Longitudinal and radial distensibility of the porcine aortic root

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

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

Soft Biomimetic 3D Free-Form Artificial Vascular Graft Using a Highly Uniform Microspherical Porous Structure

This study presents a biomimetic 3D customizable artificial vascular graft with a highly porous and uniform microscale structure. The structural features were obtained by dip coating of a highly close-packed microsphere suspension on a 3D printed sacrificial template. Considering the structured arrangement of microspherical porogens in the coating layer, the microsphere-leached constructs showed higher uniformity and porosity than the conventionally particulate-leached structures, leading to ultrasoft mechanical compliance. Considering biomechanical compatibility, the resulting elastic moduli were at the sub-MPa level, comparable with those of native vascular tissues. In addition, the developed porous graft was reinforced selectively at the edge regions using a nonporous coating to secure its practical sutureability for clinical use. The sufficiently low cytotoxicity was clinically confirmed to alleviate the stiffness mismatch issues at the anastomotic interface between the native tissue and the artificial graft, thus overcoming the relevant clinical complications. Furthermore, the overall superior properties could be implemented on the 3D printed template for patient-specific medicare, thus implying the manufacturability of patient-specific vascular grafts.

Quantification of structural compliance of aged human and porcine aortic root tissues

The structural compliance of the aortic root has a significant implication for valve procedures such as transcatheter aortic valve implantation and valve-sparing aortic root replacement. However, a detailed quantification of human aortic root structural compliance, particularly in different regions, has been incomplete. In this study, the structural properties of human aortic roots (81 ± 8.74 years, n = 10) were characterized and compared with those of porcine ones (6-9 months, n = 10) using a vessel pressure-inflation test. The test involved tracking three-dimensional deformation of the markers affixed on the different surface regions of the aortic roots, including the three sinuses: the noncoronary sinus (NCS), the left-coronary sinus (LCS), and the right-coronary sinus (RCS), and at three regions along the longitudinal direction of each sinus: the upper sinus (US), the middle sinus (MS), and the lower sinus (LS), and the ascending aorta (AA) region above the NCS. We found that tissue stiffness in physiological pressure range was similar among the three human sinuses. A variation in regional structural stiffness of human aorta was observed. In the circumferential direction, the LS regions were the stiffest in the LCS and RCS, whereas NCS had relatively uniform stiffness. In the longitudinal direction, the human AA regions were more compliant than all sinuses. There was a significant difference in tissue stiffness between human and porcine aortic tissues, suggesting that the mechanical properties of porcine tissues may not be analogous to aged human ones.

Accurate guidance of a catheter by ultrasound imaging and identification of a catheter tip by pulsed-wave Doppler

BACKGROUND

With the advent of numerous minimally invasive medical procedures, accurate catheter guidance has become imperative. We introduce and test an approach for catheter guidance by ultrasound imaging and pulsed-wave (PW) Doppler.

METHODS

A steerable catheter is fitted with a small piezoelectric crystal at its tip that actively transmits signals driven by a function generator. We call this an active-tip (AT) catheter. In a water tank, we immersed a "target" crystal and a rectangular matrix of four "reference" crystals. Two-dimensional (2D) ultrasound imaging was used for initial guidance and visualization of the catheter shaft, and then PW Doppler mode was used to identify the AT catheter tip and guide it to the simulated target that was also visible in the 2D ultrasound image. Ten guiding trials were performed from random initial positions of the AT catheter, each starting at approximately 8 cm from the target.

RESULTS

After the ten navigational trials, the average final distance of the catheter tip from the target was 2.4 ± 1.2 mm, and the range of distances from the trials was from a minimum of 1.0 mm to a maximum of 4.5 mm.

CONCLUSIONS

Although early in the development process, these quantitative in vitro results show promise for catheter guidance with ultrasound imaging and tip identification by PW Doppler.

