Mitigation of bioprosthetic heart valve degeneration through biocompatibility: in vitro versus spontaneous endothelialization

Is cell regeneration and infiltration a double edged sword for porcine aortic valve deterioration? A large cohort of histopathological analysis

BACKGROUND AND OBJECTIVE

Bioprostheses are the most common prostheses used for valve replacement in the Western medicine. The major flaw of bioprostheses is the occurrence of structural valve deterioration (SVD). This study aimed to assess the pathological features of porcine aortic valve (PAV)-SVD based on histomorphological and immunopathological characteristics of a large cohort of patients.

METHODS

Histopathological data of 109 cases with resected PAV were collected. The type and amount of infiltrated cells were evaluated in the different types of bioprosthetic SVD by immunohistochemical staining.

RESULTS

The most common cause of SVD was calcification, leaflet tear, and dehiscence (23.9%, 19.3%, and 18.3%, respectively). Immunohistochemical staining demonstrated that macrophages were infiltrated in the calcified, lacerated and dehiscence PAV, in which both M1 and M2 macrophages were existed in the calcified PAV. Importantly, the higher content of M1 macrophages and less content of M2 macrophages were found in the lacerated and dehiscence PAV, and MMP-1 expression was mainly found in the lacerated PAV. The endothelialization rate of leaflet dehiscence was higher than that of calcified and lacerated leaflets. A large number of CD31+/CD11b+ cells was aggregated in the spongy layer in the lacerated and dehiscence PAV.

CONCLUSION

Cell regeneration and infiltration is a double edged sword for the PAV deterioration. Macrophage infiltration is involved in the different types of SVD, while only MMP-1 expression is involved in lacerated leaflets. The macrophage subtype of circulating angiogenic cells in dehiscence and tear PAV could be identified, which could reserve macrophages in the PAV-SVD.

Long-Term Stability and Biocompatibility of Pericardial Bioprosthetic Heart Valves

The use of bioprostheses for heart valve therapy has gradually evolved over several decades and both surgical and transcatheter devices are now highly successful. The rapid expansion of the transcatheter concept has clearly placed a significant onus on the need for improved production methods, particularly the pre-treatment of bovine pericardium. Two of the difficulties associated with the biocompatibility of bioprosthetic valves are the possibilities of immune responses and calcification, which have led to either catastrophic failure or slow dystrophic changes. These have been addressed by evolutionary trends in cross-linking and decellularization techniques and, over the last two decades, the improvements have resulted in somewhat greater durability. However, as the need to consider the use of bioprosthetic valves in younger patients has become an important clinical and sociological issue, the requirement for even greater longevity and safety is now paramount. This is especially true with respect to potential therapies for young people who are afflicted by rheumatic heart disease, mostly in low- to middle-income countries, for whom no clinically acceptable and cost-effective treatments currently exist. To extend longevity to this new level, it has been necessary to evaluate the mechanisms of pericardium biocompatibility, with special emphasis on the interplay between cross-linking, decellularization and anti-immunogenicity processes. These mechanisms are reviewed in this paper. On the basis of a better understanding of these mechanisms, a few alternative treatment protocols have been developed in the last few years. The most promising protocol here is based on a carefully designed combination of phases of tissue-protective decellularization with a finely-titrated cross-linking sequence. Such refined protocols offer considerable potential in the progress toward superior longevity of pericardial heart valves and introduce a scientific dimension beyond the largely disappointing 'anti-calcification' treatments of past decades.

A bioprosthetic heart valve cross-linked by a non-glutaraldehyde reagent with improved biocompatibility, endothelialization, anti-coagulation and anti-calcification properties

