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Abstract
Objectives: The prospects for a durable, athrombogenic, synthetic, ¯exible lea¯et heart valve are enhanced by the recent availability of
novel, biostable polyurethanes. As a forerunner to evaluation of such biostable valves, a prototype trilea¯et polyurethane valve (utilising
conventional material of known in vitro behaviour) was compared with mechanical and bioprosthetic valves for assessment of in vivo
function, durability, thromboembolic potential and calci®cation. Methods: Polyurethane (PU), ATS bilea¯et mechanical, and Carpentier±
Edwards porcine (CE) valves were implanted in the mitral position of growing sheep. Counting of high-intensity transient signals (HITS) in
the carotid arteries, echocardiographic assessment of valve function, and examination of blood smears for platelet aggregates were under-
taken during the 6-month anticoagulant-free survival period. Valve structure and hydrodynamic performance were assessed following
elective sacri®ce. Results: Twenty-eight animals survived surgery (ten ATS; ten CE; eight PU). At 6 months the mechanical valve group
(n 9) showed highest numbers of HITS (mean 40/h, P 0:01 cf. porcine valves), and platelet aggregates (mean 62.22/standard ®eld), but
no thromboembolism, and no structural or functional change. The bioprosthetic group (n 6) showed low HITS (1/h) and fewer aggregates
(41.67, P 1:00, not signi®cant), calci®cation and severe pannus overgrowth with progressive stenosis. The PU valves (n 8) showed a
small degree of ®brin attachment to lea¯et surfaces, no pannus overgrowth, little change in haemodynamic performance, low levels of HITS
(5/h) and platelet aggregates (17.50, P , 0:01 cf. mechanical valves, P 0:23 cf. porcine valves), and no evidence of thromboembolism.-
Conclusions: In the absence of valve-related death and morbidity, and retention of good haemodynamic function, the PU valve was superior
to the bioprosthesis; lower HITS and aggregate counts in the PU valve imply lower thrombogenicity compared with the mechanical valve. A
biostable polyurethane valve could offer clinical advantage with the promise of improved durability (cf. bioprostheses) and low thrombo-
genicity (cf. mechanical valves). q 2000 Elsevier Science B.V. All rights reserved.
Keywords: Polyurethane; Prosthetic heart valve; In vivo; Thrombogenicity
1010-7940/00/$ - see front matter q 2000 Elsevier Science B.V. All rights reserved.
PII: S10 10-7940(00)0038 1-X
mechanical strength within the same material. They are bio- via the main pulmonary artery. Normothermic cardiopul-
and blood-compatible, with applications in a wide range of monary bypass was set up and the heart was electrically
medical devices [12,13]. Several research groups have ®brillated. The left atrial appendage was opened and the
investigated a variety of polyurethanes for application in anterior lea¯et of the mitral valve was resected leaving a
heart valves [8,9] and have reported problems with calci®- 1±2 mm cuff of lea¯et base. The posterior lea¯et was
cation and thrombosis. Long-term in vitro durability of partially resected with preservation of secondary chordae.
polyurethane valves has been achieved [14] and, in our The valve was sutured into the mitral position using 12
own experience, polyurethane valves manufactured from a interrupted 2/0 Ethibond pledgeted sutures, placed with
commercially available textile polyurethane were capable the pledgets on the ventricular side and tied on the atrial
of achieving more than 800 million cycles in laboratory side of the mitral annulus. No anticoagulation was used
fatigue testing (equivalent to more than 20 years of `normal' postoperatively.
function) [15]. Calci®cation localised only to tears and Investigative studies were carried out at 6 weeks, 3
wear-induced defects in the material, during in vitro fatigue months and 6 months after surgery. The sheep were killed
testing [16,17]. Our previous research highlighted the need humanely by intravenous overdose of barbiturate. They
to modify the valve lea¯et [18] and frame design (unpub- were exsanguinated and full post-mortem examinations
lished data) to minimise stenosis of the valve by reducing performed. The hearts were removed and the valves excised
the pressure gradient across the valve, especially critical in for further examination. Samples of myocardium from the
smaller sizes. A prototype polyurethane valve has resulted free wall of the left ventricle, caudal lobe of the lung, spleen,
with lea¯et geometries as previously de®ned [19,20]. The kidney, cerebral cortex and right lobe of the liver were
frame was machined from polyetheretherketone (PEEK), collected into 10% neutral buffered formalin for histological
coated with a thin layer of lea¯et polyurethane. Lea¯ets of examination.
