Cardiovascular implant calcification: a survey and update

Thoracic endovascular aortic repair for hemolysis 17 years after insertion of classical elephant trunk: a case report

BACKGROUND

The classical elephant trunk (ET) technique is a very useful surgical procedure; however, haemolysis in the aorta associated with ET has been previously reported. It normally occurs within several years after the surgery, and it is a rare case of rapidly progressing haemolysis 10 or more years after aortic arch replacement with ET.

CASE PRESENTATION

A 53-year-old man with a history of Stanford type A aortic dissection (DeBakey type Is), who was treated with total arch aortic replacement and aorto-femoral bypass using a prosthetic graft 17 years ago, developed severe progressive haemolytic anaemia. The ET used for the initial surgery was narrowed, and mechanical haemolysis was suspected. We assumed that progressive mechanical haemolysis occurred because of degeneration of the prosthetic graft. Thoracic endovascular aortic repair was performed, and haemolysis and anaemia were mitigated postoperatively.

CONCLUSIONS

Haemolysis occurred 17 years after the initial surgery with ET. When haemolysis is suspected in a patient with ET, it must be identified as a cause of haemolysis even if 10 years or more have passed since the ET was inserted. To prevent this complication, attention should be paid to an appropriate ET length and diameter to avoid folding of the ET, particularly when the true cavity diameter is small.

Calcification of Synthetic Vascular Grafts: A Systematic Review

Objective

Calcification of vascular grafts, including polyethylene terephthalate (PET) and expanded polytetrafluoroethylene (ePTFE) grafts may contribute to graft failure, but is under reported. The aim of this study was to review the literature to assess whether vascular graft calcification is deleterious to vascular graft outcomes.

Data sources

The Medline and Embase databases were searched.

Review methods

A systematic literature search according to PRISMA Guidelines was performed using a combined search strategy of MeSH terms. The MeSH terms used were "calcification, physiologic", "calcinosis", "vascular grafting", "blood vessel prosthesis", "polyethylene terephthalates", and "polytetrafluoroethylene".

Results

The systematic search identified 17 cases of PET graft calcification and 73 cases of ePTFE graft calcification over a 35 year period. All cases of PET graft calcification were reported in grafts explanted for graft failure. The majority of cases of ePTFE graft calcification were unexpectedly noted in grafts used during cardiovascular procedures and subsequently removed.

Conclusion

Calcification of synthetic vascular grafts is under reported but can compromise the long term performance of the grafts. More data, including specific analysis of radiological findings as well as explant analysis are needed to obtain a more sensitive and specific analysis of the prevalence and incidence of vascular graft calcification and the impact of calcification on synthetic graft outcomes.

Prosthetic vascular grafts engineered to combat calcification: Progress and future directions

Calcification in prosthetic vascular conduits is a major challenge in cardiac and vascular surgery that compromises the long-term performance of these devices. Significant research efforts have been made to understand the etiology of calcification in the cardiovascular system and to combat calcification in various cardiovascular devices. Novel biomaterial design and tissue engineering strategies have shown promise in preventing or delaying calcification in prosthetic vascular grafts. In this review, we highlight recent advancements in the development of acellular prosthetic vascular grafts with preclinical success in attenuating calcification through advanced biomaterial design. We also discuss the mechanisms of action involved in the designs that will contribute to the further understanding of cardiovascular calcification. Lastly, recent insights into the etiology of vascular calcification will guide the design of future prosthetic vascular grafts with greater potential for translational success.

A comparative study of different tissue materials for bioprosthetic aortic valves using experimental assays and finite element analysis

BACKGROUND AND OBJECTIVE

Extracting the mechanical behaviors of bioprosthetic aortic valve leaflets is necessary for the appropriate design and manufacture of the prosthetic valves. The goal of this study was to opt a proper tissue for the valve leaflets by comparing the mechanical properties of the equine, porcine, and donkey pericardia with those of the bovine pericardium and human aortic valve leaflets.

METHODS

After tissue fixation in glutaraldehyde, the mechanical behaviors of the pericardial tissues were experimentally evaluated through computational methods. The relaxation tests were performed along the tissue fiber direction. The Mooney-Rivlin model was utilized to describe the hyperelastic behavior of the tissues at the ramp portion. The viscous behaviors at the hold portion were extracted using the Fung quasi-linear viscoelastic (QLV) model. Furthermore, the extracted parameters were used in the modeling of the bovine, equine, porcine, and donkey pericardia through finite element analysis (FEA).

RESULTS

Based on the results, relaxation percentages of the equine, donkey, and bovine pericardia were greater than that of the porcine pericardium and similar to the native human aortic valve leaflets. Indeed, the equine and donkey pericardia were found more viscous and less elastic than the porcine pericardium. Compared with the porcine pericardium, the mechanical properties of the equine and donkey pericardia were rather closer to those of the native human leaflets and bovine pericardium. The computational analysis demonstrated that the donkey pericardium is preferable over other types of pericardium due to the low stress on the leaflets during the systolic and diastolic phases and the large geometric orifice area (GOA).

CONCLUSION

The donkey pericardium might be a good candidate valve leaflet material for bioprosthetic aortic valves.

Polyethylene terephthalate textile heart valve: How poly(ethylene glycol) grafting limits fibrosis

Transcatheter aortic valve replacement (TAVR) is an alternative technique to surgical valve replacement for over 300,000 patients worldwide. The valve material used in the TAVR is made of biological tissues, whose durability remains unknown. The success of the TAVR favors the research toward synthetic valve leaflet materials as an alternative to biological tissues. In particular, polyethylene terephthalate (PET) textile valves have recently proven durability over a 6-month period in animal sheep models. Excessive fibrotic tissue formation remains, however, a critical issue to be addressed. The aim of this work was therefore to investigate the potential of PET textiles covalently conjugated with polyethylene glycol (PEG), known for its antifouling properties, to modulate the fibrosis formation both in vitro and in vivo. For this purpose, the surfaces of heart valves made of PET textiles were functionalized with an atmospheric pressure plasma, leading to the formation of carboxylic acid (COOH) groups, further used for PEG-NH₂ conjugation. Surface modification efficiency was assessed by X-ray photoelectron spectroscopy and water contact angle measurements. The biological behavior of the as-modified surfaces was evaluated by in vitro assays, using rat cardiac fibroblast cells. The results show that PEG treated substrates restrained the fibroblasts adhesion and proliferation. The PEG treated valve, implanted in a juvenile sheep model, showed a significant fibrosis reduction. The explant also revealed calcification issues that need to be addressed.