Valvular heart disease is an important disease that endangers human health and heart valve replacement has become one of the main treatments for patients with severe valvular heart disease. However, the traditional surgical valve replacement (SVR) suffers several drawbacks such as high risk, great trauma and long recovery time, and more than 30% of patients are intolerant to SVR, especially elderly patients. In recent years, with the development of minimally invasive technology, transcatheter heart valve replacement (THVR) as a method of implantation without thoracotomy has become an optimal treatment for severe valvular heart disease due to its advantages of minimal trauma, low risk and fast recovery. Meanwhile, the usage of bioprosthetic heart valves (BHVs) has been enlarged greatly with the rapid development of THVR and the aging population. Most BHVs in clinics are crosslinked by glutaraldehyde (Glut), which shows great mechanical properties and chemical stability. However, some problems such as poor biocompatibility, calcification, coagulation and endothelialization difficulty also need to be solved urgently for Glut-treated BHVs. In this work, a non-Glut treated BHV from 7a-ethyltetrahydro-oxazolo[3,4-c]oxazole (OX-Et) crosslinked porcine pericardium (PP) has been developed. Compared with glutaraldehyde-crosslinked porcine pericardium (Glut-PP), good physical and chemical properties similar to Glut-PP are shown for OX-Et treated porcine pericardium (OX-Et-PP). It is noteworthy that better biocompatibility, endothelialization performance, and anti-coagulant effect as well as the improved anti-calcification property can also be observed for OX-Et-PP in the in vitro and in vivo study, potentially making OX-Et-PP a good candidate in the application of BHVs.

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.

An In Vitro Model to Study Endothelialization of Cardiac Graft Tissues Under Flow

Pulmonary valve replacement is performed with excellent resultant hemodynamics in patients that have underlying congenital or acquired heart valve defects. Despite recent advancements in right ventricular outflow tract reconstruction, an increased risk of developing infective endocarditis remains, which has a more common occurrence for conduits of bovine jugular vein (BJV) origin compared with cryopreserved homografts. The reason for this is unclear although it is hypothesized to be associated with an aberrant phenotypic state of cells that reendothelialize the graft tissue postimplantation. The aim of this study was to develop an in vitro model that enables the analysis of endothelial cell (EC) attachment to cardiac graft tissues under flow. In the experiments, EC attachment was optimized on bovine pericardium (BP) patch using human umbilical vein ECs. Different biological coatings, namely gelatin, fibronectin, plasma, or a combination of fibronectin and plasma were tested. After cell adaptation, graft tissues were exposed to laminar flow in a parallel-plate flow chamber. Cell retention to the tissue was analyzed after nuclear staining with YO-PRO-1 and a membranous localization of VE-cadherin. Experiments showed that combined coating with fibronectin and blood plasma together with a two-phased shear pattern resulted in a relevant cell monolayer on BP patch and cryopreserved homograft. For BJV tissue, no adherent cells under both static and shear conditions were initially observed. In conclusion, having established the new flow chamber system we could obtain EC layers on the surface of BP patch and cryopreserved pulmonary homograft tissues. The presented in vitro system can serve as a competent model to study cell phenotypes on cardiac grafts in the close-to-physiologic environment. Moreover, this approach allows broad applications and enables further development by testing more complex conditions.

Progressive Reinvention or Destination Lost? Half a Century of Cardiovascular Tissue Engineering

The concept of tissue engineering evolved long before the phrase was forged, driven by the thromboembolic complications associated with the early total artificial heart programs of the 1960s. Yet more than half a century of dedicated research has not fulfilled the promise of successful broad clinical implementation. A historical account outlines reasons for this scientific impasse. For one, there was a disconnect between distinct eras each characterized by different clinical needs and different advocates. Initiated by the pioneers of cardiac surgery attempting to create neointimas on total artificial hearts, tissue engineering became fashionable when vascular surgeons pursued the endothelialisation of vascular grafts in the late 1970s. A decade later, it were cardiac surgeons again who strived to improve the longevity of tissue heart valves, and lastly, cardiologists entered the fray pursuing myocardial regeneration. Each of these disciplines and eras started with immense enthusiasm but were only remotely aware of the preceding efforts. Over the decades, the growing complexity of cellular and molecular biology as well as polymer sciences have led to surgeons gradually being replaced by scientists as the champions of tissue engineering. Together with a widening chasm between clinical purpose, human pathobiology and laboratory-based solutions, clinical implementation increasingly faded away as the singular endpoint of all strategies. Moreover, a loss of insight into the healing of cardiovascular prostheses in humans resulted in the acceptance of misleading animal models compromising the translation from laboratory to clinical reality. This was most evident in vascular graft healing, where the two main impediments to the in-situ generation of functional tissue in humans remained unheeded–the trans-anastomotic outgrowth stoppage of endothelium and the build-up of an impenetrable surface thrombus. To overcome this dead-lock, research focus needs to shift from a biologically possible tissue regeneration response to one that is feasible at the intended site and in the intended host environment of patients. Equipped with an impressive toolbox of modern biomaterials and deep insight into cues for facilitated healing, reconnecting to the “user needs” of patients would bring one of the most exciting concepts of cardiovascular medicine closer to clinical reality.

