Failure Of Bioprosthetic Heart Valves Research Articles

Biomimetic-modified bioprosthetic heart valves with Cysteine-Alanine-Glycine peptide for anti-thrombotic, endothelialization and anti-calcification

In recent years, bioprosthetic heart valves (BHVs) prepared by cross-linking porcine or bovine pericardium with glutaraldehyde (Glut) have received widespread attention due to their excellent hemocompatibility and hydrodynamic properties. However, the failure of BHVs induced by thrombosis and difficulty in endothelialization still exists in clinical practice. Improving the biocompatibility and endothelialization potential of BHVs is conducive to promoting their anti-thrombosis properties and prolonging their service life. Herein, Cysteine-Alanine-Glycine (CAG) peptide was introduced into the biomimetic BHV materials modified by 2-methacryloyloxyethyl phosphorylcholine (MPC) to improve their anti-thrombosis and promoting-endothelialization performances. MPC can improve the anti-adsorption performance of BHV materials, as well as, CAG contributes to the adhesion and proliferation of endothelial cells on the surface of BHV materials. The results of experiments showed that the biomimetic modification strategy with MPC and CAG reduce the thrombosis of BHV materials and improve their endothelialization in vitro. More importantly, the calcification of BHV significantly reduced by inhibiting the expression of M1 macrophage-related factors (IL-6, iNOS) and promoting the expression of M2 macrophage-related factors (IL-10, CD206). We believe that the valve-modified strategy is expected to provide effective solutions to clinical valve problems.

A universal strategy for the construction of polymer brush hybrid non-glutaraldehyde heart valves with robust anti-biological contamination performance and improved endothelialization potential.

With the intensification of the aging population and the development of transcatheter heart valve replacement technology (THVR), clinical demand for bioprosthetic valves is increasing rapidly. However, commercial bioprosthetic heart valves (BHVs), mainly manufactured from glutaraldehyde cross-linked porcine or bovine pericardium, generally undergo degeneration within 10-15 years due to calcification, thrombosis and poor biocompatibility, which are closely related to glutaraldehyde cross-linking. In addition, endocarditis caused by post-implantation bacterial infection also accelerates the failure of BHVs. Herein, a functional cross-linking agent bromo bicyclic-oxazolidine (OX-Br) has been designed and synthesized to crosslink BHVs and construct a bio-functionalization scaffold for subsequent in-situ atom transfer radical polymerization (ATRP). The porcine pericardium cross-linked by OX-Br (OX-PP) exhibits better biocompatibility and anti-calcification property than the glutaraldehyde-treated porcine pericardium (Glut-PP) as well as comparable physical and structural stability to Glut-PP. Furthermore, the resistance to biological contamination especially bacterial infection of OX-PP along with anti-thrombus and endothelialization need to be enhanced to reduce the risk of implantation failure due to infection. Therefore, amphiphilic polymer brush is grafted to OX-PP through in-situ ATRP polymerization to prepare polymer brush hybrid BHV material SA@OX-PP. SA@OX-PP has been demonstrated to significantly resist biological contamination including plasma proteins, bacteria, platelets, thrombus and calcium, and facilitate the proliferation of endothelial cells, resulting in reduced risk of thrombosis, calcification and endocarditis. Altogether, the proposed crosslinking and functionalization strategy synergistically achieves the improvement of stability, endothelialization potential, anti-calcification and anti-biofouling performances for BHVs, which would resist the degeneration and prolong the lifespan of BHVs. The facile and practical strategy has great potential for clinical application in fabricating functional polymer hybrid BHVs or other tissue-based cardiac biomaterials. STATEMENT OF SIGNIFICANCE: Bioprosthetic heart valves (BHVs) are widely used in valve replacements for severe heart valve disease, and clinical demand is increasing year over year. Unfortunately, the commercial BHVs, mainly cross-linked by glutaraldehyde, can serve for only 10-15 years because of calcification, thrombus, biological contamination, and difficulties in endothelialization. Many studies have been conducted to explore non-glutaraldehyde crosslinkers, but few can meet high requirements in all aspects. A new crosslinker, OX-Br, has been developed for BHVs. It can not only crosslink BHVs but also serve as a reactive site for in-situ ATRP polymerization and construct a bio-functionalization platform for subsequent modification. The proposed crosslinking and functionalization strategy synergistically achieves the high requirements for stability, biocompability, endothelialization, anti-calcification, and anti-biofouling propeties of BHVs.