Providing direction improves function: Comparison of a radial pore-orientated acellular collagen scaffold to clinical alternatives in a surgically induced rabbit diaphragmatic tissue defect model

Gore-Tex® is a widely used durable patch for repair of congenital diaphragmatic defects yet may result in complications. We compared Gore-Tex with a composite of a radial pore-orientated collagen scaffold (RP-Composite) and clinically used porcine small intestinal submucosa (SIS; Surgisis®) in a rabbit model for diaphragmatic hernia. The growing rabbit mimics the rapid rib cage growth and reherniation rates seen in children. We created and immediately repaired left hemidiaphragmatic defects in 6-week-old rabbits with Gore-Tex, SIS, and an RP-Composite scaffold. An additional group of rabbits had a sham operation. At 90 days, survivors more than doubled in weight. We observed few reherniations or eventrations in Gore-Tex (17%) and RP-Composite (22%) implanted animals. However, SIS failed in all rabbits. Maximum transdiaphragmatic pressure was lower in Gore-Tex (71%) than RP-Composite implanted animals (112%) or sham (134%). Gore-Tex repairs were less compliant than RP-Composite, which behaved as sham diaphragm (p < 0.01). RP-Composite induced less foreign body giant cell reaction than Gore-Tex (p < 0.05) with more collagen deposition (p < 0.001), although there was a tendency for the scaffold to calcify. Unlike Gore-Tex, the compliance of diaphragms reconstructed with RP-Composite scaffolds were comparable with native diaphragm, whereas reherniation rates and transdiaphragmatic pressure measurements were similar.

Surface-Immobilized Biomolecules on Albumin Modified Porcine Pericardium for Preventing Thrombosis and Calcification

The search for a noncalcifying tissue material to be used for valve replacement application continues to be a field of extensive investigation. A series of porcine pericardial membranes was prepared by modifying the glutaraldehyde - treated tissues with albumin and subsequently immobilizing bioactive molecules like PGE1, PGI2 or heparin via the carbodiimide functionalities. The in vitro calcification and collagenase degradation of these modified tissues were studied as a function of exposure time. Furthermore, the biocompatibility aspects of such novel interfaces were established by platelet adhesion and fibrinogen adsorption.

The results reported in this article propose that the treatment with antiplatelet agents such as albumin, heparin and prostaglandins (PGE1 or PGI2) change the surface conditioning of pericardial tissues, suggesting a possible role of deposited serum components in affecting mineralization process on bioprosthesis. Therefore, it is worthy to hypothesize that besides inhibiting the accumulation of calcium in the devitalized cells, the early formation of a conditioning layer on the bioprosthesis surface may affect salt precipitations, determining the propensity of the implant to calcify. More detailed studies are needed to understand the involvement of plasma proteins and cellular components of the recipient blood in tissue-associated calcification.

A new polymer valve for mechanical circulatory support systems

A new low-cost artificial heart valve with easily modified dimensions according to its application was developed using segmented polyurethane (SPU). It consists of a convex frame and a concave membrane which floats in the center of the frame while working. The hydrodynamic performance of the polymer valve was compared with that of the Björk-Shiley mechanical valve using a mock circulatory testing system. The hydrodynamic performance of this valve was superior to the Björk-Shiley mechanical valve. The valve was applied to a ventricular assist device (VAD) developed in our institute. In vivo performances of these systems were tested using mongrel dogs. During the experiments, there were no complications related to malfunction of the valve. At postmortem examinations, no thrombus formation was found on the valve surface, and no embolus was detected in the kidneys. We believe this valve could prove a very useful alternative for valves of mechanical circulatory support systems (MCSS) such as VAD and TAH.

Long-term evaluation of vascular grafts with circumferentially aligned microfibers in a rat abdominal aorta replacement model

Long-term results of implants in small animal models can be used to optimize the design of grafts to further promote tissue regeneration. In previous study, we fabricated a poly(ɛ-caprolactone) (PCL) bi-layered vascular graft consisting of an internal layer with circumferentially aligned microfibers and an external layer with random nanofibers. The circumferentially oriented vascular smooth muscle cells (VSMCs) were successfully regenerated after the grafts were implanted in rat abdominal aorta for 3 months. Here we investigated the long-term (18 months) performance of the bi-layered grafts in the same model. All the grafts were patent. No thrombosis, aneurysm, or stenosis occurred. The endothelium maintained complete. However, most of circumferentially oriented VSMCs migrated to luminal surface of the grafts to form a neointima with uniform thickness. Accordingly, extracellular matrix including collagen, elastin, and glycosaminoglycan displayed high density in neointima layer while with low density in the grafts wall because of the incomplete degradation of PCL. A small amounts of calcification occurred in the grafts. The contraction and relaxation function of regenerated neoartery almost disappeared. These data indicated that based on the structure design, many other factors of grafts should be considered to achieve the regenerated neoartery similar to the native vessels after long-term implantation. © 2018 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 106B: 2596-2604, 2018.

Engineering Concepts in Stem Cell Research

The field of regenerative medicine integrates advancements made in stem cells, molecular biology, engineering, and clinical methodologies. Stem cells serve as a fundamental ingredient for therapeutic application in regenerative medicine. Apart from stem cells, engineering concepts have equally contributed to the success of stem cell based applications in improving human health. The purpose of various engineering methodologies is to develop regenerative and preventive medicine to combat various diseases and deformities. Explosion of stem cell discoveries and their implementation in clinical setting warrants new engineering concepts and new biomaterials. Biomaterials, microfluidics, and nanotechnology are the major engineering concepts used for the implementation of stem cells in regenerative medicine. Many of these engineering technologies target the specific niche of the cell for better functional capability. Controlling the niche is the key for various developmental activities leading to organogenesis and tissue homeostasis. Biomimetic understanding not only helped to improve the design of the matrices or scaffolds by incorporating suitable biological and physical components, but also ultimately aided adoption of designs that helped these materials/devices have better function. Adoption of engineering concepts in stem cell research improved overall achievement, however, several important issues such as long-term effects with respect to systems biology needs to be addressed. Here, in this review the authors will highlight some interesting breakthroughs in stem cell biology that use engineering methodologies.

Calcification of a Synthetic Renovascular Graft in a Child

INTRODUCTION

Vascular grafts, especially in paediatric cases, need to be durable. Common failures such as thrombosis are well documented with research efforts directed towards them. However, there are lesser known causes of graft failure, such as graft calcification, and these also require further research focus.

REPORT

A paediatric case is described in which a synthetic renovascular graft, implanted for mid-aortic syndrome, became calcified, necessitating surgical intervention to resolve graft malfunction. Significant calcification in the limb of a bifurcated polyethylene terephthalate graft was found to be the cause of resistant stenosis and refractory hypertension. Histology conducted on the explanted limb showed the presence of multinuclear giant cells, indicating a chronic foreign body response.

