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Arbona MA, David TE, David CM, Rao V. Results of mitral valve reconstruction using substitute extracellular matrix. JTCVS Tech 2022; 16:43-48. [PMID: 36510520 PMCID: PMC9735417 DOI: 10.1016/j.xjtc.2022.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Revised: 08/14/2022] [Accepted: 09/11/2022] [Indexed: 12/12/2022] Open
Abstract
Background During the ongoing search for an ideal patch material for reconstructive heart surgery, several versions of extracellular matrix (ECM) have been used. However, long-term performance in different cardiac positions is unknown. Methods We performed a retrospective review of outcomes after mitral valve surgery using ECM in 29 patients from 2011 to 2014. Clinical and echocardiographic follow-up was reviewed (mean time, 6.3 ± 2.8 years). Results ECM was used to reconstruct the posterior mitral annulus in 69% and to repair the mitral leaflet in 65% of the patients. The most prevalent etiology was dystrophic calcification of the annulus (80%) versus endocarditis for leaflet repair (60%). Fifty-five percent of the patients who required annular reconstruction received a mitral valve replacement (MVR). There were 2 perioperative deaths (7%). Long-term data were analyzed according to surgical technique; namely, isolated leaflet repair compared with annular reconstruction with or without MVR. There were 3 late deaths (1 per group). Overall survival was 83% at 7 years. Ninety percent of cases with mitral valve repair with or without annular reconstruction were free from more than mild mitral regurgitation, compared with 45% in the MVR and annular reconstruction group. The mechanism of failure was patch degeneration creating a severe paravalvular leak due to prosthesis dehiscence. Conclusions ECM used to repair the mitral valve leaflets with or without annular reconstruction offers acceptable results. However, caution should be taken with the use of ECM adjacent to prosthetic valve material because of a high rate of failure associated with patch degeneration.
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Affiliation(s)
| | | | | | - Vivek Rao
- Address for reprints: Vivek Rao, MD, PhD, Division of Cardiovascular Surgery, Toronto General Hospital, 200 Elizabeth St, 4N464, Toronto, Ontario M5G 2C4, Canada.
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Hu K, Siddiqi U, Lee B, Pena E, Schulz K, Vogel M, Combs P, El-Zein C, Ilbawi M, Vricella L, Hibino N. Pediatric aortic valve repair: Any development in the material for cusp extension valvuloplasty? J Card Surg 2021; 36:4054-4060. [PMID: 34423475 DOI: 10.1111/jocs.15931] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 08/13/2021] [Accepted: 08/15/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Aortic cusp extension is a technique for aortic valve (AV) repairs in pediatric patients. The choice of the material used in this procedure may influence the time before reoperation is required. We aimed to assess postoperative and long-term outcomes of patients receiving either pericardial or synthetic repairs. METHODS We conducted a single-center, retrospective study of pediatric patients undergoing aortic cusp extension valvuloplasty (N = 38) with either autologous pericardium (n = 30) or CorMatrix (n = 8) between April 2009 and July 2016. Short- and long-term postoperative outcomes were compared between the two groups. Freedom from reoperation was compared using Kaplan-Meier analysis. Degree of aortic stenosis (AS) and aortic regurgitation (AR) were recorded at baseline, postoperatively, and at outpatient follow-up. RESULTS At 5 years after repair, freedom from reoperation was significantly lower in the CorMatrix group (12.5%) compared to the pericardium group (62.5%) (p = .01). For the entire cohort, there was a statistically significant decrease in the peak trans-valvar gradient between preoperative and postoperative assessments with no significant change at outpatient follow-up. In the pericardium group, 28 (93%) had moderate to severe AR at baseline which improved to 11 (37%) postoperatively and increased to 21 (70%) at time of follow-up. In the biomaterial group, eight (100%) had moderate to severe AR which improved to three (38%) postoperatively and increased to seven (88%) at time of follow-up. CONCLUSION In terms of durability, the traditional autologous pericardium may outperform the new CorMatrix for AV repairs using the cusp extension method.
