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4
U. Bortolotti and G. Thiene
of bovine pericardium, in the attempt to minimize the
intraoperative ischemic times and counterbalance the
increasing impact of transcatheter valve implantation.
Evolution ofMechanical Prostheses
In reviewing the history of prosthetic valves, it appears evident how many improvements and technical advances have
been obtained in this eld. Looking to the past, it must also
be underlined how some old concepts, which can be considered quite revolutionary for those years, clearly indicate the
great skill of those who conceived them. The Hufnagel principle was substantially derived from the patent of the bottle
stopper dating back to 1858, which was later transferred to
the Starr-Edwards caged-ball prosthesis which has been in
clinical use for many years with extremely long-term longevity. It is however interesting to recall that the Hufnagel
principle was revisited almost 40years later by implanting a
tilting-disc prosthesis in the descending aorta of patients
with a failing aortic prosthetic valve considered otherwise
inoperable.
Another unique mechanical prosthesis was developed in
Cape Town, South Africa, by Christiaan Barnard in 1962. It
consisted of a double cone-shaped poppet resembling a toilet
plunger from which the idea was taken. A modication of
such design was adopted by others to reduce the high rate of
thromboembolic complications, obtaining a disc valve
resembling a collar button.
Currently the only mechanical prostheses available in the
market are those who incorporate the bileaet mechanism.
Again, this concept is only apparently modern since it was
pioneered by Vincent Gott in 1963 while developing a
central- hinging bileaet valve with a polycarbonate housing
and leaets made of silicone rubber and Teon fabric. This
device has demonstrated unexpected durability with apparently no reported cases of structural failures. In 1968, Walton
Lillehei developed an all titanium bileaet prosthesis with
improved hemodynamics invitro owing to a central laminar
ow. This prosthesis was implanted in mitral position only in
a patient who did not survive the operation and then abandoned. In the continuous effort to provide a prosthesis with
reduced resistance to ow, the bileaet model has been consistently revitalized in more recent years yielding various
mechanical prostheses with excellent hemodynamic performances and no reports of structural failures in the recent
models. These devices are the only still in the market and,
after an initial skepticism, are now considered extremely
reliable with unsurpassed records of durability. Failures of
some early bileaet prostheses, with episodes of leaet rupture and embolization, were mainly referred to a faulty
design.
Another milestone in mechanical prostheses manufacturing is represented by the introduction of pyrolytic carbon,
which eliminated the risk of deformation or wear of other
materials such as Delrin®, an acetyl resin, used in some
prosthetic models. Interestingly, pyrolytic carbon was rst
used to manufacture the poppet of the DeBakey-Surgitool
caged-ball prosthesis. Sorin Biomedica (Saluggia, Italy) was
particularly active in this eld, under the leadership of Franco
Vallana, producing both tilting disc and bileaet prostheses
with excellent results and absence of mechanical failures.
Subsequently, a new technology yielded the Carbolm®, a
thin lm of turbostratic carbon to cover the sewing ring and
other valve components, with the potential to reduce
thrombogenicity.
More recently, a bileaet prosthesis has been approved
for clinical use which has been designed to function with a
lower anticoagulation level than previously recommended.
Evolution ofBiological Prostheses
In addition, biological prostheses have undergone a wide
variety of changes, before obtaining denite acceptance,
favored by the superior resistance to structural valve deterioration in third-generation devices. Indiscriminate use of
commercially manufactured porcine and pericardial bioprostheses led surgeons to face an increasingly frequent number
of reoperations for valve failures. Calcic cusp degeneration
in porcine and fatigue-induced lesions in pericardial bioprostheses were soon identied as the main modes of failure.
Important advances in bioprosthetic technology allowed to
minimize or even eliminate such complications. Among
these, replacement of a rigid stent with a exible one in porcine xenografts reduced mechanical stresses particularly on
the commissures. Although the use of buffered glutaraldehyde in tissue xation was an important achievement, by
obtaining stability of collagen cross-links, it also caused
xenograft cell death by providing the initial sites for the calcic cascade. Thereafter, numerous anticalcication treatments, mostly based on removal during manufacturing of
cell debris or glutaraldehyde residuals, have been added to
tissue processing and many of which have been shown to
have an effective antimineralization action both in experimental and in clinical settings. Furthermore, the concept of
low to zero pressure xation was accepted for its fundamental role in maintaining normal collagen waviness of the
brosa in the porcine aortic cusps, preserving their elasticity
and function.