Synthesis, characterization and in vitro cell compatibility study of a poly(amic acid) graft/cross-linked poly(vinyl alcohol) hydrogel

Although physically cross-linked poly(vinyl alcohol) (PVA) hydrogels have tunable mechanical properties to match that of soft tissues, such as vascular tissue, their hydrophilic nature is not conducive to cell adhesion and spreading. For applications such as small diameter vascular grafts for coronary bypass both mechanical matching and hemocompatibility are important. Poly(amic acid) (PAA), derived from ethylene diamine tetraacetic dianhydride, is a cell-compatible polymer. It was grafted/cross-linked onto physically cross-linked PVA to provide cell compatibility. Functionalization was achieved via a one-step esterification reaction using 1,3-dicyclohexylcarbodiimide as the coupling agent and 4-dimethylaminopyridine as the catalyst. The success of the grafting reaction was verified using Fourier transform infrared spectroscopy, solid-state nuclear magnetic resonance spectroscopy and X-ray photoelectron spectroscopy. The mechanical properties of the starting PVA hydrogel were largely preserved after the grafting reaction within the physiological strain range of vascular tissue. In vitro cell culture studies using primary porcine endothelial cells confirmed cell compatibility of the PAA graft PVA hydrogel, making it an attractive candidate for small diameter vascular graft development.

Asymmetric mechanical properties of porcine aortic sinuses

BACKGROUND

Aortic sinuses are crucial components of the aortic root and important for aortic valve function. Mathematical modeling of various aortic valve or root replacements requires tissue material properties, and those of the aortic sinuses are unknown. The aim of this study is to compare the biaxial mechanical properties of the individual porcine aortic sinuses.

METHODS

Square specimens, oriented in the longitudinal and circumferential directions, were excised from the left coronary, right coronary, and noncoronary porcine sinuses. Tissue thickness was measured, and specimens were subjected to equibiaxial mechanical testing. Stress-strain data corresponding to a 35% stretch were fitted to a Fung strain energy function. Tissue stiffness and anisotropy were compared at 0.3 strain.

RESULTS

The circumferential direction was more compliant than the longitudinal one for left coronary (183.03 +/- 40.78 kPa versus 231.17 +/- 45.38 kPa, respectively; p = 0.04) and right coronary sinuses (321.74 +/- 129.68 kPa versus 443.49 +/- 143.59 kPa, respectively; p = 0.02) at 30% strain. No such differences were noted for noncoronary sinuses (331.74 +/- 129.68 kPa versus 415.98 +/- 191.38 kPa; p = 0.19). Left coronary sinus was also significantly more compliant than right and noncoronary sinuses. There were no differences between right coronary and noncoronary sinus tissues.

CONCLUSIONS

We demonstrate that the material properties of the porcine aortic sinuses are not symmetric. The left coronary sinus is significantly more compliant than the remaining sinuses. Realistic modeling of the aortic root must take into account the asymmetric differences in tissue material properties of the aortic sinuses.

Aortic root dynamics and surgery: from craft to science

Since the fifteenth century beginning with Leonardo da Vinci's studies, the precise structure and functional dynamics of the aortic root throughout the cardiac cycle continues to elude investigators. The last five decades of experimental work have contributed substantially to our current understanding of aortic root dynamics. In this article, we review and summarize the relevant structural analyses, using radiopaque markers and sonomicrometric crystals, concerning aortic root three-dimensional deformations and describe aortic root dynamics in detail throughout the cardiac cycle. We then compare data between different studies and discuss the mechanisms responsible for the modes of aortic root deformation, including the haemodynamics, anatomical and temporal determinants of those deformations. These modes of aortic root deformation are closely coupled to maximize ejection, optimize transvalvular ejection haemodynamics and-perhaps most importantly-reduce stress on the aortic valve cusps by optimal diastolic load sharing and minimizing transvalvular turbulence throughout the cardiac cycle. This more comprehensive understanding of aortic root mechanics and physiology will contribute to improved medical and surgical treatment methods, enhanced therapeutic decision making and better post-intervention care of patients. With a better understanding of aortic root physiology, future research on aortic valve repair and replacement should take into account the integrated structural and functional asymmetry of aortic root dynamics to minimize stress on the aortic cusps in order to prevent premature structural valve deterioration.