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Affiliation(s)
- Kelli Hu
- Section of Cardiac Surgery, Department of Surgery, University of Chicago Medicine, Chicago, Illinois, USA
| | - Umar Siddiqi
- Section of Cardiac Surgery, Department of Surgery, University of Chicago Medicine, Chicago, Illinois, USA
| | - Brian Lee
- Pediatric Cardiology, Advocate Children's Hospital, Oak Lawn, Illinois, USA
| | - Emily Pena
- Pediatric Cardiology, Advocate Children's Hospital, Oak Lawn, Illinois, USA
| | - Kelci Schulz
- Pediatric Cardiology, Advocate Children's Hospital, Oak Lawn, Illinois, USA
| | - Maggie Vogel
- Pediatric Cardiology, Advocate Children's Hospital, Oak Lawn, Illinois, USA
| | - Pamela Combs
- Section of Cardiac Surgery, Department of Surgery, University of Chicago Medicine, Chicago, Illinois, USA
| | - Chawki El-Zein
- Pediatric Cardiology, Advocate Children's Hospital, Oak Lawn, Illinois, USA
| | - Michel Ilbawi
- Pediatric Cardiology, Advocate Children's Hospital, Oak Lawn, Illinois, USA
| | - Luca Vricella
- Pediatric Cardiology, Advocate Children's Hospital, Oak Lawn, Illinois, USA
| | - Narutoshi Hibino
- Section of Cardiac Surgery, Department of Surgery, University of Chicago Medicine, Chicago, Illinois, USA
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3
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Tjørnild MJ, Carlson Hanse L, Skov SN, Poulsen KB, Sharghbin M, Benhassen LL, Røpcke DM, Nielsen SL, Hasenkam JM. Annular and subvalvular dynamics after extracellular matrix mitral tube graft implantation in pigs. Interact Cardiovasc Thorac Surg 2021; 32:978-987. [PMID: 33595082 DOI: 10.1093/icvts/ivab027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Revised: 11/24/2020] [Accepted: 12/20/2020] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Entire mitral valve reconstruction with an extracellular matrix tube graft is a potential candidate to overcome the current limitations of mechanical and bioprosthetic valves. However, clinical data have raised concern with respect to patch failure. The aim of our study was to evaluate the impact of extracellular matrix mitral tube graft implantation on mitral annular and subvalvular regional dynamics in pigs. METHODS A modified tube graft design made of 2-ply extracellular matrix was used (CorMatrix®; Cardiovascular Inc., Alpharetta, GA, USA). The reconstructions were performed in an acute 80-kg porcine model (N = 8), where each pig acted as its own control. Haemodynamics were assessed with Mikro-Tip pressure catheters and mitral annular and subvalvular geometry and dynamics with sonomicrometry. RESULTS Catheter-based peak left atrial pressure and pressure difference across the mitral and aortic valves in the reconstructions were comparable to the values seen in the native mitral valves. Also comparable were maximum mitral annular area (755 ± 100 mm2), maximum septal-lateral distance (29.7 ± 1.7 mm), maximum commissure-commissure distance (35.0 ± 3.4 mm), end-systolic annular height-to-commissural width ratio (10.2 ± 1.0%) and end-diastolic interpapillary muscle distance (27.7 ± 3.3 mm). Systolic expansion of the mitral annulus was, however, observed after reconstruction. CONCLUSIONS The reconstructed mitral valves were fully functional without regurgitation, obstruction or stenosis. The reconstructed mitral annular and subvalvular geometry and subvalvular dynamics were found in the same range to those in the native mitral valve. A regional annular ballooning effect occurred that might predispose to patch failure. However, the greatest risk was found at the papillary muscle attachments.