Pre-mounted dry TAVI valve with improved endothelialization potential using REDV-loaded PEGMA hydrogel hybrid pericardium

Schematic diagram for the preparation of hydrogel hybrid dry valve.

Hydrogel hybrid porcine pericardium for the fabrication of a pre-mounted TAVI valve with improved biocompatibility

Transcatheter aortic valve implantation (TAVI) has been developed years ago for patients who cannot undergo a surgical aortic valve replacement (SAVR). Although TAVI possesses the advantages of lower trauma and simpler manipulation compared to SAVR, the need for storage in glutaraldehyde (GLU) and a tedious intraoperative assembly process have caused great inconvenience for its further application. A pre-mounted TAVI valve assembled by mounting a dry valve frame to a delivery system is expected to address these problems. However, the currently used GLU treated leaflet cannot unfold normally after being crimped for a long-term and loses its function when the BHV is assembled to the catheter. Besides, its cytotoxicity and immune response after implantation are still problems to be solved. In the present study, a hydrogel hybrid porcine pericardium (HHPP) approach was developed to endow the BHVs with a favorable unfolding property and good biocompatibility. Three monomers with different charge characteristics (sodium acrylate, 2-methacryloyloxyethyl phosphorylcholine, and acryloyloxyethyltrimethyl ammonium chloride) were complexed with GLU treated PP (GLU-PP) to form three kinds of HHPPs (SAAH-PP, MPCH-PP, and DACH-PP). The results of the crimping simulation experiment showed that all HHPPs could quickly recover in PBS after being folded for 10 days, while the traditional BHVs (GLU-PP) could not recover under the same conditions. Bovine serum albumin adsorption and platelet adhesion test showed that SAAH-PP and MPCH-PP had good anti-adhesion abilities. A cell culture study indicated that all the three HHPPs promoted HUVEC growth and proliferation. In vivo biocompatibility studies showed that the immune response induced by MPCH-PP was reduced compared to that by GLU-PP. These studies demonstrated that the strategy of MPC hydrogel hybridization may be an effective approach to prepare a pre-mounted TAVI valve with improved biocompatibility.

Chitosan coatings with enhanced biostability in vivo

In this article, we study the stability of chitosan coatings applied on glutaraldehyde-stabilized bovine pericardium when exposed to biodegradation in vivo in the course of model subcutaneous tests on rats. The coatings were deposited from carbonic acid solutions, that is, H₂ O saturated with CO₂ at high pressure. Histological sections of treated pericardium samples demonstrated that the structure of pericardial connective tissues was not significantly altered by the coating application method. It was revealed that the dynamics of biodegradation depended on the total mass of chitosan applied as well as on the DDA of chitosan used. As long as the amount of chitosan did not exceed a certain threshold limit, no detectable degradation occurred within the time of the tests (12 weeks for the rat model). For higher chitosan amounts, we detected a ∼20% reduction of the mass after the in vivo exposition. The presumed mechanism of such behavior is discussed. © 2017 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 106B: 270-277, 2018.

