An artificial heart valve is a
one-way valve
A check valve, non-return valve, reflux valve, retention valve, foot valve, or one-way valve is a valve that normally allows fluid ( liquid or gas) to flow through it in only one direction.
Check valves are two-port valves, meaning they have ...
implanted into a person's
heart
The heart is a muscular organ in most animals. This organ pumps blood through the blood vessels of the circulatory system. The pumped blood carries oxygen and nutrients to the body, while carrying metabolic waste such as carbon dioxide t ...
to replace a
heart valve
A heart valve is a one-way valve that allows blood to flow in one direction through the chambers of the heart. Four valves are usually present in a mammalian heart and together they determine the pathway of blood flow through the heart. A heart v ...
that is not functioning properly (
valvular heart disease
Valvular heart disease is any cardiovascular disease process involving one or more of the four valves of the heart (the aortic and mitral valves on the left side of heart and the pulmonic and tricuspid valves on the right side of heart). These ...
). Artificial heart valves can be separated into three broad classes: mechanical heart valves, bioprosthetic tissue valves and engineered tissue valves.
The human heart contains four valves:
tricuspid valve
The tricuspid valve, or right atrioventricular valve, is on the right dorsal side of the mammalian heart, at the superior portion of the right ventricle. The function of the valve is to allow blood to flow from the right atrium to the right vent ...
,
pulmonary valve
The pulmonary valve (sometimes referred to as the pulmonic valve) is a valve of the heart that lies between the right ventricle and the pulmonary artery and has three cusps. It is one of the four valves of the heart and one of the two semilunar va ...
,
mitral valve
The mitral valve (), also known as the bicuspid valve or left atrioventricular valve, is one of the four heart valves. It has two cusps or flaps and lies between the left atrium and the left ventricle of the heart. The heart valves are all one-w ...
and
aortic valve
The aortic valve is a valve in the heart of humans and most other animals, located between the left ventricle and the aorta. It is one of the four valves of the heart and one of the two semilunar valves, the other being the pulmonary valve. The ...
. Their main purpose is to keep blood flowing in the proper direction through the heart, and from the heart into the major blood vessels connected to it (the
pulmonary artery
A pulmonary artery is an artery in the pulmonary circulation that carries deoxygenated blood from the right side of the heart to the lungs. The largest pulmonary artery is the ''main pulmonary artery'' or ''pulmonary trunk'' from the heart, and t ...
and the
aorta
The aorta ( ) is the main and largest artery in the human body, originating from the left ventricle of the heart and extending down to the abdomen, where it splits into two smaller arteries (the common iliac arteries). The aorta distributes ...
). Heart valves can malfunction for a variety of reasons, which can impede the flow of blood through the valve (
stenosis
A stenosis (from Ancient Greek στενός, "narrow") is an abnormal narrowing in a blood vessel or other tubular organ or structure such as foramina and canals. It is also sometimes called a stricture (as in urethral stricture).
''Stricture'' ...
) and/or let blood flow backwards through the valve (
regurgitation). Both processes put strain on the heart and may lead to serious problems, including
heart failure
Heart failure (HF), also known as congestive heart failure (CHF), is a syndrome, a group of signs and symptoms caused by an impairment of the heart's blood pumping function. Symptoms typically include shortness of breath, excessive fatigue, a ...
. While some dysfunctional valves can be treated with drugs or repaired, others need to be replaced with an artificial valve.
Background
![3D Medical Animation still shot Artificial Heart Valve](https://upload.wikimedia.org/wikipedia/commons/4/4a/3D_Medical_Animation_still_shot_Artificial_Heart_Valve.jpg)
A heart contains four valves (tricuspid, pulmonary, mitral and aortic valves) which open and close as blood passes through the heart. Blood enters the heart in the right atrium and passes through the
tricuspid valve
The tricuspid valve, or right atrioventricular valve, is on the right dorsal side of the mammalian heart, at the superior portion of the right ventricle. The function of the valve is to allow blood to flow from the right atrium to the right vent ...
to the right ventricle. From there, blood is pumped through the
pulmonary valve
The pulmonary valve (sometimes referred to as the pulmonic valve) is a valve of the heart that lies between the right ventricle and the pulmonary artery and has three cusps. It is one of the four valves of the heart and one of the two semilunar va ...
to enter the lungs. After being oxygenated, blood passes to the left atrium, where is it pumped through the
mitral valve
The mitral valve (), also known as the bicuspid valve or left atrioventricular valve, is one of the four heart valves. It has two cusps or flaps and lies between the left atrium and the left ventricle of the heart. The heart valves are all one-w ...
to the left ventricle. The left ventricle pumps blood to the aorta through the
aortic valve
The aortic valve is a valve in the heart of humans and most other animals, located between the left ventricle and the aorta. It is one of the four valves of the heart and one of the two semilunar valves, the other being the pulmonary valve. The ...