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Affiliation(s)
- Marcell J Tjørnild
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark.,Department of Orthopaedic Surgery, Randers Regional Hospital, Denmark
| | - Lisa Carlson Hanse
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Søren N Skov
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Karen B Poulsen
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Mona Sharghbin
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Leila L Benhassen
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Diana M Røpcke
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Sten L Nielsen
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - J Michael Hasenkam
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark.,Department of Surgery, University of the Witwatersrand, Johannesburg, South Africa
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Chakraborty B, Wang H. Pathological Changes of Adult Mitral Valves after Failed CorMatrix ECM Repair. JOURNAL OF CLINICAL AND TRANSLATIONAL PATHOLOGY 2021; 1:9-15. [PMID: 34957472 PMCID: PMC8697744 DOI: 10.14218/jctp.2021.00009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND AND OBJECTIVES CorMatrix acts as a tissue scaffold and is intended to promote the proliferation of small vessels and tissue remodeling to replicate normal tissue function. METHODS At Temple University Hospital, Philadelphia, PA, USA from 2013 to 2016, CorMatrix material was utilized during mitral valve anterior leaflet augmentation repair in 25 adult patients, and four patients required repeat interventions at 4-12 months (8.25 ± 4.35 months) after the initial repair. This study evaluated the pathological changes in four patients. RESULTS Histological examination of the CorMatrix showed matrix degradation in all cases. At 4 months after repair, mixed acute and chronic inflammatory cells that included eosinophils were visible within the matrix, which was more severe around the suture material. Later, the extent of inflammation abated and became more chronic with macrophage dominance. Some macrophages and multinucleated cells were visible deep in the matrix. The neovascularization was limited to the tissue-matrix boundary at early time points; the more mature vessels with dilated lumens extended deeper into the matrix as time increased, combined with some elongated fibroblast-like cells. In addition, marked acute and chronic inflammation with neutrophil and eosinophil infiltrate was identified in the surrounding native tissue at 4 months, especially around the suture material. Marked granulomatous inflammation was identified in all cases, with prominent multinucleated giant cells present at later time points (50%). Immunohistochemical staining for CD68 and CD163 showed prominent M2 macrophages in the CorMatrix and surrounding tissue. CONCLUSIONS Our results demonstrated time-dependent changes in failed CorMatrix repaired valves after mitral valve repair, with macrophages and neovascularization in the matrix 12 months after the initial repair.
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Affiliation(s)
- Baidarbhi Chakraborty
- Department of Pathology and Laboratory Medicine, Temple University Hospital, Philadelphia, PA, USA
| | - He Wang
- Department of Pathology, Yale University School of Medicine, 310 Cedar Street, New Haven, CT, USA
- Correspondence to: He Wang, Department of Pathology, Yale University School of Medicine, 310 Cedar Street, New Haven, CT 06520, USA. Tel: +1-203-789-3707, Fax: +1-203-789-3710,
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5
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Brockbank B, Nicoara A, Klinger RY, Swaminathan M, Haney JC, Maisonave Y. Transesophageal Echocardiographic Evaluation of Novel Extracellular Matrix Valve for Tricuspid Valve Endocarditis. ACTA ACUST UNITED AC 2020; 4:429-432. [PMID: 33117943 PMCID: PMC7581605 DOI: 10.1016/j.case.2020.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Intravenous drug abuse is a common cause of infective TV endocarditis. The use of a novel ECM valve is a surgical alternative to TV replacement. TEE evaluation is a useful tool to evaluate the unique valve appearance and function.
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Affiliation(s)
- Benjamin Brockbank
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Alina Nicoara
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Rebecca Y Klinger
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Madhav Swaminathan
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - John C Haney
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Yasmin Maisonave
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
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Liakopoulos OJ. Commentary: Extracellular matrix tube graft in the mitral position: It's feasible, but is it durable? J Thorac Cardiovasc Surg 2019; 160:113-114. [PMID: 31627950 DOI: 10.1016/j.jtcvs.2019.08.096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 08/27/2019] [Accepted: 08/27/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Oliver J Liakopoulos
- Department of Cardiothoracic Surgery, Heart Center, University of Cologne, Cologne, Germany.
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7
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Tomdio AN, Moey MYY, Siddiqui I, Movahed A. Dehiscence and embolization of CorMatrix tricuspid valve replacement in the setting of infective endocarditis: a case report. EUROPEAN HEART JOURNAL-CASE REPORTS 2019; 2:yty086. [PMID: 31020163 PMCID: PMC6177076 DOI: 10.1093/ehjcr/yty086] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/28/2018] [Accepted: 07/05/2018] [Indexed: 11/22/2022]
Abstract
Background Due to increased morbidity and mortality, prosthetic valve infective endocarditis (IE) with dehiscence requires urgent intervention. Early identification and therapy may prevent embolization. Case summary A 27-year-old Caucasian woman with a history of hepatitis C, intravenous drug abuse, and tricuspid valve (TV) replacement was admitted for recurrent IE. She was found to have bacteraemia and fungaemia, and empiric antibiotics were initiated. Transthoracic echocardiogram (TTE) revealed a mobile ‘mass’ on the TV and dehiscence. The patient developed cardiogenic shock and repeat TTE showed a ruptured TV and absence of the ‘mass’, suspicious of embolization. She underwent emergent surgery with TV replacement using a Biocor valve and retrieval of the old CorMatrix valve found in the right mid pulmonary artery (PA). The patient was successfully weaned off inotropic agents and completed a prolonged course of antibiotics and anti-fungals. Discussion The multi-disciplinary decision on timing of surgical intervention was challenging, especially due to ongoing mycobacterial infection that increased operative risk. With clinical deterioration, urgent surgery was performed revealing an embolized prosthetic valve in the PA. New surgical options for TV replacement in IE with extracellular-based material have shown promising outcomes with little reported data of long term complications. This case demonstrates a rare occurrence of embolized CorMatrix TV and highlights the challenge in timing of appropriate surgical intervention in a septic patient with thrombocytopenia.