Inflammation in cardiovascular tissue engineering: the challenge to a promise: a minireview

Tissue engineering employs scaffolds, cells, and stimuli brought together in such a way as to mimic the functional architecture of the target tissue or organ. Exhilarating advances in tissue engineering and regenerative medicine allow us to envision in vitro creation or in vivo regeneration of cardiovascular tissues. Such accomplishments have the potential to revolutionize medicine and greatly improve our standard of life. However, enthusiasm has been hampered in recent years because of abnormal reactions at the implant-host interface, including cell proliferation, fibrosis, calcification and degeneration, as compared to the highly desired healing and remodeling. Animal and clinical studies have highlighted uncontrolled chronic inflammation as the main cause of these processes. In this minireview, we present three case studies highlighting the importance of inflammation in tissue engineering heart valves, vascular grafts, and myocardium and propose to focus on the endothelial barrier, the “final frontier” endowed with the natural potential and ability to regulate inflammatory signals.

Tissue-engineered heart valve prostheses: ‘state of the heart’

In this article, we will review the current state of the art in heart valve tissue engineering. We provide an overview of mechanical and biological replacement options, outlining advantages and limitations of each option. Tissue engineering, as a field, is introduced, and specific aspects of valve tissue engineering are discussed (e.g., biomaterials, cells and bioreactors). Technological hurdles, which need to be overcome for advancement of the field, are also discussed.

Successful Endothelialization of Porcine Glutaraldehyde-Fixed Aortic Valves in a Heterotopic Sheep Model

PURPOSE

The purpose of our study was to evaluate the stability of an artificially seeded endothelial cell layer on porcine aortic prostheses under in vivo conditions in the arterial system.

DESCRIPTION

Ten female sheep were divided into two groups. Animals of the study group (n = 7) had dissection of their right external jugular vein for cell harvesting. Myofibroblasts and endothelial cells were labelled with PKH-26, seeded onto pretreated (10% citric acid) porcine glutaraldehyde-fixed aortic valves (Freestyle, Medtronic Inc, Duesseldorf, Germany), and the valves were implanted into the descending aorta. Controls (n = 3) received pretreated but unseeded valves. A shunt between the aortic arch and the left atrial appendage ensured systolic or diastolic leaflet motions, or both, that were documented by sonography. After 3 months the valves were explanted. Specimens for scanning electron microscopy and immunohistochemical staining were taken prior to implantation and after explantation.

EVALUATION

A neointimal proliferation was detected in the control group. No endothelial cells were found on the leaflets and the sinuses, but erythrocytes and thrombocytes were seen entrapped within the collagen fibers. Thrombus formation was documented macroscopically and histologically on the leaflets and the sinuses. In the study group a confluent endothelial cell layer was documented on the walls and leaflets. Neither neointimal proliferation nor any clots were seen. Some cells were still labelled positively indicating their origin from the initial cell seeding. No dilatation of any prosthesis was observed, but all valves showed slight thickening of the leaflets.

CONCLUSIONS

The artificially seeded endothelial cell layers remained stable under in vivo conditions in the arterial system. Biocompatibility of the prostheses seemed to be improved by reduction of thrombogenicity.

Crosslinking of decellularized porcine heart valve matrix by procyanidins

Heart valve diseases have a significant high mortality, and the valve replacement using glutaraldehyde crosslinked porcine heart valves is one of the main curing techniques. But its application is limited due to poor durability, calcification of the valves and immunogenic reactions. The aim of this study was to evaluate the crosslinking effect of procyanidins on porcine heart valve matrix. After crosslinking of the decellularized porcine aortic heart valves by procyanidins, the tensile strength, the in vitro enzymatic degradation resistance, procyanidins release from the crosslinked materials and the cytotoxicity of procyanidins to heart valvular interstitial cells were examined. The results showed that the tensile strength of procyanidins crosslinked valve matrix was higher than that of glutaraldehyde crosslinked valve matrix. Valve matrix crosslinked by 10 mg/ml procyanidins could be stored in D-Hanks solution for at least 45 days without any decline in ultimate tensile strength and maintained the elasticity as the fresh valves. Furthermore, procyanidins was found to release when the crosslinked tissue stored in D-Hanks solution. The release rate was high during the first 4 days and then dramatically decreased thereafter. During releasing phase, the concentration of procyanidins was no toxicity to heart valve interstitial cells. In vitro enzymatic degradation revealed that crosslinked matrix could resist the enzymatic hydrolysis, and the resistant capacity was approximately the same as glutaraldehyde crosslinked valve matrix. This study shows that procyanidins can crosslink porcine heart valves effectively without toxicity. Our results suggested that this method might be a useful approach for preparation of bioprosthetic heart valve.