The polyvinyl alcohol-bacterial cellulose system as a new nanocomposite for biomedical applications

Finding materials suitable for soft tissue replacement is an important aspect for medical devices design and fabrication. There is a need to develop a material that will not only display similar mechanical properties as the tissue it is replacing, but also shows improved life span, biocompatibility, nonthrombogenic, and low degree of calcification. Polyvinyl alcohol (PVA) is a hydrophilic biocompatible polymer with various characteristics desired for biomedical applications. PVA can be transformed into a solid hydrogel with good mechanical properties by physical crosslinking, using freeze-thaw cycles. Hydrophilic bacterial cellulose (BC) fibers of an average diameter of 50 nm are produced by the bacterium Acetobacter xylinum, using a fermentation process. They are used in combination with PVA to form biocompatible nanocomposites. The resulting nanocomposites possess a broad range of mechanical properties and can be made with mechanical properties similar to that of cardiovascular tissues, such as aorta and heart valve leaflets. The stress-strain properties for porcine aorta are matched by at least one type of PVA-BC nanocomposite in both the circumferential and the axial tissue directions. A PVA-BC nanocomposite with similar properties as heart valve tissue is also developed. Relaxation properties of all samples, which are important for cardiovascular applications, were also studied and found to relax at a faster rate and to a lower residual stress than the tissues they might replace. The new PVA-BC composite is a promising material for cardiovascular soft tissue replacement applications.

Anisotropic polyvinyl alcohol hydrogel for cardiovascular applications

Polyvinyl alcohol (PVA) is a hydrophilic polymer with various characteristics desired for biomedical applications and can be transformed into a solid hydrogel by physical crosslinking, using a low-temperature thermal cycling process. As with most polymeric materials, the mechanical properties of the resultant PVA are isotropic, as oppose to most soft tissues, which are anisotropic. The objective of this research is to develop a PVA-based hydrogel that not only mimics the nonlinear mechanical properties displayed by cardiovascular tissues, but also their anisotropic behavior. By applying a controlled strain to the PVA samples, while undergoing low-temperature thermal cycling, we were able to create oriented mechanical properties in PVA hydrogels. The oriented stress-strain properties of porcine aorta were matched simultaneously by a PVA hydrogel prepared (10% PVA, cycle 3, 75% initial strain). This novel technique allows the controlled introduction of anisotropy to PVA hydrogel, and gives a broad range of control of its mechanical properties, for specific medical device applications.

In vitro hydrodynamics, cusp-bending deformation, and root distensibility for different types of aortic valve–sparing operations: Remodeling, sinus prosthesis, and reimplantation

OBJECTIVE

Preserving aortic valve cusps during operations for aortic root pathology theoretically offers several advantages over alternative prosthetic valve-bearing conduits. Functional properties of different valve-sparing techniques under defined conditions are not well studied.

METHODS

Fresh porcine aortic roots were investigated in a pulsatile flow simulator, either native root or after different types of valve-sparing procedures (remodeling, sinus prosthesis, and reimplantation). Functional parameters, such as transvalvular pressure gradient, closing volume, cusp-bending deformation, and distensibility at different levels of the root were analyzed.

RESULTS

The mean pressure gradient was highest in reimplantation techniques (8.4 +/- 1.8 mm Hg) compared with sinus prostheses (7.2 +/- 0.9 mm Hg, P = .01) and remodeling techniques (6.8 +/- 1.0 mm Hg, P = .002), mirror imaging the closing volume (reimplantation, 1.5 +/- 0.4 mL; sinus prostheses, 2.3 +/- 0.7 mL [P < .001]; remodeling, 3.4 +/- 1.1 mL [P < .001]). Bending deformation indices increased significantly from remodeling (0.45 +/- 0.05) and sinus prostheses (0.58 +/- 0.06) to reimplantation techniques (0.73 +/- 0.09). Dynamic changes in area of all techniques were decreased at the sinotubular junction and the commissural and sinus levels when compared with those seen in native roots but increased at the annular level for techniques with unfixed annulus (remodeling and modified sinus prosthesis).

CONCLUSIONS

In vitro the various aortic valve-sparing operations differed characteristically in their ability to spare valve function, none of them completely meeting native valve behavior. The remodeling techniques exhibited valve dynamics closest to those of the native aortic root. The more the aortic valve is fixed with noncompliant prosthetic material, the more the native root dynamics are impaired.