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Affiliation(s)
- Anna N Tomdio
- Department of Internal Medicine, Vidant Medical Center/East Carolina University, Greenville, NC, USA
| | - Melissa Y Y Moey
- Department of Internal Medicine, Vidant Medical Center/East Carolina University, Greenville, NC, USA
| | - Irfan Siddiqui
- Department of Cardiology, Vidant Medical Center/East Carolina University, Greenville, NC, USA
| | - Assad Movahed
- Department of Cardiology, Vidant Medical Center/East Carolina University, Greenville, NC, USA
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8
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Lipar M, Zdilar B, Kreszinger M, Ćorić M, Radišić B, Samardžija M, Žic R, Pećin M. Extracellular matrix supports healing of transected rabbit Achilles tendon. Heliyon 2018; 4:e00781. [PMID: 30225380 PMCID: PMC6138787 DOI: 10.1016/j.heliyon.2018.e00781] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Revised: 07/20/2018] [Accepted: 09/06/2018] [Indexed: 01/17/2023] Open
Abstract
Extracellular matrix (ECM) has been intensively used in cardio surgery. The main goal of this research was to determine if Achilles tendon healing could be promoted by applying extracellular matrix scaffold (CorMatrix®, USA). Sixteen (n = 16) New Zealand white mature rabbits (Oryctolagus cuniculus) were randomly allocated into two groups. Following complete surgical transection, rabbits in group A (ECM applied) (n = 8) had their Achilles tendons reconstructed using both, nylon suture and extracellular matrix scaffold, whereas in group B (without ECM) the tendons were reconstructed using nylon suture only. After four weeks, the rabbits were euthanized and tendon samples harvested and stained with hematoxylin eosin, Mallory, and Gomory and subsequently histologically analyzed according to modified Bonnar scale. Group B had significantly stronger inflammatory response, including abundant cell infiltration and neovascularization. In group A collagen fibers were predominantly found, whereas in group B reticular fibers were more abundant. Extracellular matrix scaffold has been found to have the real potential for promoting tendon healing through accelerating collagen formation, which is crucial for restoring biomechanical properties of a tendon, decreasing peritendineous adhesion formation, and reducing inflammatory edema and subsequently pain.
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Affiliation(s)
- Marija Lipar
- Faculty of Veterinary Medicine, University of Zagreb, Heinzelova 55, 10000 Zagreb, Croatia
| | - Boris Zdilar
- Hospital Sveti Duh, Ulica Sveti Duh 1, 10000 Zagreb, Croatia
| | - Mario Kreszinger
- Faculty of Veterinary Medicine, University of Zagreb, Heinzelova 55, 10000 Zagreb, Croatia
| | - Marijana Ćorić
- School of Medicine, University of Zagreb, Ulica Šalata 2, 10000 Zagreb, Croatia
| | - Berislav Radišić
- Faculty of Veterinary Medicine, University of Zagreb, Heinzelova 55, 10000 Zagreb, Croatia
| | - Marko Samardžija
- Faculty of Veterinary Medicine, University of Zagreb, Heinzelova 55, 10000 Zagreb, Croatia
| | - Rado Žic
- School of Medicine, University of Zagreb, Ulica Šalata 2, 10000 Zagreb, Croatia
| | - Marko Pećin
- Faculty of Veterinary Medicine, University of Zagreb, Heinzelova 55, 10000 Zagreb, Croatia
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9
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Rao V. All that glitters is not gold-but it may be silver. J Thorac Cardiovasc Surg 2017; 154:e61-e62. [PMID: 28526503 DOI: 10.1016/j.jtcvs.2017.04.050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Accepted: 04/22/2017] [Indexed: 10/19/2022]
Affiliation(s)
- Vivek Rao
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada.