DISCUSSION

Calcification of vascular grafts is probably more common than previously recognised. Stenosis typically resistant to angioplasty may result in the long term and thus leading to surgical intervention. In young children, this is suboptimal as these grafts need to last throughout adulthood. Explanted prosthetic grafts should be sent to specialist registries such as that in Strasbourg to be optimally assessed so that contributory factors can be identified.

Calcification of Experimental Valve Bioprostheses

Bovine pericardial strips, porcine valve strips, and canine valve strips were treated with 0.625% glutaraldehyde and implanted subdermally in rats. Weight and calcium content were examined 9 weeks later. Bovine pericardial strips underwent calcification after implantation; electron microscopy showed concentric electron-dense calcified deposits in the collagen fibers. Implanted porcine valve strips also underwent calcification; electron microscopy showed concentric electron-dense calcified deposits in the interstitium. Calcification was also detected in canine valve strips after implantation, but the proportion of calcium was lower than in the other tissues; electron microscopy showed collagen bundles with speckled calcified granules. The process of calcification started on the surface of the collagen fibrils and in the interfibrillar space. It was concluded that preservation of collagen fibers would be helpful in preventing calcification. The use of canine cardiac valves might improve the durability of bioprostheses.

A novel technique for simultaneous whole-body and multi-organ decellularization: umbilical artery catheterization as a perfusion-based method in a sheep foetus model

The aim of this study was to develop a method to generate multi-organ acellular matrices. Using a foetal sheep model have developed a method of systemic pulsatile perfusion via the umbilical artery which allows for simultaneous multi-organ decellularization. Twenty sheep foetuses were systemically perfused with Triton X-100 and sodium dodecyl sulphate. Following completion of the whole-body decellularization, multiple biopsy samples were taken from different parts of 21 organs to ascertain complete cell component removal in the preserved extracellular matrices. Both the natural and decellularized organs were subjected to several examinations. The samples were obtained from the skin, eye, ear, nose, throat, cardiovascular, respiratory, gastrointestinal, urinary, musculoskeletal, central nervous and peripheral nervous systems. The histological results depicted well-preserved extracellular matrix (ECM) integrity and intact vascular structures, without any evidence of residual cellular materials, in all decellularized bioscaffolds. Scanning electron microscope (SEM) and biochemical properties remained intact, similar to their age-matched native counterparts. Preservation of the collagen structure was evaluated by a hydroxyproline assay. Dense organs such as bone and muscle were also completely decellularized, with a preserved ECM structure. Thus, as shown in this study, several organs and different tissues were decellularized using a perfusion-based method, which has not been previously accomplished. Given the technical challenges that exist for the efficient generation of biological scaffolds, the current results may pave the way for obtaining a variety of decellularized scaffolds from a single donor. In this study, there have been unique responses to the single acellularization protocol in foetuses, which may reflect the homogeneity of tissues and organs in the developing foetal body.

A Novel Design of a Polymeric Aortic Valve

Introduction

In this paper we propose a novel method for developing a polymeric heart valve that could potentially offer an optimum solution for a heart valve substitute. The valve design proposed will provide superior hydrodynamic performance and excellent structural integrity. A full description of the design process is given together with an analysis of the hemodynamic performance using a 2-way strongly coupled Fluid Structure Interaction (FSI).

Method

A polymeric tri-leaflet heart valve is designed based on a patient's sinus of Valsalva (SOV) geometry. The design strategy aims to improve valve hemodynamic performance as well as valve durability by avoiding stress concentrations in the leaflets and reducing the maximum stress level. The valve dynamics and stress levels are also validated by comparing the predicted data to existing experimental and numerical data.

Results

The stress distribution in the valve structure is fully characterized throughout the simulation and Von Mises stress is found to be up to 5.32 Mpa during diastole. The results show that an effective orifice area (EOA) and a pressure drop of 3.22 cm^2, and 3.52 mmHg, respectively, can be achieved using the proposed design.

Conclusions

The optimized valve demonstrates high hemodynamic performance with no sign of damaging stress concentration in the entire cardiac cycle.

Mapping the calcification of bovine pericardium in rat model by enhanced micro-computed tomography

The calcification initiation and progression of bioprosthetic heart valve were investigated in a rat model by enhanced micro-computed tomography, together with histologic study and scanning electron microscope analysis. The implantation data at early stage showed apparent dendritic patterns in the radiographic images for the glutaraldehyde-treated bovine pericardium and this dendritic pattern was verified to be associated with the vessel distribution in the tissue. Histologic study and scanning electron microscope analysis both indicated that the calcium deposits in the pericardium vessels regions were more grievous than those scattered in the collagen fibers in the first two weeks after implantation. Subsequently, calcification spreaded and the entire sample was severely calcified in 60 days.

In vivo calcification of glutaraldehyde-fixed cardiac valve and pericardium of Phoca groenlandica

Calcification remains the main reason for failure of bioprosthetic valves. The aim of this study was to evaluate the in vivo calcification response of a new bioprosthetic valve, derived from cardiac tissue of Phoca groenlandica. Aortic and pulmonary leaflets, bovine, and Phoca groenlandica pericardia were fixed in buffered glutaraldehyde solution. Tissues were divided into four groups: group 1, bovine pericardium (BP); group 2, pulmonary leaflets; group 3, seal pericardium; and group 4, aortic leaflets. All samples were implanted subdermally into four sets of eight female 12-day-old Wistar rats for 21 days. The tissues were divided into two parts for calcium measurement, and histology with hematoxylin-eosin, von Kossa, and Weigert Van Gieson staining. All groups experienced significant calcification. Group 1 with 1.39 mg/g (0.34) before and 125.78 mg/g (21.48) after implantation (p < 0.001), group 2 with 1.50 mg/g (0.43) before and 151.85 mg/g (19.1) after (p < 0.001), group 3 with 3.15 mg/g (0.62) before and 116.38 mg/g (33.74) after (p < 0.001), and group 4 with 1.84 mg/g (0.52) before and 126.95 mg/g (13.37) after (p < 0.001). Explant samples showed foreign body response, disorganized collagen, and obvious calcification. The cardiac valve and pericardium of Phoca groenlandica calcify to the same extent as the BP.

Pathological calcification and replicating calcifying-nanoparticles: general approach and correlation

Calcification, a phenomenon often regarded by pathologists little more than evidence of cell death, is becoming recognized to be important in the dynamics of a variety of diseases from which millions of beings suffer in all ages. In calcification, all that is needed for crystal formation to start is nidi (nuclei) and an environment of available dissolved components at or near saturation concentrations, along with the absence of inhibitors for crystal formation. Calcifying nanoparticles (CNP) are the first calcium phosphate mineral containing particles isolated from human blood and were detected in numerous pathologic calcification related diseases. Controversy and critical role of CNP as nidi and triggering factor in human pathologic calcification are discussed.