Proteolytic Degradation Is a Major Contributor to Bioprosthetic Heart Valve Failure.

Background Whereas the risk factors for structural valve degeneration (SVD) of glutaraldehyde-treated bioprosthetic heart valves (BHVs) are well studied, those responsible for the failure of BHVs fixed with alternative next-generation chemicals remain largely unknown. This study aimed to investigate the reasons behind the development of SVD in ethylene glycol diglycidyl ether-treated BHVs. Methods and Results Ten ethylene glycol diglycidyl ether-treated BHVs excised because of SVD, and 5 calcified aortic valves (AVs) replaced with BHVs because of calcific AV disease were collected and their proteomic profile was deciphered. Then, BHVs and AVs were interrogated for immune cell infiltration, microbial contamination, distribution of matrix-degrading enzymes and their tissue inhibitors, lipid deposition, and calcification. In contrast with dysfunctional AVs, failing BHVs suffered from complement-driven neutrophil invasion, excessive proteolysis, unwanted coagulation, and lipid deposition. Neutrophil infiltration was triggered by an asymptomatic bacterial colonization of the prosthetic tissue. Neutrophil elastase, myeloblastin/proteinase 3, cathepsin G, and matrix metalloproteinases (MMPs; neutrophil-derived MMP-8 and plasma-derived MMP-9), were significantly overexpressed, while tissue inhibitors of metalloproteinases 1/2 were downregulated in the BHVs as compared with AVs, together indicative of unbalanced proteolysis in the failing BHVs. As opposed to other proteases, MMP-9 was mostly expressed in the disorganized prosthetic extracellular matrix, suggesting plasma-derived proteases as the primary culprit of SVD in ethylene glycol diglycidyl ether-treated BHVs. Hence, hemodynamic stress and progressive accumulation of proteases led to the extracellular matrix degeneration and dystrophic calcification, ultimately resulting in SVD. Conclusions Neutrophil- and plasma-derived proteases are responsible for the loss of BHV mechanical competence and need to be thwarted to prevent SVD.

Investigation into early stage fatigue-damage accumulation in glutaraldehyde-fixed bovine pericardium using a novel equibiaxial bulge inflation system

A primary cause of bioprosthetic heart valve failure is premature degeneration of the pericardial leaflets, owing specifically to mechanical fatigue. There remains a paucity of experimental data and understanding of the fatigue-damage behaviour of this collagenous tissue under complex loading regimes. To meet this knowledge gap, a novel pressure inflation system was designed and built, to cyclically load circular samples of glutaraldehyde fixed bovine pericardium, under equibiaxial bulge conditions. A study up to 60 million cycles revealed new insights into the fatigue behaviour of pericardial tissue, where a statistically significantly higher level of permanent set was found in samples with high collagen fibre dispersion, in comparison to those with highly aligned fibres. Whilst permanent set is known to occur in the non-collagenous matrix of pericardium, this study demonstrates that at physiological loads, which elicit a matrix dominant mechanical response, permanent set and thus tissue-level damage, is still mediated by the underlying collagen fibres.