a commercially available polyetherurethane suitable for
animal implantation (Estane 58315, BF Goodrich, 2.2. Follow-up investigations
Westerlo-Oevel, Belgium) were dip-coated onto the frame
as previously described [19,20]. This valve design has Carotid Doppler studies for detection of high-intensity
achieved durabilities in excess of 400 million cycles during transient signals (HITS), echocardiographic assessment of
in vitro fatigue testing. valve function and examination of blood smears for platelet
The present study compares this prototype polyurethane aggregation were performed at follow-up. Valve structure
valve with well-established mechanical and bioprosthetic and hydrodynamic performance were assessed following
valves in a sheep implant model, in terms of in vivo func- elective sacri®ce at 6 months.
tion, durability, thromboembolic potential and calci®cation To collect the Doppler ultrasound data, the animal was
risk. sedated with an intravenous bolus dose of 0.4 mg kg 21
diazepam. Additional boluses of 0.2 mg kg 21 were adminis-
tered every 20 min when required. Thirty minutes of the
2. Methods Doppler spectra and audio signal were then recorded from
the thoracic outlet of the carotid artery at the base of the
2.1. Valve implantation neck, using an EME TC 4040 multichannel transcranial
Doppler ultrasound machine (Eden Medizinische Elektro-
Polyurethane valves (24 mm) were implanted in growing nik, Uberlingen, Germany) equipped with a dual-depth
Texel sheep. ATS bilea¯et mechanical valves (24 mm) and probe. HITS were counted according to standard criteria
Carpentier±Edwards supra-annular porcine aortic valves (25 [21]. HITS data for all valves were collected at 3 months
mm) were implanted for comparison. All valves were and 6 months of follow-up.
placed in the mitral position. The procedures were carried Blood smears were made from femoral arterial samples
out in conformance with the Home Of®ce code of practice collected into EDTA/formalin at 6 weeks, 3 months and 6
and standards, and with the appropriate Home Of®ce project months follow-up, and stained with May±Grunwald±
and personal licences granted under the Animals (Scienti®c Giemsa stain. Platelet aggregate counts were averaged
Procedure) Act 1986. over nine standard ®elds under light microscopy at £100
Anaesthesia was induced with alfaxalone/alfadolone magni®cation.
(0.333 ml kg 21) following intravenous diazepam premedi- Haemodynamic function of the valves was assessed by
cation (0.2 mg kg 21) and maintained with 3% inhaled transthoracic echocardiography, performed after sedation of
iso¯urane. A single bolus of atracurium (0.5 mg kg 21) the animal with a single dose of 0.2 ml kg 21 of intramus-
was given intravenously. cular ketamine. Pressure gradient and ¯ow velocity across
A left thoracotomy was performed through the bed of the the prosthesis was measured at 6 weeks, 3 months and 6
resected ®fth rib. The animal was heparinised (300 units months.
kg 21). The descending aorta was cannulated for arterial Mean pressure gradients across the explant valves were
return and venous blood drained from the right ventricle measured in vitro using a pulse duplicator, described
Table 1
Summary of valve implantation and survival
Valve Number Age at implant (weeks, Post-op. Survivors to 6 Age of 6-month Valve-related
implanted mean ^ SD, range) survivors months survivors at implant deaths
(weeks, mean ^ SD, range)
previously [19]. The valves were tested in the mitral posi- group, one death occurred at 6.6 weeks but no de®nitive
tion at ®ve pulsatile ¯ow rates, ranging from 3.6 to 9.6 l pathology was discovered at post-mortem examination. A
min 21, at a mean aortic pressure of 95 mmHg. total of nine sheep survived to 6 months with a mechanical
Organ sections were stained with haematoxylin±eosin. In valve implant. Two out of ten post-operative survivors in the
addition, kidney sections were stained with Sirius Red to porcine valve group died, at 2 weeks and 15.14 weeks, from
demonstrate collagen and splenic sections by the Perl's valve-related causes: both valves were heavily stenosed,
method for iron. Thin sections of explant polyurethane associated with pannus overgrowth of the lea¯ets. A total
valve lea¯ets were prepared from wax-embedded portions of six sheep survived to 6 months with a porcine valve
of lea¯et. The sections were stained for calcium using implant. No animals in the polyurethane valve group
Alizarin Red S or von Kossa: von Kossa-stained sections (eight post-operative survivors) died from valve-related
were counter-stained with haematoxylin±eosin, Gomori or causes. All eight post-operative survivors with a polyur-
Von Gieson stains for examination of ®brous material ethane valve implant survived to 6 months. The mechanical
attached to the explanted lea¯ets. Following sputter-coating valves were unchanged in appearance at explant with no
with gold, segments of lea¯et surface were mounted for signi®cant pannus overgrowth of the valve lea¯ets (Fig.
scanning electron microscopy and examined at 15 kV accel- 1). All the porcine valve explants were affected by extensive
erating voltage. pannus overgrowth with minor focal calci®cation (Fig. 2).