Thermal and spectrophotometric studies of new crosslinking method for collagen matrix with glutaraldehyde acetals

Despite the many existing crosslinking procedures, glutaraldehyde (GA) is still the method of choice used in the manufacture of bioprosthesis. The major problems with GA are: (a) uncontrolled reactivity due to the chemical complexity or GA solutions; (b) toxicity due to the release of GA from polymeric crosslinks; and (c) tissue impermeabilization due to polymeric and heterogeneous crosslinks formation, partially responsible for the undesirable calcification of the bioprosthesis. A new method of crosslinking glutaraldehyde acetals has been developed with GA in acid ethanolic solution, and after the distribution inside de matrix, GA is released to crosslinking. Concentrations of hydrochloride acid in ethanolic solutions between 0.1 and 0.001 mol/L with GA concentration between 0.1 and 1.0% were measured in an ultraviolet spectrophotometer to verify the presence of free aldehyde groups and polymeric compounds of GA. After these measurements, the solutions were used to crosslink bovine pericardium. The spectrophotometric results showed that GA was better protected in acetal forms for acid ethanolic solution with HCl at 0.003 mol/L and GA 1.0%(v/v). The shrinkage temperature results of bovine pericardium crosslinked with acetal solutions showed values near 85 degrees C after the exposure to triethylamine vapors.

Evidence of mitigated calcification of the Mosaic versus Hancock Standard valve xenograft in the mitral position of young sheep

OBJECTIVES

Durability remains the main problem of all bioprosthetic valves, and calcification is the major cause of failure. New tissue treatment processes are expected to reduce mineralization. A comparative animal study was undertaken to evaluate the behavior of a new-generation porcine bioprosthesis in contrast with a first-generation porcine bioprosthesis. The primary goal was to evaluate the efficacy of alpha-amino-oleic acid as an anticalcification treatment.

METHODS

Seventeen Targhee sheep (aged 4.5-7 months) had a mitral valve replacement with a Mosaic or Hancock Standard. The animals were followed up to 20 weeks (144.1 +/- 4.0 days vs 144.3 +/- 8.2 days) and then euthanized as scheduled. After gross examination, the explants were radiographed for the presence of calcification. The central portions were preserved for histologic examination, and the remainder of the sample was analyzed for quantitative calcium content by atomic absorption spectroscopy.

RESULTS

Four Mosaic sheep were excluded because of perioperative surgical mortality. The remaining 13 were enrolled in the study (9 Mosaic and 4 Hancock Standard). The mean calcium content was 1.97 +/- 2.21 microg/mg tissue weight for Mosaic versus 8.36 +/- 4.12 microg/mg for Hancock Standard valves (P < .01). Mild fibrous tissue overgrowth and fibrinous lining were observed regardless the xenograft type.

CONCLUSIONS

The low level of calcification in the Mosaic versus Hancock Standard xenografts confirms the efficacy of alpha-amino-oleic acid treatment in mitigating mineralization. A longer durability is expected with the clinical use of the Mosaic porcine valve.

Treatment of bioprosthetic heart valve tissue with long chain alcohol solution to lower calcification potential

The use of glutaraldehyde-treated biological tissue in heart valve substitutes is an important option in the treatment of heart valve disease. These devices have limited durability, in part, because of tissue calcification and subsequent tearing of the valve leaflets. Components thought to induce calcification include lipids, cell remnants, and residual glutaraldehyde. We hypothesized that treatment of glutaraldehyde-treated bioprosthetic heart valve material using a short and long chain alcohol (LCA) combination, composed of 5% 1,2-octanediol in an ethanolic buffered solution, would reduce phospholipid content and subsequently lower the propensity of these tissues to calcify in vivo. Phospholipid content of glutaraldehyde-treated porcine valve leaflets and bovine pericardium was found to be 10.1 +/- 4.3 (n = 7) and 3.9 +/- 0.48 (n = 2) microg/mg dry tissue, respectively, which was reduced to 0.041 +/- 0.06 (n = 7) and 0.21 +/- 0.05 (n = 4) microg/mg dry tissue, respectively, after LCA treatment. Calcification potential of the treated tissues was assessed using a rat subcutaneous implant model. After 60 days of implantation, calcium levels were found to be 171 +/- 32 (n = 11) and 83 +/- 70 (n = 12) mg/g dry weight for glutaraldehyde-treated porcine leaflets and bovine pericardium, respectively, whereas prior LCA treatment resulted in reduced calcium levels of 1.1 +/- 0.6 (n = 12) and 0.82 +/- 0.1 (n = 12) mg/g dry weight, respectively. These data, taken together, support the notion that treatment of glutaraldehyde-treated tissue with a short and long chain alcohol combination will reduce both extractable phospholipids and the propensity for in vivo calcification.

A novel mouse-driven ex vivo flow chamber for the study of leukocyte and platelet function

Various in vitro and in vivo techniques exist for study of the microcirculation. Whereas in vivo systems impress with their physiological fidelity, in vitro systems excel in the amount of reduction that can be achieved. Here we introduce the autoperfused ex vivo flow chamber designed to study murine leukocytes and platelets under well-defined hemodynamic conditions. In our model, the murine heart continuously drives the blood flow through the chamber, providing a wide range of physiological shear rates. We used a balance of force approach to quantify the prevailing forces at the chamber walls. Numerical simulations show the flow characteristics in the chamber based on a shear-thinning fluid model. We demonstrate specific rolling of wild-type leukocytes on immobilized P-selectin, abolished by a blocking MAb. When uncoated, the surfaces having a constant shear rate supported individual platelet rolling, whereas on areas showing a rapid drop in shear platelets interacted in previously unreported grapelike conglomerates, suggesting an influence of shear rate on the type of platelet interaction. In summary, the ex vivo chamber amounts to an external vessel connecting the arterial and venous systems of a live mouse. This method combines the strengths of existing in vivo and in vitro systems in the study of leukocyte and platelet function.