STRUCTURE OF CALCIFICATES IN HUMAN CAROTID ARTERY ATHEROSCLEROTIC PLAQUES BY MEANS OF BACKSCATTERED SCANNING ELECTRON MICROSCOPY

Aim of the study was to investigate the atherosclerotic calcification employing our original technique of tissue staining, embedding, and backscattered scanning electron microscopy. Materials and methods . Atherosclerotic plaques excised during the carotid endarterectomy have been fixed in 10 % neutral phosphate buffered saline formalin for 24 hours, stained in 2 % osmium tetroxide for 60 hours and in alcoholic uranyl acetate for 5 hours with the subsequent epoxy resin embedding, grinding, polishing, lead citrate counterstaining for 7 minutes, sputter coating with carbon and backscattered scanning electron microscopy. We then analysed localisation, structure, and microenvironment of the calcium deposits. Results . Within the atherosclerotic plaques, we identified 3 distinct calcification morphologies: compact homogenous macrocalcifications, sheet-like heterogeneous macrocalcifications along the destructed collagen and elastin fibers, and microcalcifications around large calcium deposits with the sharp margins. However, even relatively homogenous compact macrocalcifications had uneven distribution of electron density. In conjunction with groups of mineral deposits of distinct calcium phosphate phases including nascent calcified loci, this testified to ongoing calcium phosphate maturation while multiple microcalcifications merging into the single macrocalcification indicated ossification. Compact ossifying macrocalcifications with smooth margins frequently had a dense connective tissue capsule. The microenvironment of calcium deposits was often characterised by leaky neovessels. Conclusion . Diversity of calcification morphologies and ossification in atherosclerotic plaques is similar to those observed in calcific aortic valve disease and bioprosthetic heart valve failure. Combined with atherosclerotic plaque disaggregation followed by flow cytometry and singlecell RNA sequencing, our technique may improve our understanding of atherosclerotic calcification and lead to the identification of appropriate therapeutic targets to prevent or retard this process.

In Vitro Calcification of Bioprosthetic Heart Valves: Investigation of Test Fluids

Calcification is a major reason for the failure of bioprosthetic heart valves. Therefore, several attempts towards an accelerated in vitro model were undertaken in order to provide a cost- and time-saving method for the analysis of calcification processes. Due to the problem of superficial or spontaneous precipitation, which occurred in the fluids applied, we focused our study on the development of a near-physiological calcification fluid. The desired fluid should not precipitate spontaneously and should neither promote nor inhibit calcification. Eleven different fluid compositions were tested without contact to potentially calcifying materials. Crucial factors regarding the fluid properties were the ionic product, the ionic strength, and the degree of supersaturation concerning dicalciumphosphate-dihydrate, octacalciumphosphate, and hydroxyapatite. The fluids were kept in polyethylene bottles and exposed to a slight vibration within a durability tester at 37°C. The precipitation propensity was monitored optically and colorimetrically. A structural analysis of the deposits was carried out by x-ray powder diffraction and IR-spectroscopy, which showed the development of the crystal phases that are relevant in vivo. Only two of the fluids did not precipitate. Resulting from the computations of the effective fluid contents, the saturation degree concerning dicalciumphosphate-dihydrate seems to be the key factor for spontaneous precipitation.

Surface heparin treatment of the decellularized porcine heart valve: Effect on tissue calcification.

Tissue calcification is a major cause of failure of bioprosthetic heart valves. Aim of this study was to examine whether surface heparin treatment of the decellularized porcine heart valve reduces tissue calcification. Fresh porcine aortic heart valves were dissected as tissue discs and divided into four groups. Group A: controls without treatment, Group B: decellularization only, Group C: decellularization and glutaraldehyde cross-linking, Group D: decellularization and glutaraldehyde cross-linking followed by surface heparin treatment. After implantation in New Zealand White rabbits for 60 days, the explanted heart valve discs from the different study groups underwent a series of histological examinations as well as determination of calcium content by the methyl thyme phenol blue colorimetric method. Results of the explanted heart valve discs for the Von Kossa staining demonstrated that in Group A the heart valve tissue was the most severely stained with black color, whereas in Group D there was hardly any area that was stained black after implantation indicating the least tissue calcification. Furthermore, the inflammatory cells identified by the Hematoxylin-eosin staining appeared to be the least in Group D. The average tissue calcium content was highest in Group A (0.197 ± 0.115 μmolmg-1 ), modest in Group B (0.113 ± 0.041 μmolmg-1 ), and Group C (0.089 ± 0.049 μmolmg-1 ), and the lowest in Group D (0.019 ± 0.019 μmolmg-1 , p < 0.05). These results suggest that surface heparin treatment tends to reduce tissue calcification of the dellellularized porcine heart valve in a rabbit intramuscular implantation model. © 2015 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 105B: 400-405, 2017.