One polyurethane valve had two lea¯ets restrained by a
2.3. Statistical analysis chordal loop. All polyurethane valve lea¯ets showed a
degree of ®brin attachment with no signi®cant pannus over-
Results are expressed as mean (SD) unless otherwise growth and calci®cation that was exclusively associated
stated. Statistical analyses were performed using Minitab with ®brin material attached to the lea¯ets (Fig. 3).
for Windows, release 12 (Minitab Inc.), assuming a signi®- HITS per hour are detailed in Table 2. Overall, there was
cance level of 5%. HITS data were incremented by 1, to a signi®cant effect of valve type, with the mechanical valve
remove zero values, followed by logarithmic transforma- group producing greater numbers of HITS than either the
tion, to approximate normality among groups. The trans- porcine (P , 0:01) or the PU (P , 0:01) valve types. At 3
formed data were then analysed using a general linear months, mechanical valves produced signi®cantly greater
model (ANOVA), incorporating the three follow-up times
as a repeated-measures variable, with Bonferroni-corrected
multiple post hoc comparisons (using a Minitab macro
supplied by Glasgow University Department of Statistics).
Logarithmic transformation was applied to aggregate data
prior to similar data analysis. Velocity data from echocar-
diographic studies were compared by similar methods with-
out data transformation. Pressure gradient data could not be
transformed to approximate normality and equal variance,
and hence were analysed using Kruskal±Wallis one-way
analysis of variance.
3. Results
Table 4
Echocardiographic data at 6 weeks, 3 months and 6 months follow-up
Valve type n Follow-up time Mean velocity (m s 21) SD Mean pressure gradient (mmHg) SD
Fig. 5. Thin section of polyurethane valve lea¯et, stained for calcium, with von Kossa (£312).
between 24 and 25 weeks. No other factors were different was a surface layer, clearly separate from the underlying
among the valves. The differences in the three younger lea¯et polymer. A number of points on the lea¯et surface
sheep implanted with polyurethane valves may have been indicated a concentration of this thrombus, with associated
partly related to the age at implant of the sheep or to physi- calci®cation, penetrating into the body of the polyurethane
cal factors associated with the individual implants. (Fig. 5). This is suggestive of a degradative process affect-
However, further implant experience with various ages of ing the polyurethane surface structure, which is likely to
animals would be required to clarify this. accelerate as calci®ed host material penetrates the polymer.
Overall, the polyurethane valve performed better than the A few areas of the most severely ®brosed/thrombosed poly-
porcine bioprosthesis. In terms of blood ¯ow parameters, urethane valve lea¯ets appeared to be undergoing a degra-
the mechanical valve performed best, but the risk of throm- dative process, viewed by scanning electron microscopy
boembolic events remained and may have caused the (Fig. 6). Calci®cation of the lea¯ets was entirely associated
premature death of one animal in this group. Only the with extrinsically calci®ed material attached to the lea¯et
porcine valve function was affected by pannus overgrowth, with some early penetration from the surface (Fig. 5), which
resulting in severe stenosis of the valve. There was only appeared to be associated with polymer degradation. No
minor focal calci®cation detected (Fig. 2c), which was intrinsic polyurethane calci®cation was found associated
insuf®cient to affect lea¯et function. There were no failures with intact areas of polymer. It is likely that such ingressions
of the polyurethane valve lea¯ets and the slight increase in would cause stress concentrations and/or material thinning,
valve stenosis was due to the attachment of ®brous and leading eventually to material failure. The problems of poly-
thrombotic material to the lea¯et surface and the subsequent urethane biostability are well known [12] and such polymers
calci®cation of this extrinsically attached material. In are especially vulnerable when used in demanding ¯exing
general, the ®brous, thrombosed network on the lea¯et applications in which fatigue-induced damage seems to
accelerate material biodegradation [25]. This problem has
been the subject of much research interest, and a variety of
approaches to its solution has been attempted. Many of these
approaches have improved the biostability of polyurethanes
and it is well recognised that a safe, durable and effective
polymeric prosthetic valve is imminent [12].
As part of a multi-disciplinary programme 1 to develop a
polyurethane valve design with good biological durability,
fatigue resistance and haemodynamics, we are now working
with a new generation of biostable polyurethanes which
have proven themselves of superior biostability in a
demanding 6-month, strained, rat implant model. We antici-
1
Current MedLINK programme, in association with the University of
Liverpool, Department of Clinical Engineering, the University of Leeds,
Department of Mechanical Engineering, and AorTech International, with
Fig. 6. Scanning electron microscopy image of polyurethane valve lea¯et, funding from the U.K. Department of Health and the Engineering and
showing area of degradation surrounded by intact polymer. Physical Sciences Research Council.
pate early development of a polyurethane valve which has [18] Bernacca GM, Mackay TG, Gulbransen MJ, Donn AW, Wheatley DJ.
good haemodynamic function maintained during long-term Polyurethane heart valve durability: effects of lea¯et thickness. Int J
Artif Organs 1997;20:327±331.
implant, and which neither fails from biological degradation [19] Mackay TG, Wheatley DJ, Bernacca GM, Hindle CS, Fisher AC. A
nor from fatigue-induced material failure, while maintain- new polyurethane heart valve prosthesis: design, manufacture and
ing a low thrombogenic surface. evaluation. Biomaterials 1996;17:1857±1863.