Compression-induced changes on physical structures and calcification of the aromatic polyether polyurethane composite

It is generally accepted that stress causes calcification in both bio-prosthetic and polyurethane heart valves. However, simple uni-axially- and bi-axially-stretched samples did not yield a feasible model for the elaboration of the stress-induced calcification. In this study, heat compaction combined with the incorporation of polyethylene has been explored. Specimens of polyurethane were solution cast onto a porous bi-axially-drawn ultra-high-molecular-weight polyethylene film and then heat compacted under a pressure of 18 MPa at a chosen temperature for 1.5 h. The heat-compaction-induced calcification and physical changes of the polyurethane composite were evaluated using a 28-day in vitro calcification model and Attenuated Total Reflection-Fourier Transform-Infrared (ATR-FT-IR) spectroscopy. The calcification results indicated that heat-compaction-induced calcification was double that achieved without heat compaction. Heat-compacted polyurethane composite showed higher affinity to calcium ions than the non-heat compacted sample. The ATR-FT-IR results showed that the heat-compaction-induced physical changes include distortions of polymeric molecules and permanent changes of microstructures. The distortions of polymeric molecules could be deteriorated in contact with different media. The relaxation of the stressed structures of the polyether moiety might serve as a calcium trap and a heterogeneous nucleation site for calcification. The permanent changes of microstructures resulted from high distortions also served as affinity sites attracting calcification.

Calcification resistance, biostability, and low immunogenic potential of porcine heart valves modified by dye-mediated photooxidation

The calcification potential, biostability, and immunogenic response of materials intended for long-term in vivo use, such as in heart-valve bioprostheses, are essential components of device performance. Here we explore these properties in photooxidized porcine heart valves. To study immunological sensitization, we injected tissue extracts intradermally into guinea pigs. Test and control animals received a challenge patch of the appropriate extract and were scored for dermal reactions. Neither cottonseed oil nor sodium chloride extracts of photooxidized heart-valve tissues caused any dermal inflammatory response. After implantation in the rat subcutaneous model for 90 days, the calcium content of 48-h-treated photooxidized cusp tissue [0.04 +/- 0.00 mg/g wet weight (gww)] was comparable to that of unimplanted control tissues (usually <1 mg/gww) and much lower than that of glutaraldehyde-treated controls (71 +/- 15 mg/gww). The porcine aortic wall calcium content (49 +/- 31 mg/gww) was comparable to that of glutaraldehyde-treated controls (59 +/- 8 mg/gww). Histologically, a time-dependent decrease in inflammation and vascularization with increasing photooxidation time was noted in the rat model along with an increase in the stability and organization of collagen bundles. In summary, porcine valve tissues treated by dye-mediated photooxidation were resistant to calcification, were biostable, and demonstrated a low immunogenic response, indicating potential for use in heart-valve bioprostheses.

In vivo hemodynamic, histologic, and antimineralization characteristics of the Mosaic bioprosthesis

BACKGROUND

Performance of bioprosthetic valves is limited by tissue degeneration due to calcification with reduced performance and longevity. The Mosaic bioprosthetic valve (Medtronic Heart Valves, Inc, Minneapolis, MN) combines zero pressure fixation, antimineralization properties of alpha-amino oleic acid (AOA), and a proven stent design. We tested the hypothesis that AOA treatment of Mosaic valves improves hemodynamics, antimineralization properties, and survival in a chronic ovine model.

METHODS

Mitral valves were implanted in juvenile sheep with Mosaic valves with AOA treatment (n = 8) or without AOA treatment (non-AOA, n = 8), or Hancock I (HAN, n = 4) tissue valves, and explanted at 20 postoperative weeks.

RESULTS

Survival was equivalent in AOA and non-AOA (140 +/- 0.4 and 129 +/- 30 days), but was significantly less in HAN (82 +/- 35). Leaflet calcium (microgCa/mg tissue) was less in AOA (9.6 +/- 13.9; p < 0.05 versus non-AOA and HAN) than non-AOA (96.3 +/- 63.8) and HAN (130.8 +/- 43.2). Explant valve orifice area (cm2) was significantly preserved in the AOA group compared with the non-AOA group (1.5 +/- 0.7 vs 0.8 +/- 0.3; p < 0.05 versus non-AOA and HAN).

CONCLUSIONS

We conclude that AOA treatment of Mosaic valves reduces leaflet calcification and valve gradient in juvenile sheep, and that the Mosaic design and fixation features may offer survival advantages that must be confirmed in extended trials.

Acellular vascular tissues: natural biomaterials for tissue repair and tissue engineering

Various research groups around the world are actively investigating cardiovascular prostheses of biological origin. This review article discusses the need for such bioprosthetics and the potential role for natural tissues in cardiovascular applications such as cardiac valves and vascular grafts. Upon implantation, unmodified natural materials are subject to chemical and enzymatic degradation, seriously decreasing the life of the prosthesis. Therefore, methods such as glutaraldehyde and polyepoxide crosslinking treatments and dye-mediated photooxidation have been developed to stabilize the tissue while attempting to maintain its natural mechanical properties. Also, residual cellular components in a bioprosthetic material have been associated with undesired effects, such as calcification and immunological recognition, and thus have been the motivation for various decellularization processes. The effects of these stabilization and decellularization treatments on mechanical, biological and chemical properties of treated tissues have been investigated, specifically with regard to calcification, immunogenicity, and cytotoxicity concerns. Despite significant advances in the area of cardiovascular prostheses, there has yet to be developed a completely biocompatible, long-lasting implant. However, with the recent advent of tissue engineering, the possibility of applying selective cell seeding to naturally derived bioprosthetics moves us closer to a living tissue replacement.

Calcification of leaflets from porcine aortic valves crosslinked by ultraviolet irradiation

Glutaraldehyde (GA)-pretreated porcine aortic valves are generally used as a bioprosthetic valve, but gradual calcification of the leaflets often occurs. It has been hypothesized that the crosslinking agent, GA, stabilizes and perhaps modifies phosphorus-rich calcifiable structures in the bioprosthetic tissue. This is supported by our findings that calcium deposition is induced rapidly in GA-pretreated leaflets in comparison with ultraviolet (UV) irradiated leaflets. After 3 days of in vitro calcification test, calcium levels were 257.6 +/- 23.5 microg/cm3 in GA-pretreated, 57.7 +/- 10.2 microg/cm3 in the control, and 108.6 +/- 7.6 microg/cm3 in 24 h UV irradiated leaflets. The calcium level in all test groups increased as time proceeds and the calcium level of GA-pretreated leaflets was significantly higher than the control and UV irradiated leaflets during test. This rapid calcium deposition on the GA-pretreated leaflets may be due to residual aldehyde groups after pretreatment. The exposure time of UV irradiation was not significantly correlated with the extent of calcification. After 14 days of the test, calcium levels in leaflets UV irradiated for 1, 2, 4, and 24 h were 502.6 +/- 12.3 microg/cm3, 547.5 +/- 34.1 microg/cm3, 564.3 +/- 26.1 microg/cm3, and 543.0 +/- 55.5 microg/cm3. In all test groups, [Ca]/[P] molar ratio decreased toward that of hydroxyapatite as the predominant mineral phase as time proceeds. This study suggests that UV irradiation can be considerable as an efficient crosslinking method to surmount the side effects induced by GA-pretreatment and may endow tissue with mechanical property.