Transcatheter heart valve failure: a systematic review.

A comprehensive description of transcatheter heart valve (THV) failure has not been performed. We undertook a systematic review to investigate the aetiology, diagnosis, management, and outcomes of THV failure. The systematic review was performed in accordance with the PRISMA guidelines using EMBASE, MEDLINE, and Scopus. Between December 2002 and March 2014, 70 publications reported 87 individual cases of transcatheter aortic valve implantation (TAVI) failure. Similar to surgical bioprosthetic heart valve failure, we observed cases of prosthetic valve endocarditis (PVE) (n = 34), structural valve failure (n = 13), and THV thrombosis (n = 15). The microbiological profile of THV PVE was similar to surgical PVE, though one-quarter had satellite mitral valve endocarditis, and surgical intervention was required in 40% (75% survival). Structural valve failure occurred most frequently due to leaflet calcification and was predominantly treated by redo-THV (60%). Transcatheter heart valve thrombosis occurred at a mean 9 ± 7 months post-implantation and was successfully treated by prolonged anticoagulation in three-quarters of cases. Two novel causes of THV failure were identified: late THV embolization (n = 18); and THV compression (n = 7) following cardiopulmonary resuscitation (CPR). These failure modes have not been reported in the surgical literature. Potential risk factors for late THV embolization include low prosthesis implantation, THV undersizing/underexpansion, bicuspid, and non-calcified anatomy. Transcatheter heart valve embolization mandated surgery in 80% of patients. Transcatheter heart valve compression was noted at post-mortem in most cases. Transcatheter heart valves are susceptible to failure modes typical to those of surgical bioprostheses and unique to their specific design. Transcatheter heart valve compression and late embolization represent complications previously unreported in the surgical literature.

In VivoEfficacy of Alpha-Galactosidase as Possible Promise for Prolonged Durability of Bioprosthetic Heart Valve Using Alpha1,3-Galactosyltransferase Knockout Mouse

The immune response due to Galα1,3-Galβ1-4GlcNAc-R(α-Gal) epitopes is an important factor in bioprosthetic heart valve failure. The aim of this study was to evaluate the immune reaction and anticalcification effect of α-galactosidase and decellularization for glutaraldehyde (GA)/genipin fixed bovine pericardium using α1,3-galactosyltransferase knockout(α-Gal KO) mouse(C57BL/6). Bovine pericardial tissues were decellularized and treated with α-galactosidase before fixation with 0.25% GA/0.4% genipin in organic solvent (75% ethanol and 5% octanol) and treatment with glycine. The removal of α-gal epitope from the bovine pericardium was analyzed by 3,3'-Diaminobenzidine staining intensity. The bovine pericardial tissues were subcutaneously implanted into wild type mice (n=19) and α-Gal KO mice (n=66), which had been presensitized with rabbit red blood cells to maximize immunologic response or not, and anti α-Gal antibodies were measured at various time intervals. Calcium contents of the explanted tissues (n=104) were measured 3 months after implantation. The treatment of α-galactosidase effectively removed the α-gal epitopes expressed on bovine pericardial tissues. In both GA and genipin groups, titers for both anti α-Gal IgM and IgG of α-Gal KO mice increased according to the duration of implantation, and were lower in the groups with decellularization than without decellularization, and were lower in the groups with α-galactosidase+decellularization than with decellularization. The calcium contents of GA/genipin fixed tissues were lower in the groups with decellularization than without decellularization, and were lower in the groups with α-galactosidase+decellularization than with decellularization. Treatment of α-galactosidase with decellularization is useful for removal of the immunogenicity, and reduced calcification in both GA and genipin fixed bovine pericardia, supporting the hypothesis that the immune reaction may cause the calcification. Treatment of α-galactosidase has possible promise to enhance durability of bioprosthetic heart valve. To our knowledge, this is the first report that demonstrates the in vivo efficacy of α-galactosidase using presensitized α-Gal KO mouse to mimic the human immunologic environment.