Heart valve tissue engineering

Valvular heart disease is a significant cause of morbidity and mortality world-wide. Classical replacement surgery involves the implantation of mechanical valves or biological valves (xeno- or homografts). Tissue engineering of heart valves represents a new experimental concept to improve current modes of therapy in valvular heart surgery. Various approaches have been developed differing either in the choice of scaffold (synthetic biodegradable polymers, decellularised xeno- or homografts) or cell source for the production of living tissue (vascular derived cells, bone marrow cells or progenitor cells from the peripheral blood). The use of autologous bone marrow cells in combination with synthetic biodegradable scaffolds bears advantages over other tissue engineering approaches: it is safe, it leads to complete autologous prostheses and the cells are more easily obtained in the clinical routine. Even though we demonstrated the feasibility to construct living functional tissue engineered heart valves from human bone marrow cells, so far their general potential to differentiate into non-hematopoietic cell lineages is not fully exploited for tissue engineering applications.

Preseeding with autologous fibroblasts improves endothelialization of glutaraldehyde-fixed porcine aortic valves

OBJECTIVE

This study represents the development of a treatment and seeding procedure to improve endothelial cellular adhesion on glutaraldehyde-fixed valves.

METHODS

Porcine aortic valves were fixed with 0.2% glutaraldehyde. Wall pieces of these valves had either no additional treatment (n = 4), incubation in M199 Earle (1x), with sodium carbonate at 2.2 g/L without l-glutamine for 24 hours (n = 4), or additional pretreatment with 5%, 10%, or 15% citric acid (three groups, n = 4 each). Thereafter the pieces were washed and buffered to a physiologic pH. This was followed by seeding of human endothelial cells (5 x 10(6) cells). On the basis of the results of these pilot tests, complete glutaraldehyde-fixed aortic roots treated with 10% citric acid were subjected to cell seeding. The valves were seeded with endothelial cells (4.3 x 10(6) cells) either alone (n = 4) or in combination with preseeding of autologous fibroblasts (2.4 x 10(7) cells, n = 4). After each seeding procedure specimens of the free wall of the grafts were taken. In addition, one leaflet was taken for histologic examination after endothelial cell seeding, after 7 days, and after 21 days. Finally, two commercially available stentless aortic valve prostheses (Freestyle; Medtronic, Inc, Minneapolis, Minn) were treated with 10% citric acid and seeded with human fibroblasts and endothelial cells. Specimen were taken according to the glutaraldehyde-fixed aortic roots. Specimen of all experiments were examined with scanning electron microscopy. Frozen sections were stained immunohistochemically for collagen IV, factor VIII, and CD31.

RESULTS

On untreated glutaraldehyde-fixed aortic wall pieces, only poor adhesion (24%) was seen. No viable cells were found after 1 week. Cellular adhesion was best on aortic wall pieces pretreated with 10% citric acid. After 7 days, the cells formed a confluent layer. Endothelial cell seeding on citric acid-treated complete aortic valves showed 45% adhesion, but no confluent layer was found after 1 week. Preseeding of these valves with autologous fibroblasts resulted in an endothelial cellular adhesion of 76% and a confluent endothelial cell layer after 7 days. The layer remained stable for at least 21 days. Results of staining for collagen IV, factor VIII, and CD31 were positive on the luminal side of these valves, indicating the synthesis of matrix proteins and viability of the cells. Pretreatment of commercially available porcine valves with 10% citric acid and preseeding with autologous fibroblasts followed by endothelial cell seeding resulted in an adhesion of 78%. The cells formed a confluent cell layer after 7 days.

CONCLUSIONS

Pretreatment of glutaraldehyde-fixed porcine aortic valves with citric acid established a surface more suitable for cellular attachment. Preseeding these valves with autologous fibroblasts resulted in a confluent endothelial cell layer on the luminal surface. Flow tests and animal experiments are necessary for further assessment of durability and shear stress resistance.