Evaluation of porcine valves prepared by dye-mediated photooxidation

BACKGROUND

Previous studies demonstrated that dye-mediated photooxidation can stabilize bovine pericardium. Here, photooxidized porcine valve cusp and root tissue were assessed in comparison to fresh and glutaraldehyde-treated samples.

METHODS AND RESULTS

In an in vitro tissue solubility test, both photooxidized and glutaraldehyde-treated tissues were resistant to protein extraction compared to fresh tissue. A rat subcutaneous model was used to test in vivo stability and calcification potential. In this study, four of the six fresh leaflets were not visible because of resorption while both photooxidized and glutaraldehyde-treated tissues were biostable. Mineral contents of the rat explants were much lower for both fresh and photooxidized leaflets when compared with glutaraldehyde-treated leaflets. Also, the aortic root calcified whether treated or not with the most mineral being associated with glutaraldehyde-treated root. Analysis of photooxidized porcine valves explanted from the mitral position in sheep indicated a material that was biostable and contained only minor calcification, perhaps due to deformed stents.

CONCLUSIONS

Porcine valve tissue treated by dye-mediated photooxidation is biostable and resistant to calcification, and has potential for use in heart valve bioprostheses.

Changes in pericardial calcification due to antiplatelet agents: in vitro studies

To develop tissue valves for prolonged use in the cardiovascular system, the complicated process of surface induced calcification must be better understood. Calcification was examined for 60 days on glutaraldehyde treated bovine pericardium (GABP) and enzyme extracted tissues fixed in glutaraldehyde (GATBP) incubated in metastable solutions of calcium phosphate, and the roles of aspirin and persantine in conjunction with vitamins C, B, or E, gentamycin (antibiotic), or pentothal sodium (anesthetic) in the medium were examined. Further, the diffusion of calcium across the GATBP was evaluated using a diffusion cell with 2 compartments. Pericardial calcification was also observed using scanning electron microscopy (SEM) techniques. It seems that the examined antiplatelet agents can modify the pericardial surfaces and subsequently their mineralization processes (GATBP, 31.7 micrograms/mg tissue; in the presence of 5 mg% vitamin C, 13.1 micrograms/mg tissue; in 1.5 mg% aspirin, 17.2 micrograms/mg tissue; and 1 mg% gentamycin, 14.8 micrograms/mg tissue) on exposure with the metastable calcium phosphate solution for 60 days. In addition, these agents may modify calcium transport and interfere with the adsorption at the surface, hence reducing calcium nodulation on GATBP. Scanning electron micrographs also revealed a reduction in calcium deposition on the pericardium due to these antiplatelet agents. It may be hypothesized that the influx of calcium on GATBP may be due to the cellular components or the involvement of plasma proteins like the fibrinogen molecule. The exact mechanism of these changes in the calcification of the pericardium are still unknown. From these in vitro findings, it appears that a combined vitamin therapy with low doses of aspirin may be beneficial for platelet suppression and thereby for prevention of thrombosis and calcification. However, more in vivo studies are needed to develop applications.

Identification of specific calcium-binding noncollagenous proteins associated with glutaraldehyde-preserved bovine pericardium in the rat subdermal model

Calcification of glutaraldehyde-preserved bioprosthetic heart valves (BHVs) results in their clinical failure. The mechanism of this pathologic calcification is not well defined. Since serum proteins are known to be taken up in mineralized tissue, we hypothesized that serum proteins derived from several calcium-binding noncollagenous proteins (NCPs) of bone and teeth also may be associated with pathologically mineralized BHVs. Using a rat subdermal model of BHV calcification, glutaraldehyde-preserved bovine pericardium (GPBP) was implanted for 1, 3, 14, and 60 days, and then subjected to an extraction procedure designed to isolate only NCPs tightly bound to the mineral phase. Gel electrophoresis and Coomassie Brilliant Blue staining demonstrated that these proteins became associated with GPBP over time, paralleling reported calcium uptake by the tissue. Stains-All staining demonstrated a marked accumulation of highly acidic, phosphorylated NCPs associated with 60-day GPBP extracts. Some of these proteins were detected in rat serum but were absent from extracts of GPBP incubated in rat serum in vitro. Western blotting with antibodies to three NCPs found in bone and teeth-bone acidic glycoprotein 75 (BAG 75), osteopontin, and SPARC-demonstrated that these NCPs were tightly bound to the mineral phase of calcified GPBP. A fourth NCP, bone sialoprotein II (BSP II) was barely detectable. Thus each identified NCP showed a different pattern of GPBP association relative to mineral deposition, suggesting unique roles for each in pathologic calcification. SPARC increased within 3 days of GPBP implantation but decreased by 2 weeks. BAG 75 and osteopontin uptake was detected in the initial mineral deposits and increased mineralization proceeded. BSP II never increased significantly over the entire-period. Further studies, which should include immunohistochemistry, will be important for delineating the source, location, and function of these three NCPs and for identifying others that also may be involved in this pathological process. Most important, the new insights into the mechanism of pathologic calcification described here present exciting opportunities for novel approaches to BHV calcification prevention.

Novel anti-calcification treatment of biological tissues by grafting of sulphonated poly(ethylene oxide)

Biological porcine tissue was modified by the direct coupling of sulphonated poly(ethylene oxide) (PEO-SO3) containing amino acid end groups after glutaraldehyde fixation. The calcification of the modified tissue [bioprosthetic tissue (BT)-PEO-SO3] and control (BT control) was investigated by in vivo rate subdermal, canine aorta-illiac shunt and right ventricle-pulmonary artery shunt implantation models. Less calcium deposition of BT-PEO-SP3 than of BT control was observed in in vivo tests. Such a reduced calcification of BT-PEO-SO3 can be explained by decreases of residual glutaraldehyde groups, a space filling effect and, therefore, improved biostability and synergistic blood-compatible effects of PEO and SO3 groups after the covalent binding of PEO-SO3 to tissue. This simple method can be a useful anti-calcification treatment for implantable tissue valves.