Interactions of U937 macrophage-like cells with decellularized pericardial matrix materials: Influence of crosslinking treatment

While macrophages have been implicated in the failure of bioprosthetic heart valves, the macrophage response to crosslinked native pericardial collagen has not been previously investigated. Using decellularized bovine pericardium (DBP) as a model for native collagen, this study investigated the response of macrophage-like cells (U937s) to DBP, either: (i) untreated, or (ii) exogenously crosslinked with glutaraldehyde or 1-ethyl-3-(3-dimethyl-aminopropyl)-carbodiimide (EDC). We have previously validated the use of U937 cells as models for the response of human monocyte-derived macrophages to decellularized pericardial materials and, per our previous work, differentiated the U937 cells directly on the three material surfaces. After 72h in culture, the cells and medium were analyzed for DNA content, acid phosphatase activity, and cytokine and matrix metalloproteinase release. As well, cell/substrate samples were fixed for SEM. Fewer cells attached to or survived on the glutaraldehyde-treated substrate, and some showed an abnormal morphology compared to cells cultured on the other surfaces. Further, cells on glutaraldehyde-treated surfaces released more pro-inflammatory cytokines, more MMP-1 and less MMP-2 and MMP-9. The poor performance of the U937 macrophage-like cells on the glutaraldehyde-treated surfaces appears to be due to surface characteristics rather than to soluble aldehyde or other components leaching from the crosslinked material. These results provide evidence that crosslinking with glutaraldehyde is cytotoxic to macrophage-like cells, and that crosslinking with a zero-length crosslinker like EDC can be an acceptable alternative crosslinking treatment for biomaterials.

Transcatheter valve-in-valve implantation with the Edwards SAPIEN in patients with bioprosthetic heart valve failure: the Milan experience

Reoperation for bioprosthetic heart valve failure is associated with significant morbidity and mortality, particularly in high-risk patients. Transcatheter valve-in-valve (VIV) implantation may offer a less invasive alternative. The aim of this study was to report our initial experience with transcatheter VIV implantation to treat degenerated tissue valves. VIV implantation with the Edwards SAPIEN transcatheter heart valve (THV; Edwards Lifesciences Inc, Irvine, CA, USA) was performed in 18 high-risk patients (STS 8.2±5.2%; logistic EuroSCORE 37.4±20.8%) with symptomatic bioprosthetic failure (17 aortic, one mitral). Valve Academic Research Consortium (VARC) definitions were applied for endpoint adjudication. Transfemoral access was the preferred vascular approach (16 patients, with the mitral VIV delivered anterogradely through the femoral vein; one transaxillary and one transapical). The majority (83%) of procedures were performed under local anaesthesia and sedation. Device success was achieved in all but one patient who had a final transaortic gradient ≥20mmHg. Acute kidney injury occurred in three patients (Stage 3 in 1), life-threatening or major bleeding in four patients, while major vascular complications occurred in one patient. Permanent pacemaker implantation was required in two patients. There were no deaths or neurological events at 30-day follow-up. At a median follow-up of 11 months (interquartile range 6-16), the mortality rate was 5.6% and all patients were in NYHA class II or lower. Transcatheter implantation of the Edwards THV within a degenerated aortic bioprosthesis, performed predominantly via the transfemoral route, is feasible and associated with good periprocedural and clinical outcomes in high-risk surgical patients.