All such modications have led to the manufacture of
various new models of bioprostheses which represent an
ideal substitute especially in an elderly population where
such devices are expected to outlive their recipient owing to
2 Story Telling ofProsthetic Cardiac Valves
5
a prolonged durability. These considerations appear undoubtedly important considering the rapid growth of transcatheter
procedures employing prostheses of bovine pericardium,
which could render surgical valve replacement obsolete in a
near future. In the attempt to counteract or delay this trend,
sutureless and rapid deployment bioprostheses have been
introduced in the clinical practice. Such devices have demonstrated to allow a signicant reduction of implantation
time and cardiopulmonary bypass length and consequently
of myocardial ischemia, being therefore particularly useful
and indicated in high-risk, critical patients.
Dysfunctioning biological prostheses, in the past replaced
with standard reoperations, are currently managed in many
cases by implantation of transcatheter devices in a valve-invalve fashion. Accordingly, the industry has adapted to this
trend by developing more exible, resilient pericardial bioprostheses which have the potential to facilitate possible
future valve-in-valve procedures.
Conclusion
In reviewing the history of prosthetic valves, it appears evident
how many improvements and technical advances have been
obtained in this eld. Looking to the past, it must also be underlined how some old concepts, which could be considered quite
revolutionary for that time, clearly indicate the great skill and
ingenuity of those who conceived them. Both mechanical and
biological prostheses have gone a long way before reaching
their current reliability, which is the result of both lessons and
mistakes from the past. Nevertheless, in reviewing the early
and more recent years and recognizing the many steps forward
in prosthetic valve evolution, one cannot ignore that history
sometimes repeats itself, and this is once again demonstrated
by the revival of old and initially unsuccessful concepts.
Further Reading
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F. Fatigue-induced failure of the Ionescu-Shiley pericardial xenograft in the mitral position: In vivo and invitro correlation and a
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Gott VL, Alejo DE, Cameron D.Mechanical heart valves: 50 years of
evolution. Ann Thorac Surg. 2003;76:S2230–9.
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6
U. Bortolotti and G. Thiene
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Anatomy ofNative Heart Valves
Aortic Valve Apparatus
• Sinuses of Valsalva
dimensions
Diameter of LVOT
• Cusps
• Commissures
• Intercusp triangles
• Aortic wall
GaetanoThiene andStefaniaRizzo
3
Aortic Valve
Leonardo Da Vinci compared the aortic valve to a gate and
depicted the blood ow through the aortic orice with vortexes starting to close the cusps at the end of the ventricular
systole.
The aortic cusps are located within the sinusal portion of
the ascending aorta (Fig.3.1).
The aortic sinuses, known as sinuses of Valsalva, were
rst described by Antonio Maria Valsalva in his book Opera
Fig. 3.1 The aortic valve
apparatus within the sinusal
part of the ascending aorta
Diameter of sinus
of valsalva
Omnia, published posthumous in 1740 by his pupil Giovanni
Battista Morgagni.
The aortic valve apparatus consists of cusps, commis-
sures, intercuspal triangles, and the aortic wall (Fig.3.2).
The cusps are three semilunar, swallow’s nest in shape,
one posterior and two anterior (right and left) (Fig.3.3).
The right aortic cusp lies over the ventricular septum, the
left aortic cusp on the antero-lateral myocardial band,
whereas the posterior cusp is in brous continuity with the
anterior mitral leaet (Figs.3.3, 3.4 and 3.5). Triangles indicate interleaet triangles.
Height of LMS
G. Thiene · S. Rizzo (*)
Department of Cardiac, Thoracic, Vascular Sciences and Public
Health, University of Padua Medical School, and Cardiovascular
Pathology Unit, University Hospital of Padua, Padua, Italy
e-mail: gaetano.thiene@unipd.it; s.rizzo@unipd.it
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
G. Thiene et al. (eds.), Pathology of Cardiac Valve Disease, https://doi.org/10.1007/978-3-031-35498-4_3
Aortic valve annulus,
maximum and minimum
7
8
G. Thiene and S. Rizzo
a
b
Fig. 3.3 The aortic cusps are similar to swallow nests. Note the coronary ostia (arrows) located just below the sinotubular junction. L, P,
R=left, posterior, right cusps
The aortic root is located in between the mitral and tricus-
pid valves (Fig.3.6).
The top conuence of the semilunar cusps, where they
approximate to each other, represents the commissures. At
variance with the mitral and tricuspid valves, the semilunar
cusps at the commissures are in discontinuity (Fig.3.3).
