Impact of valve calcification on systolic and diastolic valvular function--an in vitro model

Despite continuous development of anticalcification treatment for bioprosthetic valves, calcification remains one major cause of structural failure. The aim of this study is to investigate changes in hemodynamic performance and leaflet kinematics in progressively calcified pericardial and porcine aortic valve prostheses.

Five pericardial (Edwards Perimount Magna) and 5 porcine (Medtronic Mosaic Ultra) aortic valve prostheses (Ø23 mm) were exposed to a high concentration Calcium-phosphate fluid in an in vitro pulse duplicator (300 cycles/minute) for 6 weeks. The prostheses were removed weekly and tested in an artificial circulation system (70 beats/min, Cardiac Output 5 l/min). All prostheses underwent X-ray, computed tomography (CT)-Scan and photographic examination for evaluation of progressive calcification. Leaflet kinematics were visualized with a high-speed camera.

Pericardial valves demonstrated faster degeneration with significantly larger radiographic areas of leaflet calcification (16.5+/-4.3% versus 5.6%+/-2.0%) and also significantly higher Ca-uptake (170+/-71 microg/mg versus 103+/-49 microg/mg) after 6 weeks. Despite degeneration systolic function remained superior for pericardial valves (mean effective orifice area [EOA] 1.52+/-0.05 versus 1.28+/-0.11 cm2, P<0.01), but leaflet kinematics showed longer closing times (135+/-11 msec versus 85+/-9 msec after 6 weeks) accompanied by higher regurgitant flow (7.8+/-1.12 mL versus 1.2+/-0.28 mL, P<0.001).

In vitro pericardial valves calcified faster and more severe than porcine valves leading to impaired diastolic function with prolongation of closing times and higher closing volume. Systolic function remained almost undisturbed by the calcification process. As a consequence in clinical settings, follow-up examinations for structural valve deterioration in porcine valves should focus on systolic performance, in pericardial valves on diastolic function.