Triglycidyl Amine Crosslinking Combined With Ethanol Inhibits Bioprosthetic Heart Valve Calcification

One of the most important factors responsible for the calcific failure of bioprosthetic heart valves is glutaraldehyde crosslinking. Ethanol (EtOH) incubation after glutaraldehyde crosslinking has previously been reported to confer anticalcification efficacy for bioprostheses. The present studies investigated the anticalcification efficacy in vivo of the novel crosslinking agent, triglycidyl amine (TGA), with or without EtOH incubation, in comparison with glutaraldehyde. The TGA crosslinking (±EtOH) was used to prepare porcine aortic valves for both rat subdermal implants and sheep mitral valve replacements, for comparisons with glutaraldehyde-fixed controls. Thermal denaturation temperature, an index of crosslinking, cholesterol extraction, and hydrodynamic properties were quantified. Explant endpoints included quantitative and morphologic assessment of calcification. Thermal denaturation temperatures after TGA were intermediate between unfixed and glutaraldehyde-fixed. EtOH incubation resulted in almost complete extraction of cholesterol from TGA or glutaraldehyde-fixed cusps. Rat subdermal explants (90 days) demonstrated that TGA-EtOH resulted in a significantly greater level of inhibition of calcification than other conditions. Thus, TGA-ethanol stent mounted porcine aortic valve bioprostheses were fabricated for comparisons with glutaraldehyde-pretreated controls. In hydrodynamic studies, TGA-EtOH bioprostheses had lower pressure gradients than glutaraldehyde-fixed. The TGA-ethanol bioprostheses used as mitral valve replacements in juvenile sheep (150 days) demonstrated significantly lower calcium levels in both explanted porcine aortic cusp and aortic wall samples compared with glutaraldehyde-fixed controls. However, TGA-EtOH sheep explants also demonstrated isolated calcific nodules and intracuspal hematomas. The TGA-EtOH pretreatment of porcine aortic valves confers significant calcification resistance in both rat subdermal and sheep circulatory implants, but with associated structural instability.

Transcatheter Valve-in-Valve Implantation — A New Option for Failed Bioprostheses

Reoperation for structural failure of bioprosthetic heart valves carries considerable surgical risk. In this report, investigators describe the results of transcatheter heart valve implantation in 24 patients with degenerating bioprostheses. The failing valves were aortic in 10 patients, mitral in 7, pulmonary in 6, and tricuspid in …

A Theoretical Framework to Analyze Bend Testing of Soft Tissue

It has been hypothesized that repetitive flexural stresses contribute to the fatigue-induced failure of bioprosthetic heart valves. Although experimental apparatuses capable of measuring the bending properties of biomaterials have been described, a theoretical framework to analyze the resulting data is lacking. Given the large displacements present in these bending experiments and the nonlinear constitutive behavior of most biomaterials, such a formulation must be based on finite elasticity theory. We present such a theory in this work, which is capable of fitting bending moment versus radius of curvature experimental data to an arbitrary strain energy function. A simple finite element model was constructed to study the validity of the proposed method. To demonstrate the application of the proposed approach, bend testing data from the literature for gluteraldehyde-fixed bovine pericardium were fit to a nonlinear strain energy function, which showed good agreement to the data. This method may be used to integrate bending behavior in constitutive models for soft tissue.

Bioprosthetic Valves and Laudable Inflammation?