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10
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Miller JR, Henn MC, Lancaster TS, Lawrance CP, Schuessler RB, Shepard M, Anderson M, Kovacs A, Matheny RG, Eghtesady P, Damiano RJ, Boston US. Pulmonary Valve Replacement With Small Intestine Submucosa-Extracellular Matrix in a Porcine Model. World J Pediatr Congenit Heart Surg 2017; 7:475-83. [PMID: 27358303 DOI: 10.1177/2150135116651113] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Accepted: 04/25/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND Prosthetic materials available for pediatric pulmonary valve replacement (PVR) lack growth potential, inevitably leading to a size mismatch. Small intestine submucosa-derived extracellular matrix (SIS-ECM) has been suggested to possess regenerative properties. We aimed to investigate its function and potential to increase in size as a PVR in a piglet. METHODS An SIS-ECM trileaflet valved conduit was designed. Hanford minipigs, n = 6 (10-34 kg), underwent PVR with an intended survival of six months, with monthly echocardiograms evaluating valve size and function. The conduit was excised for histologic analysis. RESULTS Of the six, one was sacrificed at three months for midterm analysis, and one at month 3 due to endocarditis. The remaining four constituted the study cohort. The piglet weight increased by 186% (19.56 ± 10.22 kg to 56.00 ± 7.87 kg). Conduit size increased by 30% (1.42 ± 0.14 cm to 1.84 ± 0.14 cm; P < .01). The native right ventricular outflow tract increased by 43% and the native pulmonary artery by 84%, resulting in a peak gradient increase from 10.08 ± 2.47 mm Hg to 36.25 ± 18.80 mm Hg (P = .03). Additionally, all valves developed at least moderate regurgitation. Conduit histology showed advanced remodeling with myofibroblast infiltration, neovascularization, and endothelialization. The leaflets remodeled beginning at the base with the leaflet edge being less cellular. In addition to the known endocarditis, bacterial colonies were discovered within a leaflet in another. CONCLUSIONS The SIS-ECM valved conduit implanted into a piglet demonstrated cellular infiltration with vascular remodeling and an increase in diameter. Conduit stenosis was a result of slower rates of size increase than native tissue. Suboptimal leaflet performance requires design modifications.
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Affiliation(s)
- Jacob R Miller
- Section of Adult Cardiac Surgery, Barnes-Jewish Hospital, Washington University School of Medicine, St Louis, MO, USA
| | - Matthew C Henn
- Section of Adult Cardiac Surgery, Barnes-Jewish Hospital, Washington University School of Medicine, St Louis, MO, USA
| | - Timothy S Lancaster
- Section of Adult Cardiac Surgery, Barnes-Jewish Hospital, Washington University School of Medicine, St Louis, MO, USA
| | - Christopher P Lawrance
- Section of Adult Cardiac Surgery, Barnes-Jewish Hospital, Washington University School of Medicine, St Louis, MO, USA
| | - Richard B Schuessler
- Section of Adult Cardiac Surgery, Barnes-Jewish Hospital, Washington University School of Medicine, St Louis, MO, USA
| | - Mark Shepard
- Section of Pediatric Cardiothoracic Surgery, St. Louis Children's Hospital, Washington University School of Medicine, St Louis, MO, USA
| | - Mark Anderson
- Section of Pediatric Cardiothoracic Surgery, St. Louis Children's Hospital, Washington University School of Medicine, St Louis, MO, USA
| | - Attila Kovacs
- Section of Cardiology, Barnes-Jewish Hospital, Washington University School of Medicine, St Louis, MO, USA
| | | | - Pirooz Eghtesady
- Section of Pediatric Cardiothoracic Surgery, St. Louis Children's Hospital, Washington University School of Medicine, St Louis, MO, USA
| | - Ralph J Damiano
- Section of Adult Cardiac Surgery, Barnes-Jewish Hospital, Washington University School of Medicine, St Louis, MO, USA
| | - Umar S Boston
- Section of Pediatric Cardiovascular Surgery, LeBonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, TN, USA
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11
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David TE. Invited Commentary. Ann Thorac Surg 2017; 103:120-121. [DOI: 10.1016/j.athoracsur.2016.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Revised: 06/07/2016] [Accepted: 06/08/2016] [Indexed: 11/29/2022]
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12