Limitations of implantable, miniature ultrasonic transducers to measure wall movement in the canine jejunum

BACKGROUND

We used implantable miniature ultrasonic transducers to measure longitudinal distance, circumference, and wall thickness dynamically in vivo in canine jejunum. We hoped to differentiate circular from longitudinal smooth muscle contractions and to correlate physical measurements of change in distance within the jejunal wall with intraluminal manometry.

MATERIALS AND METHODS

In acute experiments at the time of celiotomy, longitudinal distances, circumferences, and wall thickness were measured directly and by ultrasonic transducers sewn to serosa and mucosa. Measurements were obtained with the intestine empty and after distention with air, water, or semisolid slurry. In chronic in vivo experiments in conscious dogs with indwelling ultrasonic transducers and intraluminal manometers, sonometric dimensions were correlated with manometric recordings. In acute experiments, sonometric measurements were similar to direct measurements. In chronic experiments in vivo, smallest ultrasonometric measurements of circumferences of the jejunum correlated in a phase-locked temporal manner with both highest intraluminal pressures and greatest wall thickness.

RESULTS

Longitudinal distances increased during decreases in circumference. Distances orad to the site maximal intraluminal pressure peaked at 0.58 +/- 0.04 s ( x +/- SEM) before, and those aborad to this point 0.42 +/- 0.04 s after attaining minimum circumferences.

CONCLUSIONS

Ultrasonic crystals can monitor geometric changes in the bowel wall with certain limitations, especially when obtained in vivo. Contraction of circular and longitudinal muscles, although phase-locked, do not appear to occur exactly synchronously in canine jejunum.

Miniaturization: an overview of biotechnologies for monitoring the physiology and pathophysiology of rodent animal models

Recent advances in bioengineering technologies have made it possible to collect high-quality reproducible data quantitatively in a wide range of laboratory animal species, including rodents. Several of these technologies are incorporated into a plan called Miniaturization, which aims to design, develop, and maintain rodent animal models to study the pathophysiology and therapy of human diseases. Laser Doppler flowmetry, digital sonomicrometry, bioelectrical impedance, and microdialysis are some of the most widely used methods under the plan because they cause minimal pain and distress, reduce the number of animals used in biomedical research, and allow chronic, nonterminal assessment of physiological parameters in rodents. An overview of each of these technologies and their major applications in rodents used for biomedical research is provided.

The evolution of bioprosthetic heart valve design and its impact on durability

Bioprosthetic heart valves have evolved over the years into remarkably useful and predictable devices. During this process, a number of specific designs have come and gone, and a few have remained. Many design changes were successful, and many were not. This article will describe the successes and failures of the various bioprosthetic valve designs and will detail the specific reasons why a particular design change succeeded or failed to improve bioprosthetic valve performance.

Optimizing the tensile properties of polyvinyl alcohol hydrogel for the construction of a bioprosthetic heart valve stent

Although bioprosthetic heart valves offer the benefits of a natural opening and closing, better hemodynamics, and avoidance of life-long anticoagulant therapy, they nevertheless tend to fail in 10-15 years from tears and calcification. Several authors, including the present ones, have identified the rigid stent as a factor contributing to these failures. The ultimate solution is an artificial heart valve that has mechanical properties that allow it to move in conformity with the aortic root during the cardiac cycle, has superior hemodynamics, is nonthrombogenic, will last more than 20 years, and mitigates the need for anticoagulants. We have identified a polymer, polyvinyl alcohol (PVA) hydrogel, that has mechanical properties similar to soft tissue. The purpose of this research is to match the tensile properties of PVA to the porcine aortic root and to fabricate a stent prototype for a bioprosthetic heart valve with the use of the PVA hydrogel. Specimens of 15% w/w PVA were prepared by processing through 1-6 cycles of freezing (-20 degrees C) at 0.2 degrees C/min freeze rate and thawing (+20 degrees C) at different thawing rates (0.2 degrees C/min and 1 degrees C/min), for different holding times (1 and 6 h) at -20 degrees C. Subsequently tensile tests and stress-relaxation tests were conducted on the specimens. The different holding times at -20 degrees C demonstrated no difference in the result. The slower thawing rate improved the tensile properties but did not produce significant changes on the stress-relaxation properties. The nonlinear stress-strain curve for the PVA after the fourth freeze-thaw cycle matched the porcine aortic root within the physiological pressure range. The stress-relaxation curve for PVA also approximated the shape of the aortic root. The complex geometry of an artificial heart valve stent was successfully injection molded. These results, in combination with other preliminary findings for biocompatibility and fatigue behavior, suggest that PVA hydrogel is a promising biomaterial for implants, catheters, and artificial skin.