In this issue of Circulation , Dr Manji and colleagues1 from the University of Alberta (Canada) report a series of animal experiments designed to test the mythic role of gluteraldehyde in preventing recognition of bioprosthetic heart valve antigenicity with subsequent rejection and failure. Gluteraldehyde–cross-linked xenograft tissues (initially porcine) have been used in the manufacturing of stented (and now stentless) heart valves since 1970. Original theories for the clinical efficacy of gluteraldehyde were based on its ability to irreversibly cross-link collagen and thus to increase mechanical strength and durability over fresh untanned cardiovascular tissues. Porcine valve leaflets, bovine pericardium, equine pericardium, and bovine jugular vein, among other structures, have been treated this way for clinical applications. Since its introduction, however, limitations and unexpected consequences of gluteraldehyde and similar chemical treatments have been recognized clinically. As pointed out by the authors, durability is quite variable, tending to be better in older patients whereas younger patients suffer early deterioration, calcification, and fibrocalcific failure.2,3 The good news has been that the failures tend to be progressive rather than catastrophic, leading to semielective reoperations. Additionally, the xenograft bioprostheses have been extremely helpful in avoiding warfarin in the very young and the very old, reducing the risk of thromboembolism. The traditional explanation for the fibrocalcific degeneration of the nonvital gluteraldehyde-treated bioprosthetic heart valves has been a combination of physical and chemical effects leading to calcification and a fixation of the structural proteins that prevent protein recycling and renewal. Mechanical theories of fatigue-induced wear resulting in calcification have been proposed, especially along the flexion lines of the cusps. Others have proposed that the gluteraldehyde has serendipitously “masked” the antigenicity of xenograft proteins, retained cells, and cellular debris, thus prolonging the period to calcification. This well-designed series of studies buttresses other studies demonstrating that gluteraldehyde fixation …

Mitigation of Ectopic Calcification in Osteopontin-Deficient Mice by Exogenous Osteopontin

Ectopic calcification is a major cause of bioprosthetic heart valve failure. New therapeutic opportunities are offered by the growing understanding that ectopic calcification is an actively regulated process involving several key gene products. One of these products, osteopontin (OPN), is a glycosylated phosphoprotein previously shown to inhibit apatite crystal formation, induce carbonic anhydrase II, and promote mineral resorption. In this study, OPN-deficient mice (OPN-/-) were utilized as an in vivo model to stimulate the ectopic calcification of glutaraldehyde-fixed bovine pericardium (GFBP) tissue and to examine OPN delivery and structure-function relationships with respect to its anti-calcific activity. Significant calcification of GFBP tissue was obtained within 7 days of subcutaneous implantation in OPN-/- mice. Direct rescue of the calcification phenotype was achieved by the administration of exogenous recombinant rat, histidine-fused OPN (rat His-OPN) to the implant site via soluble injection (up to 72% mitigation achieved) or adsorption onto the implant materials (up to 91% mitigation achieved). Effects were specific, since neither fibronectin nor polyhistidine alone could mitigate calcification of GFBP. The maximum anti-calcific effect was achieved only when rat His-OPN was adequately phosphorylated and contained a functional arginine-glycine-aspartate (RGD) cell adhesive domain. Furthermore, CAII levels in host cells surrounding GFBP were greatest when phosphorylated, RGD-containing rat His-OPN was adsorbed. These data suggest that both physical inhibition, mediated by phosphorylation sites in OPN, as well as the induction of CAII and mineral regression, mediated by the RGD domain, contribute to the unique ability of OPN to mitigate ectopic calcification of bioprosthetic valve tissue.

937. siRNA Inhibition of MMP9 Expression Inhibits TGFβ1-Induced Calcification of Aortic Valve Interstitial Cells