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Evaluation of Explanted CorMatrix Intracardiac Patches in Children With Congenital Heart Disease. Ann Thorac Surg 2016; 102:1329-35. [DOI: 10.1016/j.athoracsur.2016.03.086] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Revised: 03/13/2016] [Accepted: 03/22/2016] [Indexed: 11/21/2022]
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13
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Dijkman PE, Fioretta ES, Frese L, Pasqualini FS, Hoerstrup SP. Heart Valve Replacements with Regenerative Capacity. Transfus Med Hemother 2016; 43:282-290. [PMID: 27721704 DOI: 10.1159/000448181] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Accepted: 07/04/2016] [Indexed: 01/14/2023] Open
Abstract
The incidence of severe valvular dysfunctions (e.g., stenosis and insufficiency) is increasing, leading to over 300,000 valves implanted worldwide yearly. Clinically used heart valve replacements lack the capacity to grow, inherently requiring repetitive and high-risk surgical interventions during childhood. The aim of this review is to present how different tissue engineering strategies can overcome these limitations, providing innovative valve replacements that proved to be able to integrate and remodel in pre-clinical experiments and to have promising results in clinical studies. Upon description of the different types of heart valve tissue engineering (e.g., in vitro, in situ, in vivo, and the pre-seeding approach) we focus on the clinical translation of this technology. In particular, we will deepen the many technical, clinical, and regulatory aspects that need to be solved to endure the clinical adaptation and the commercialization of these promising regenerative valves.
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Affiliation(s)
- Petra E Dijkman
- Institute for Regenerative Medicine (IREM), University of Zurich, Zurich, Switzerland
| | - Emanuela S Fioretta
- Institute for Regenerative Medicine (IREM), University of Zurich, Zurich, Switzerland
| | - Laura Frese
- Institute for Regenerative Medicine (IREM), University of Zurich, Zurich, Switzerland
| | | | - Simon P Hoerstrup
- Institute for Regenerative Medicine (IREM), University of Zurich, Zurich, Switzerland; Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands; Wyss Translational Center Zurich, University of Zurich and ETH Zurich, Zurich, Switzerland
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14
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Schoen FJ, Gotlieb AI. Heart valve health, disease, replacement, and repair: a 25-year cardiovascular pathology perspective. Cardiovasc Pathol 2016; 25:341-352. [PMID: 27242130 DOI: 10.1016/j.carpath.2016.05.002] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Revised: 05/04/2016] [Accepted: 05/05/2016] [Indexed: 01/24/2023] Open
Abstract
The past several decades have witnessed major advances in the understanding of the structure, function, and biology of native valves and the pathobiology and clinical management of valvular heart disease. These improvements have enabled earlier and more precise diagnosis, assessment of the proper timing of surgical and interventional procedures, improved prosthetic and biologic valve replacements and repairs, recognition of postoperative complications and their management, and the introduction of minimally invasive approaches that have enabled definitive and durable treatment for patients who were previously considered inoperable. This review summarizes the current state of our understanding of the mechanisms of heart valve health and disease arrived at through innovative research on the cell and molecular biology of valves, clinical and pathological features of the most frequent intrinsic structural diseases that affect the valves, and the status and pathological considerations in the technological advances in valvular surgery and interventions. The contributions of many cardiovascular pathologists and other scientists, engineers, and clinicians are emphasized, and potentially fruitful areas for research are highlighted.
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Affiliation(s)
- Frederick J Schoen
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115; Pathology and Health Sciences and Technology (HST), Harvard Medical School, 75 Francis Street, Boston, MA 02115.
| | - Avrum I Gotlieb
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario M5S 1A8, Canada; Faculty of Medicine, University of Toronto, Toronto, Ontario M5S 1A8, Canada; Laboratory Medicine Program, University Health Network, Medical Sciences Building, 1 King's College Circle, Rm. 6275A, Toronto, Ontario M5S 1A8, Canada.