Preparation and evaluation of chitosan microspheres containing bisphosphonates

Local implantation or injection of microspheres containing bisphosphonates for site-specific therapy may aid in treating several pathological conditions associated with bone destruction. Chitosan microspheres containing two antiresorption and anticalcification agents, pamidronate and suberoylbisphosphonate (SuBP), were prepared from a w/o emulsion. Various formulation variables were studied for their effect on the release rate profile of these bone-seeking agents. Polymer coating of micromatrices yielded microspheres with the most retarded release rate, and the drug delivery system was found biocompatible in endothelial cell culture. The microspheres were examined in vitro and in vivo for release kinetics and drug disposition. The release of bisphosphonate from the microspheres was faster in vitro than in vivo. Drug disposition following implantation of microspheres in the tibialis muscle resulted in a relatively increased disposition in the adjacent tibia while injection of drug solution in the tibialis muscle resulted in uniform disposition of the drug in the femorae and tibiae. Bisphosphonate released from chitosan microspheres effectively inhibited bioprosthetic tissue calcification in the rat subdermal model.

Shrinkage temperature versus protein extraction as a measure of stabilization of photooxidized tissue

A rise in thermal denaturation temperature has been utilized as an indication of stabilization of collagen-containing materials such as pericardial tissue and porcine heart-valve leaflets following treatment with glutaraldehyde, Denacol, or other chemical agents. In contrast, stabilization of bovine pericardial tissue by dye-mediated photooxidation does not result in a significant rise in shrinkage temperature comparable with these treated materials. It was therefore hypothesized that a rise in shrinkage temperature is not a necessary indication for tissue stabilization. A sensitive protein extraction assay has been developed which can be used to monitor the stabilization of pericardial tissue by a variety of treatment methods, including photooxidation. A reduction in extractable protein, as analyzed by polyacrylamide gel electrophoresis, is noted for pericardial tissue treated with photooxidation, glutaraldehyde, or Denacol. Loss of extractable protein, as a function of treatment time, correlates well with a significant rise in shrinkage temperature for pericardium treated with glutaraldehyde or Denacol but not with photooxidation. This difference is attributed to the stabilization processes of glutaraldehyde and Denacol, which involve extensive crosslinking and polymer formation within and in addition to the native pericardial matrix, leading to a rise in matrix complexity and thermal stability. In contrast, photooxidation is a catalytic process involving modification and crosslink formation within existing matrix components, resulting in a material with little added matrix complexity.

Structural studies on bovine bioprosthetic tissues and their in vivo calcification: prevention via drug delivery

Cardiovascular calcification, the formation of calcium phosphate deposits in cardiovascular tissue, is a common end-stage phenomenon affecting a wide variety of bioprostheses. To study the process of calcification in tissue prosthetics, glutaraldehyde-treated bovine pericardium, dura mater and fascialata were implanted subcutaneously in rats and retrieved 21 days later and thereby morphological findings were correlated with biochemically determined levels of calcium. Transmission electron microscopy showed that calcification primarily involved the surface of collagen fibrils and the interfibrillar spaces. The deposition of calcium was higher with dura and fascia prostheses compared to pericardium. However, the release of Fe3+ ions from chitosan matrix had substantially inhibited the deposits of calcium in all implanted tissues. It seems that the structural and anatomical features of the tissue is one of the important factors for tissue-associated calcification. It is also confirmed that glutaraldehyde-preserved pericardium is the most suitable material for the development of cardiac prosthesis, with an appropriate drug combination therapy for prevention of pathological calcification.

Biomechanical and ultrastructural comparison of cryopreservation and a novel cellular extraction of porcine aortic valve leaflets

Heart valve substitutes of biological origin often fail by degenerative mechanisms. Many authors have hypothesized that mechanical fatigue and structural degradation are instrumental to in vivo failure. Since the properties of the structural matrix at implantation may predetermine failure, we have examined the ultrastructure, fracture, mechanics, and uniaxial high-strain-rate viscoelastic properties of: (1) fresh, (2) cryopreserved, and (3) cellular extracted porcine aortic valve leaflets. The cellular extraction process is being developed in order to reduce immunological attack and calcification. Cryopreservation causes cellular disruption and necrotic changes throughout the tissue, whereas extraction removes all cells and lipid membranes. Both processes leave an intact collagen and elastin structural matrix and preserve the high-strain-rate viscoelastic characteristics of the fresh leaflets. Extraction does cause a 20% reduction in the fracture tension and increases tissue extensibility, with the percent strain at fracture rising to 45.3 +/- 4 (mean +/- SEM) from 31.5 +/- 3 for fresh leaflets. However, extraction does preserve matrix structure and mechanics over the physiological loading range. Glutaraldehyde fixation produces increased extensibility, increased elastic behavior, and, when applied to extracted leaflets, it causes a marked drop in fracture tension, to 50% of that for fresh leaflets. The combination of extraction and fixation may lead to early degenerative failure. The cellular extraction technique alone may be a useful alternative to glutaraldehyde fixation in preparing bioprosthetic heart valves.

Physicochemical characterization of natural and bioprosthetic heart valve calcific deposits: implications for prevention

This investigation was performed to provide a comprehensive physicochemical characterization of calcific deposits (CDs) that form on human heart valves under various pathological conditions. We examined and characterized CDs associated with aortic stenosis on congenitally bicuspid valves (n = 10), degenerative aortic stenosis on valves with previously normal anatomy (n = 10), and rheumatic aortic (n = 10) and mitral (n = 10) stenosis. Native and deproteinated CDs underwent chemical analysis and structural characterization, whereas deproteinated CDs were measured for thermodynamic solubility. The CDs in valvular heart disease were microcrystalline apatitic products containing substantial amounts of sodium, magnesium, carbonate, fluoride, and organic fraction. The properties of natural heart valve CDs were compared with those of previously measured CDs that form on or in heart valve bioprostheses. Compared with bioprosthetic valve CDs, natural valve CDs have a higher ratio of calcium to phosphorus, higher crystallinity, and lower solubility. These differences indicate that natural heart valve CDs appear to comprise a more mature biomineral. If the formation of mature CDs proceeds through transient stages involving unstable precursors, then the main strategy for prevention of calcific deterioration of bioprosthetic heart valves would be the development of locally applied long-term inhibitors that both (1) suppress nucleation and growth of more soluble precursors and (2) inhibit subsequent augmentation of less soluble CDs.

Properties of blood-contacting surfaces of clinically implanted cardiac assist devices: gene expression, matrix composition, and ultrastructural characterization of cellular linings

The development of implantable cardiac assist devices for prolonged circulatory support has been impeded by the problem of excessive thrombogenesis on the blood-prosthetic interface, with subsequent embolization. To overcome this obstacle, a ventricular assist device has been developed with textured blood-contacting surfaces to encourage the formation of a tightly adherent, hemocompatible, biological lining. In this study, we applied molecular biological techniques, in conjunction with conventional ultrastructural and biochemical techniques, to characterize the biological linings associated with the blood-contacting surfaces of 11 of these devices, which had been clinically implanted for durations ranging from 21 to 324 days. No clinical thromboembolic events or pump-related thromboembolism occurred. Biological linings developed on the textured surfaces composed of patches of cellular tissue intermingled with areas of compact fibrinous material. In addition, islands of collagenous tissue containing fibroblast-like cells appeared after 30 days of implantation. Many of these cells contained microfilaments with dense bodies indicative of myofibroblasts. RNA hybridization analyses demonstrated that the colonizing cells actively expressed genes encoding proteins for cell proliferation (histones), adhesion (fibronectin), cytoskeleton (actin, vimentin) and extracellular matrix (types I and III collagen). Linings, which never exceeded 150 microns in thickness, remained free of pathological calcification. Textured blood-contacting surfaces induced the formation of a thin, tightly adherent, viable lining which exhibited excellent long-term hemocompatibility.