Cause of degenerative disease of the trileaflet aortic valve: review of subject and presentation of a new theory

Risk factors for both atherosclerotic aortic wall disease and degenerative disease of the trileaflet aortic valve are very similar if not identical. This correlation grows even stronger as the person advances in years. Because of this, it is the prevailing view that sclerosis of the trileaflet aortic valve, unless previously affected by septic or rheumatic endocarditis, is a disease similar in origin to sclerosis of the aortic wall, ie, degenerative aortic valve disease is arteriosclerosis of the aortic valve. Our studies challenge these views. The aortic valve is a functional assembly composed of the three cusps, corresponding sinuses, and the sino-tubular junction, characterized not only by morphologic features but also by its functional properties, which together create an environment that is optimal for distribution of diastolic pressure load and assures proper and timely valve opening and closure. Our more recent experiments also demonstrate that loss of aortic wall compliance at the level of the sinuses leads to significant stress-overload on the aortic leaflets and it is likely to start a chain of events, which begins with minor changes in their microstructure, then continues in more evident sclerosis, and finally ends in gross distortion or calcification of the cusps. The loss of the "pull-and-release" process may also play a part in disintegration of bioprosthetic valves and in degeneration of native aortic valves encased in noncompliant prostheses.

Deformational Dynamics of the Aortic Root

Background —Current surgical methods for treating aortic valve and aortic root pathology vary widely, and the basis for selecting one repair or replacement alternative over another continues to evolve. More precise knowledge of the interaction between normal aortic root dynamics and aortic valve mechanics may clarify the implications of various surgical procedures on long-term valve function and durability.

Methods and Results —To investigate the role of aortic root dynamics on valve function, we studied the deformation modes of the left, right, and noncoronary aortic root regions during isovolumic contraction, ejection, isovolumic relaxation, and diastole. Radiopaque markers were implanted at the top of the 3 commissures (sinotubular ridge) and at the annular base of the 3 sinuses in 6 adult sheep. After a 1-week recovery, ECG and left ventricular and aortic pressures were recorded in conscious, sedated animals, and the 3D marker coordinates were computed from biplane videofluorograms (60 Hz). Left ventricular preload, contractility, and afterload were independently manipulated to assess the effects of changing hemodynamics on aortic root 3D dynamic deformation. The ovine aortic root undergoes complex, asymmetric deformations during the various phases of the cardiac cycle, including aortoventricular and sinotubular junction strain and aortic root elongation, compression, shear, and torsional deformation. These deformations were not homogeneous among the left, right, and noncoronary regions. Furthermore, changes in left ventricular volume, pressure, and contractility affected the degree of deformation in a nonuniform manner in the 3 regions studied, and these effects varied during isovolumic contraction, ejection, isovolumic relaxation, and diastole.

Conclusions —These complex 3D aortic root deformations probably minimize aortic cusp stresses by creating optimal cusp loading conditions and minimizing transvalvular turbulence. Aortic valve repair techniques or methods of replacement using unstented autograft, allograft, or xenograft tissue valves that best preserve this normal pattern of aortic root dynamics should translate into a lower risk of long-term cusp deterioration.

New concepts in the design and use of biological prosthetic valves

The natural aortic valve is a structure that has thus far eluded all attempts at duplication with synthetic materials. Real success in the replacement of the aortic valve has come about primarily through the use of biological devices, such as the porcine aortic valve xenograft. In the future, bioprostheses based more closely on the natural aortic valve may ultimately succeed where synthetic approaches have failed. Some recent advances in the design and development of bioprosthetic heart valves, such as the absence of a stent and the better preservation of the valve's natural biomechanical properties, show considerable promise in improving the long term durability of these devices. With a greater understanding of the structure/function relationship of the aortic valve at the micromechanical level, the future of bioprostheses may be even more biologically oriented than it is today.