[20] Mackay TG, Bernacca GM, Wheatley DJ, Fisher AC, Hindle CS. In
vitro function and durability assessment of a polyurethane heart valve
Acknowledgements prosthesis. Arti®cial Organs 1996;20:1017±1025.
[21] Ringelstein EB, Droste DW, Babikian VL, Evans DH, Grosset DG,
Kaps M, Markus HS, Russell D, Siebler M. Consensus on microem-
This research was funded by the British Heart Founda- bolus detection by TCD. International Consensus Group on Micro-
tion. embolus Detection. Stroke 1998;29(3):725±729.
[22] Mackay TG, Georgiadis D, Grosset DG, Lees KR, Wheatley DJ. On
the origin of cerebrovascular microemboli associated with prosthetic
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1989;48:S98±S99. won't last 3 months, and they have craters and look like the surface of
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let heart valve prosthesis. J Thorac Cardiovasc Surg 1990;99:1074± polyurethane three-lea¯et valves for a year in sheep, and at a year they all
1081. had intrinsic calci®cation, which was de®nitely not related to a surface
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pumps. Artif Organs 1982;6:190±197. calci®cation over time.
[11] Imamura E, Kaye MP. Function of expanded polytetra¯uoroethylene Professor Wheatley: I am not sure that I can answer that question. I
laminated trilea¯et valves in animals. Mayo Clin Proc 1977;52:770± really need my biochemical and polymer chemist colleagues to tell me that,
775. but the structure of the soft segment is such that they don't believe that this
[12] Tanzi MC, Ambrosio L, Nicolais L, Iannace S, Ghislanzoni L, will calcify. We have had this in a fairly demanding animal model for quite
Mambrito B. Comparative physical tests on segmented polyurethanes a good period, 6 months, but we have also had it in a calcifying model in the
for cardiovascular applications. Clin Mater 1991;8:57±64. laboratory for equivalent periods of much longer than this, and there
[13] Zdrahala RJ, Zdrahala IJ. Biomedical applications of polyurethanes: a doesn't seem to be any intrinsic calci®cation at all. The answer is clearly
review of past promises, present realities and a vibrant future. J a biochemical one and a chemical one, and I don't know that anybody really
Biomater Appl 1999;14:67±90. understands that.
[14] Jansen J, Reul H. A synthetic three-lea¯et valve. J Med Eng Technol Mr A. Ritchie (Cambridge, UK): A question or two. The new crop of
1992;16:27±33. stentless valves that is on the market now requires no warfarin therapy, as is
[15] Bernacca GM, Mackay TG, Wheatley DJ. In vitro function and the prospect with the polyurethane valves, so they are equivalent in that sort
durability of a polyurethane heart valve: material considerations. J of a sense. The question which will remain over the stentless valves is their
Heart Valve Dis 1996;5:538±542. durability, which the polyurethane valve has to answer also. We have seen
[16] Bernacca GM, Mackay TG, Wilkinson R, Wheatley DJ. Calci®cation in three of your valves, perhaps as some may judge, early signs of failure.
and fatigue failure in a polyurethane heart valve. Biomaterials Where do you think they might lie in competing with stentless valves if that
1995;16:279±285. continues to show up?
[17] Bernacca GM, Mackay TG, Wilkinson R, Wheatley DJ. Polyurethane Professor Wheatley: The changes in three of the valves were quite
heart valves: fatigue failure, calci®cation and polyurethane structure. clearly related to a surface phenomenon. It was the expected ®nding we
J Biomed Mater Res 1997;34:371±379. would have with a nonbiostable material. We want these valves to last at
least as well as the current bioprostheses would in adults, because I think Dr Cosgrove: Could you tell us the mode of failure on the accelerated
the future for this valve, at least initially, will be the parts of the world wear tester?
where rheumatic fever occurs in young patients, where the bioprosthesis is Professor Wheatley: Usually it is a fatigue-type fracture of the material,
not an option as it behaves like the juvenile sheep, and where mechanical a crack which propagates slowly. Crack propagation is one of the concerns;
valves are not feasible. Stentless valve implantation techniques are such we have to make sure there is good resistance to that. One of the arguments
that the degree of skill needed for these makes them sometimes not the most that was put up for the homografts many years ago is that they fail slowly,
obvious option. We can certainly fatigue these in the laboratory to do better and we hope that such will be the same for these valves, not in the near
than the current frame-mounted bioprostheses, but the answers are clearly future but perhaps that is the way these will eventually fail.
going to come from a lot more further testing.