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Mosala Nezhad Z, Poncelet A, de Kerchove L, Gianello P, Fervaille C, El Khoury G. Small intestinal submucosa extracellular matrix (CorMatrix®) in cardiovascular surgery: a systematic review. Interact Cardiovasc Thorac Surg 2016; 22:839-50. [PMID: 26912574 DOI: 10.1093/icvts/ivw020] [Citation(s) in RCA: 91] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Accepted: 01/08/2016] [Indexed: 11/12/2022] Open
Abstract
Extracellular matrix (ECM) derived from small intestinal submucosa (SIS) is widely used in clinical applications as a scaffold for tissue repair. Recently, CorMatrix® porcine SIS-ECM (CorMatrix Cardiovascular, Inc., Roswell, GA, USA) has gained popularity for 'next-generation' cardiovascular tissue engineering due to its ease of use, remodelling properties, lack of immunogenicity, absorbability and potential to promote native tissue growth. Here, we provide an overview of the biology of porcine SIS-ECM and systematically review the preclinical and clinical literature on its use in cardiovascular surgery. CorMatrix® has been used in a variety of cardiovascular surgical applications, and since it is the most widely used SIS-ECM, this material is the focus of this review. Since CorMatrix® is a relatively new product for cardiovascular surgery, some clinical and preclinical studies published lack systematic reporting of functional and pathological findings in sufficient numbers of subjects. There are also emerging reports to suggest that, contrary to expectations, an undesirable inflammatory response may occur in CorMatrix® implants in humans and longer-term outcomes at particular sites, such as the heart valves, may be suboptimal. Large-scale clinical studies are needed driven by robust protocols that aim to quantify the pathological process of tissue repair.
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Affiliation(s)
- Zahra Mosala Nezhad
- Institute of Experimental and Clinical Research (IREC), Division of Cardiovascular Research (CARD), Université catholique de Louvain, Brussels, Belgium Department of Cardiovascular and Thoracic Surgery, Université catholique de Louvain, Saint-Luc University Hospital, Brussels, Belgium
| | - Alain Poncelet
- Institute of Experimental and Clinical Research (IREC), Division of Cardiovascular Research (CARD), Université catholique de Louvain, Brussels, Belgium Department of Cardiovascular and Thoracic Surgery, Université catholique de Louvain, Saint-Luc University Hospital, Brussels, Belgium
| | - Laurent de Kerchove
- Institute of Experimental and Clinical Research (IREC), Division of Cardiovascular Research (CARD), Université catholique de Louvain, Brussels, Belgium Department of Cardiovascular and Thoracic Surgery, Université catholique de Louvain, Saint-Luc University Hospital, Brussels, Belgium
| | - Pierre Gianello
- Institute of Experimental and Clinical Research (IREC), Division of Experimental Surgery and Transplantation (CHEX), Université catholique de Louvain, Brussels, Belgium
| | - Caroline Fervaille
- Laboratory of Anatomy Pathology, Université catholique de Louvain, Godinne University Hospital-CHU, Yvoir, Belgium
| | - Gebrine El Khoury
- Institute of Experimental and Clinical Research (IREC), Division of Cardiovascular Research (CARD), Université catholique de Louvain, Brussels, Belgium Department of Cardiovascular and Thoracic Surgery, Université catholique de Louvain, Saint-Luc University Hospital, Brussels, Belgium
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Parvin Nejad S, Blaser MC, Santerre JP, Caldarone CA, Simmons CA. Biomechanical conditioning of tissue engineered heart valves: Too much of a good thing? Adv Drug Deliv Rev 2016; 96:161-75. [PMID: 26555371 DOI: 10.1016/j.addr.2015.11.003] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Revised: 10/23/2015] [Accepted: 11/02/2015] [Indexed: 12/13/2022]
Abstract
Surgical replacement of dysfunctional valves is the primary option for the treatment of valvular disease and congenital defects. Existing mechanical and bioprosthetic replacement valves are far from ideal, requiring concomitant anticoagulation therapy or having limited durability, thus necessitating further surgical intervention. Heart valve tissue engineering (HVTE) is a promising alternative to existing replacement options, with the potential to synthesize mechanically robust tissue capable of growth, repair, and remodeling. The clinical realization of a bioengineered valve relies on the appropriate combination of cells, biomaterials, and/or bioreactor conditioning. Biomechanical conditioning of valves in vitro promotes differentiation of progenitor cells to tissue-synthesizing myofibroblasts and prepares the construct to withstand the complex hemodynamic environment of the native valve. While this is a crucial step in most HVTE strategies, it also may contribute to fibrosis, the primary limitation of engineered valves, through sustained myofibrogenesis. In this review, we examine the progress of HVTE and the role of mechanical conditioning in the synthesis of mechanically robust tissue, and suggest approaches to achieve myofibroblast quiescence and prevent fibrosis.
