novel studies that directly measured transmural strain in flexure of AV leaflet tissue specimens validated these findings. Interestingly, a smooth transmural strain distribution indicated that the layers of the leaflet indeed act as a bonded unit, consistent with our previous observations (Stella and Sacks in J Biomech Eng 129:757-766, 2007) of a large number of transverse collagen fibers interconnecting the fibrosa and ventricularis layers. Additionally, when the tri-layered FE model was refined to match the transmural deformations, a layer-specific bimodular material model (resulting in four total moduli) accurately matched the transmural strain and moment-curvature relations simultaneously. Collectively, these results provide evidence, contrary to previous assumptions, that the valve layers function as a bonded structure in the low-strain flexure deformation mode. Most likely, this results directly from the transverse collagen fibers that bind the layers together to disable physical sliding and maintain layer residual stresses. Further, the spongiosa may function as a general dampening layer while the AV leaflets deforms as a homogenous structure despite its heterogeneous architecture.

Real-time strain mapping via biaxial stretching in heart valve tissues

Previous studies show that the collagen fiber architecture is key to the heart valves tissue mechanical property. We report a real-time strain mapping approach that provides displacement vectors and principal strain directions during the mechanical characterization of heart valve tissues. The strain maps reported in the current study allows an individual to quickly identify the approximate strain imposed on a location of the sample. The result shows that when samples are biaxially stretched under 18% strain, less anisotropy is observed in both aortic and pulmonary valve leaflet samples. Moreover, when samples are stretched from 28% to 35%, pulmonary valves leaflet samples exhibits a stronger anisotropic effect than aortic valve. Therefore, a higher degree of straightening is required for collagen fibers to be fully aligned. This work provides an easy approach to quantify mechanical properties with the corresponding strain maps of heart valve tissues and potentially facilitates the developments of tissue engineering heart valves.

Mechanics of healthy and functionally diseased mitral valves: a critical review

The mitral valve is a complex apparatus with multiple constituents that work cohesively to ensure unidirectional flow between the left atrium and ventricle. Disruption to any or all of the components-the annulus, leaflets, chordae, and papillary muscles-can lead to backflow of blood, or regurgitation, into the left atrium, which deleteriously effects patient health. Through the years, a myriad of surgical repairs have been proposed; however, a careful appreciation for the underlying structural mechanics can help optimize long-term repair durability and inform medical device design. In this review, we aim to present the experimental methods and significant results that have shaped the current understanding of mitral valve mechanics. Data will be presented for all components of the mitral valve apparatus in control, pathological, and repaired conditions from human, animal, and in vitro studies. Finally, current strategies of patient specific and noninvasive surgical planning will be critically outlined.