Histologically, the aortic cusps show three layers: (a) a
thin ventricularis facing the ventricular cavity and consisting
of bro-elastic bers; (b) the brosa facing the aortic wall
side, consisting of collagen bundles, and (c) the spongiosa in
between with extracellular matrix made by myxoid ground
substance (Fig.3.7).
Commissural Ring
(Sinutubular junction)
Aortic wall
within ventricle
(interleaflet
triangle)
Ventricle within sinus
Fig. 3.2 Schematic representation of the aortic valve apparatus and its
components, together with the various anatomical and functional rings
Ventriculo- arterial
ring and junction
Basal ring
The coronary arteries originate just below the sinotubular
junction, with a variability up to 2.5mm, in the right and left
sinuses of Valsalva (Figs.3.8 and 3.9), facing the main pulmonary artery.
There are several aortic anatomic and functional “rings”
at the root of the aorta (Fig.3.8): the “surgical” one, corresponding to the lowest part of cuspal attachment; the contact
border of cuspal closure, namely, the physiological virtual
ring separating the aorta and ventricular cavity during diastole; the “crown-like” attachment of the cusps to the aortic
wall; the sinotubular junction separating the sinusal and
tubular portions of the ascending aorta; and the anatomic
ventricular myocardium in discontinuity with the aortic wall.
The membranous septum is situated under the commissure between the posterior and the anterior right cusps, with
the His bundle coursing in the posteroinferior rim (Fig.3.10).
The aortic wall structure (an intrinsic component of the
aortic valve apparatus) consists of intima, media, and adventitia (Fig.3.11). The intima is composed by an endothelial
lining and a myointimal layer with smooth muscle cells.
The tunica media is made by lamellar elastic units
(Figs.3.12 and 3.13), approximately 50–60in the ascending
aorta, which include smooth muscle cells (Fig.3.14) within
an extracellular matrix consisting of collagen bers and
ground substance. The smooth muscle cells of the lamellar
units represent the “parenchyma” of the aorta, which should
be considered a real “organ.”
cd
ab
3 Anatomy ofNative Heart Valves
a
b
9
NC
Sinus
RC
Sinus
S
Fig. 3.4 (a, b, d) The aortic valve partially lies over the myocardium. In particular, the right coronary cusp (RC) lies over the ventricular septum
(S), the left coronary cusp over the anterolateral band and the noncoronary (NC) one is in brous continuity with the anterior mitral leaet (c)
Fig. 3.5 The aortic cusps
seen from the ventricular
cavity (a). Note the aortic
brous continuity between the
anterior mitral leaet and the
posterior noncoronary cusp
(b)
10
Fig. 3.6 The aortic valve is wedged
between the mitral (M) and tricuspid (T)
valves. A, P, S=anterior, posterior, and
septal leaets of the T valve
G. Thiene and S. Rizzo
S
A
P
3 Anatomy ofNative Heart Valves
11
Fig. 3.7 (a) The three layers
of an aortic cusp: brosa (up),
ventricularis (down) and
spongiosa (middle). (b)
Crimping of the collagen in
systole
a
b
collagen
crimp
corrugations
elastin
Systole
Diastole
12
Sino-
tubular
junction
Fig. 3.8 The several
anatomic and functional
“rings” of an aortic valve
apparatus
G. Thiene and S. Rizzo
Fig. 3.9 The coronary ostia
are located just below the
sinotubular junction. Gross
view of the left infundibular
outow and aorta valve
apparatus (a). Histology at the
left coronary ostium (b)
a b
LC
Sinus
Aortic Wall
• TunicaI INTIM
• Tunica MEDIA
•Tunica ADVENTITIA
3 Anatomy ofNative Heart Valves
13
a
a
b
b
Fig. 3.12 The concept of aortic lamellar units ((a), elastic lamellae;
(b), smooth muscle cells in between) according to Wolinsky H and
Glagov S.From Circulation Research, Vol. 20, January 1967
Fig. 3.10 The course of the atrioventricular conduction system, seen
from the right (a) and left (b) sides. Note the relationship with the membranous septum transilluminated and the aortic valve
A
• The nomber of elastic lamellae is maximum in the
ascending aorta (about 56) and gradually
decreases distally, with a minimum in the
abdominal aorta (about 28);
Fig. 3.11 Schematic representation of the aortic wall layers with number of elastic lamellae in ascending and abdominal aorta
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