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Woo JS, Fishbein MC, Reemtsen B. Histologic examination of decellularized porcine intestinal submucosa extracellular matrix (CorMatrix) in pediatric congenital heart surgery. Cardiovasc Pathol 2015; 25:12-7. [PMID: 26453090 DOI: 10.1016/j.carpath.2015.08.007] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2015] [Revised: 08/19/2015] [Accepted: 08/20/2015] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND CorMatrix is a decellularized porcine small intestinal submucosa extracellular matrix that has gained attention as a promising alternative to current materials used in cardiac repair. While animal models demonstrate integration of CorMatrix material with host tissue, the histologic characteristics of CorMatrix used in humans are less well-characterized. In this retrospective study, we report our experience with CorMatrix material used in pediatric congenital heart surgery and describe the histology of CorMatrix material and of surrounding native tissue in explanted specimens. METHODS Records were reviewed of all pediatric patients implanted with CorMatrix from a single institution (2011-2014). Histologic examinations were performed on CorMatrix and other tissues removed. Explanted samples of CorMatrix and adherent tissues were evaluated for inflammation (acute and chronic), fibrosis, necrosis, degenerative changes, eosinophil response, foreign-body giant cell reaction, neovascularization, and calcification of tissues on a semiquantitative basis (0, none; 1, mild; 2, moderate; 3, marked). Presence of degeneration within CorMatrix and necrosis of surrounding tissue were noted. RESULTS CorMatrix was utilized in 532 pediatric heart reconstruction procedures since 2011. Twelve explanted CorMatrix specimens from 11 pediatric patients including 4 valves (2 mitral and 2 aortic) and 8 outflow/septal/conduit patches were identified and evaluated. Six cases (5 patients) demonstrated clinical evidence of graft failure prior to surgery (n=6, 1%). Chronic inflammation was seen in adjacent native tissue in 11/12 cases and consisted predominantly of a mixed population of lymphocytes, macrophages, and plasma cells. Acute inflammation was seen in three cases (3/12). Fibrosis of the surrounding native tissue was seen in all CorMatrix specimens. Eosinophils were present in 6/12 cases. Calcification in surrounding tissue was present in 3/12 cases. Giant cell reaction in adjacent native tissue was seen in 8/12 cases. Neovascularization was seen in surrounding native tissue in 5/12 cases. Degeneration of CorMatrix material was seen in 9/12 cases. Necrosis of surrounding tissue was also identified in 5/12 cases. CorMatrix was not resorbed and no cases demonstrated any remodeling of CorMatrix material by integration of native mesenchymal cells or myocytes. CONCLUSION CorMatrix may be associated with a marked inflammatory response, including a foreign-body giant cell reaction and fibrosis of the surrounding native tissue. Degenerative changes of CorMatrix material are also seen in a majority of explanted specimens. No histologic differences were seen between patients with clinical evidence of graft failure versus patients requiring graft removal due to other factors. Additionally, no cases showed evidence of tissue integration or recellularization of patch material. Our overall clinical experience with CorMatrix demonstrates a favorable outcome for pediatric patients undergoing cardiac reconstructive surgery. However, there is no histologic evidence that CorMatrix acts as a scaffold for reconstitution of the native cardiovascular structures.
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Affiliation(s)
- Jennifer S Woo
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at University of California, Los Angeles, 10833 Le Conte Avenue, CHS 13-145, Los Angeles, CA, United States.
| | - Michael C Fishbein
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at University of California, Los Angeles, 10833 Le Conte Avenue, CHS 13-145, Los Angeles, CA, United States
| | - Brian Reemtsen
- Division of Cardiothoracic Surgery, David Geffen School of Medicine at University of California, Los Angeles, 10833 Le Conte Avenue, CHS 13-145, Los Angeles, CA, United States
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