Stabilization of pericardial tissue by dye-mediated photooxidation

Bovine pericardial tissue was stabilized through a dye-mediated photooxidation reaction. Shrink temperature analysis of the stabilized tissue indicated a material with similar properties to untreated pericardial tissue and unlike identical tissue treated with glutaraldehyde. Photooxidized tissue was resistant to extraction when compared with untreated tissue or control tissues treated in the absence of light or dye. Photooxidized tissue was also resistant to enzymatic digestion by pepsin and to chemical digestion by cyanogen bromide (CNBr). In contrast, untreated or control treated tissues were readily digested by these reagents. Reduction of photooxidized tissue with beta-mercaptoethanol prior to CNBr digestion partially restored susceptibility of the tissue to CNBr digestion, indicating the photooxidation of methionine residues. Soluble collagen derived from bovine pericardium was used as a model compound for the photooxidation reaction. Polyacrylamide gel electrophoresis analysis indicated the photooxidative conversion of collagen into higher molecular weight aggregates consistent with intermolecular crosslink formation. Photooxidized tissue was stable to in vivo degradation when compared with control tissue. Results presented here indicate a crosslinked pericardial tissue produced by dye-mediated photooxidation possessing properties of chemical stability, enzymatic stability, in vivo stability, and biomechanical integrity suitable for use as a biomaterial.

In vivo biostability and calcification-resistance of surface-modified PU-PEO-SO3

To examine the biostability and calcification-resistance of polyurethanes (PUs), the surface of PU was grafted with hydrophobic perfluorodecanoic acid (PFDA) (PU-PFDA), hydrophilic polyethyleneoxide (PEO) (PU-PEO1000), and further negatively charged sulfonate groups (PU-PEO1000-SO3). An in vivo animal test was conducted by subcutaneous implantation in rats during 2, 4 and 6 months. A scanning electron microscope study demonstrated that the degree of surface cracking on explanted PUs was increased in the following order: PU-PFDA > PU > PU-PEO1000 > PU-PEO1000-SO3. In the results of energy dispersive x-ray analysis and inductively coupled plasma atomic emission spectrometry, the deposition of calcium was found abundantly, but that of phosphorus was hardly in existence in all implanted PUs, suggesting that this calcium compound is not a hydroxyapatite. The calcium contents, regardless of implantation time, were also increased in the same order (PU-PFDA > PU > PU-PEO1000 > PU-PEO1000-SO3). After 6 months implantation, no severe tissue reactions were observed and calcification almost occurred on polymer surfaces in all implants. Such superior biostability and anticalcification of PU-PEO1000-SO3 might be attributed to synergistic effects of its excellent surface smoothness, sulfonate acid (SO3-) groups, nonadhesive and mobile PEO, and the high hydrophilicity and enhanced blood compatibility. Therefore, PU-PEO1000-SO3 is promising as biostable and calcification-resistant biomaterial.

Prevention of tissue calcification on bioprosthetic heart valve by using epoxy compounds: a study of calcification tests in vitro and in vivo

Calcification is the principal cause of the clinical failures of the bioprosthetic heart valves fabricated from glutaraldehyde pretreated porcine aortic valves or bovine pericardium. In this paper, we compared the calcification on various types of bovine pericardiums pretreated with two hydrophilic epoxy compounds adding GA post-treatment (EP 1 and EP 2), glutaraldehyde (GA)- and nontreated pericardium (Fresh), respectively, by in vitro and in vivo tests. Significant decrease of calcification was found by pretreatment with both epoxy compounds rather than with glutaraldehyde: 0.250 +/- 0.001 (Fresh), 0.276 +/- 0.058 (EP 1), 0.302 +/- 0.071 (EP 2), and 0.478 +/- 0.172 (GA) micrograms (Ca)/mg (dried tissue), respectively, after 20 days dipping in a simulating serum solution in vitro; 115.13 +/- 60.11 (Fresh), 129.84 +/- 51.08 (EP 1), 167.39 +/- 20.81 (EP 2), and 205.19 +/- 16.86 (GA) micrograms/mg, respectively, after 3 months subcutaneous implantation in rabbits. The in vitro method for evaluating calcification designed by us gave the similar order among four samples with that obtained by in vivo test. Because the bovine pericardium pretreated with the epoxy compounds adding GA post-treatment possesses the greater tenacity than that pretreated only with epoxy compounds or GA, meanwhile the calcification is also significantly decreased with this pretreatment, it may be expected that the bovine pericardium with this pretreatment will have the greater anticalcification and durability in dynamic stress.

Effect of pretreatment with epoxy compounds on the mechanical properties of bovine pericardial bioprosthetic materials

Early failures of bovine pericardial heart valves are due to leaflet perforation, tearing and calcification. Since glutaraldehyde fixation has been shown to produce marked changes in leaflet mechanics and has been linked to development of calcification, bovine pericardium fixed with the four hydrophilic epoxy formulations and their mechanical properties are studied in this paper. We measured the thicknesses, shrinkage temperatures, stress relaxations and stress-strain curves of bovine pericardiums after different treatments with (1) non-treatment (fresh), (2) glutaraldehyde (GA), (3) epoxy compounds followed by the posttreatment with GA (EP 1#, EP 2#), and (4) epoxy compounds (EP 3# and EP 4#). Results of this study showed that the hydrophilic epoxy compounds are good crosslinking agents. There are no significant differences of shrinkage temperature and ultimate tensile stress among all tissue samples pretreated with GA, EP 1# and EP 2#. However, the stress relaxations of tissue-samples pretreated with epoxy compounds followed by the posttreatment with GA (EP 1# and EP 2#) are significantly slower than that pretreated with GA, and the strains at fracture of EP 1# and EP 2# are also significantly larger than that of GA or epoxy compounds. These facts show that the bovine pericardium pretreated with the epoxy compound followed by the posttreatment with GA (EP 1# and EP 2#) possesses greater tenacity and potential durability in dynamic stress.