The leading cause of both native and bioprosthetic heart valve failure is calcification, which has been linked to the expression of bone-related proteins and matrix metalloproteinases (MMP), and in particular MMP9. Previous findings in our laboratory have shown that TGFβ1 mediates calcification through an apoptotic mechanism. Furthermore, we have discovered TGFβ1 induces MMP9 expression in a time-dependent fashion in cell culture. In addition, strong positive MMP9 immunohistochemical staining in calcified aortic valves compared to minimal staining in noncalcified, bicuspid and tricuspid regurgitant valves further demonstrated MMP9 involvement in the calcification process. However, its defined role in the pathway still remains unclear. Our hypothesis is that MMP9 regulates TGFβ1 activation, ultimately influencing the calcification process in aortic valve interstitial cells. We designed small interfering RNA, siRNAs, for MMP9, targeted at both the catalytic and fibronectin sites. Zymography showed that siRNA was effective in downregulation of TGFβ1-induced MMP9 expression. The reduction of MMP9 resulted in decreased apoptosis, associated with initiation of calcification, based on negligible annexin V staining in DAPI-localized cells compared to control. Therefore, these results indicate that MMP9 may be involved in the calcification progression by influencing the activation and mechanism(s) exerted by TGFβ1.

Influence of steroid hormones on bovine pericardial calcification.

Calcification is a frequent cause of the clinical failure of bioprosthetic heart valves fabricated from glutaraldehyde pretreated bovine pericardium (GABP). The present investigation describes the influence of steroid hormones in the mineralization of GABP, in an extra-circulatory environment. Calcification was studied on GABP incubation in a metastable solution of calcium phosphate containing steroid hormones such as estrone, progesterone, 7(OH) progesterone, testosterone and beta-estradiol. It is interesting to note that certain steroids can variably increase the GABP calcification. Further, the effect of these steroids in an in vitro hydroxyapatite (HA) formation was investigated. In addition, we observed these steroids alter the calcium transport through GABP in diffusion experiments and also in HA formation. Therefore, it is conceivable that prolonged use of steroids or steroids containing oral contraceptive agents may not be advisable for patients having bioprosthetic implants in contact with blood. A better understanding of the mechanism of these drugs under in vivo conditions is needed to develop applications.

An Unusual Complication Associated with the Carpentier-Edwards Porcine Bioprosthesis

Primary tissue failure of bioprosthetic heart valves refers primarily to calcification of the leaflets of the bioprosthesis. A 75 year old patient underwent reoperation 15 years after mitral valve replacement with a Carpentier-Edwards porcine bioprosthesis. The extracted bioprosthetic valve was found to have one prolapsed leaflet and a small amount of calcification on all three leaflets without tear or perforation. The two commissures suspending the prolapsed leaflet were detached, causing mitral valve regurgitation.

Characterization of the immune response to valve bioprostheses and its role in primary tissue failure

Background. The role of an immune response in the failure of bioprosthetic heart valves is poorly understood and disregarded by many. To elucidate the nature of the immune response to glutaraldehyde-treated tissue and the possible role of graft-specific antibody in graft mineralization, we performed immune-calcification studies in the rabbit and correlated those results with the analysis of specific antibodies.Methods. Aortic wall buttons (6 mm) were punched from porcine aortic wall tissue fixed with 0.2% glutaraldehyde and detoxified with urazole and then subsequently perforated under sterile conditions. The perforated buttons were then incubated with either immune serum prepared by immunization of New Zealand White rabbits (n = 5) with Freund’s incomplete adjuvant emulsions of tissue homogenates of similarly treated aortic wall tissue, or incubated with the corresponding control preimmune sera obtained before immunization of the same animals. The tissue was then implanted subdermally on the back of unrelated New Zealand White rabbits (n = 8) for a period of 3 weeks. After the buttons were explanted, tissue calcium levels were determined by atomic absorption spectroscopy.Results. Tissue calcium was increased in all five immune serum-treated replicates (range, 61.8% to 431.2%; mean, 225.9% ± 73.2%) when compared with control samples treated with preimmune sera. Overall, the mean calcium level was significantly increased (p < 0.0001) when tissue was treated with immune sera (66.0 ± 10.0 μg/mg versus 22.6 ± 4.8 μg/mg in control tissue). Graft specificity of immune sera was confirmed by Western blot analysis.Conclusions. These results strongly suggest a role of circulating graft-specific antibody in the disease of bioprosthetic graft calcification.