.
There are many potential causes of heart valve damage, such as birth defects, age related changes, and effects from other disorders, such as rheumatic fever and infections causing
endocarditis
Endocarditis is an inflammation of the inner layer of the heart, the endocardium. It usually involves the heart valves. Other structures that may be involved include the interventricular septum, the chordae tendineae, the mural endocardium, or the ...
.
High blood pressure
Hypertension (HTN or HT), also known as high blood pressure (HBP), is a long-term medical condition in which the blood pressure in the arteries is persistently elevated. High blood pressure usually does not cause symptoms. Long-term high bl ...
and heart failure which can enlarge the heart and arteries, and scar tissue can form after a
heart attack
A myocardial infarction (MI), commonly known as a heart attack, occurs when blood flow decreases or stops to the coronary artery of the heart, causing damage to the heart muscle. The most common symptom is chest pain or discomfort which may tr ...
or injury.
The three main types of artificial heart valves are mechanical, biological (bioprosthetic/tissue), and tissue-engineered valves. In the US, UK and the European Union, the most common type of artificial heart valve is the bioprosthetic valve. Mechanical valves are more commonly used in Asia and Latin America. Companies that manufacture heart valves include Edwards Lifesciences, Medtronic, Abbott (St. Jude Medical), CryoLife, and LifeNet Health.
Mechanical valves
Mechanical valves come in three main types – caged ball, tilting-disc and bileaflet – with various modifications on these designs.
Caged ball valves are no longer implanted.
Bileaflet valves are the most common type of mechanical valve implanted in patients today.
Caged ball valves
The first artificial heart valve was the caged ball valve, a type of
ball check valve, in which a ball is housed inside a cage. When the heart contracts and the blood pressure in the chamber of the heart exceeds the pressure on the outside of the chamber, the ball is pushed against the cage and allows blood to flow. When the heart finishes contracting, the pressure inside the chamber drops and the ball moves back against the base of the valve forming a seal.
In 1952,
Charles A. Hufnagel
Charles A. Hufnagel, M.D. (August 15, 1916 – May 31, 1989) was an American surgeon who invented the first artificial heart valve in the early 1950s.
Hufnagel was born in Louisville, Kentucky and reared in Richmond, Indiana. His father w ...
implanted caged ball heart valves into ten patients (six of whom survived the operation), marking the first success in prosthetic heart valves. A similar valve was invented by Miles 'Lowell' Edwards and
Albert Starr
Albert Starr (born June 1, 1926, in New York, New York) is an American cardiovascular surgeon, inventor of the Starr heart valve. Starr resides and practices in the Portland, Oregon area and is special adviser to OHSU Dean of Medicine Mark Richard ...
in 1960, commonly referred to as the Starr-Edwards silastic ball valve.
This consisted of a silicone ball enclosed in a
methyl metacrylate cage welded to a ring. The Starr-Edwards valve was first implanted in a human on August 25, 1960, and was discontinued by Edwards Lifesciences in 2007.
Caged ball valves are strongly associated with blood clot formation, so people who have one required a high degree of
anticoagulation
Anticoagulants, commonly known as blood thinners, are chemical substances that prevent or reduce coagulation of blood, prolonging the clotting time. Some of them occur naturally in blood-eating animals such as leeches and mosquitoes, where the ...
, usually with a target
INR of 3.0–4.5.
Tilting-disc valves
![Chitra Valve](https://upload.wikimedia.org/wikipedia/commons/5/56/Chitra_Valve.jpg)
Introduced in 1969, the first clinically available tilting-disc valve was the
Bjork-Shiley valve. Tilting‑disc valves, a type of
swing check valve, are made of a metal ring covered by an
ePTFE
Polytetrafluoroethylene (PTFE) is a synthetic fluoropolymer of tetrafluoroethylene that has numerous applications. It is one of the best-known and widely applied PFAS. The commonly known brand name of PTFE-based composition is Teflon by Chemour ...
fabric. The metal ring holds, by means of two metal supports, a disc that opens when the heart beats to let blood flow through, then closes again to prevent blood flowing backwards. The disc is usually made of an extremely hard carbon material (
pyrolytic carbon
Pyrolytic carbon is a material similar to graphite, but with some covalent bonding between its graphene sheets as a result of imperfections in its production.
Pyrolytic carbon is man-made and is thought not to be found in nature.Ratner, Buddy D. ...
), enabling the valve to function for years without wearing out.
Bileaflet valves
![Aortic Karboniks-1 bileafter prosthetic heart valve](https://upload.wikimedia.org/wikipedia/commons/1/17/Aortic_Karboniks-1_bileafter_prosthetic_heart_valve.jpg)
Introduced in 1979, bileaflet valves are made of two semicircular leaflets that revolve around struts attached to the valve housing. With a larger opening than caged ball or tilting-disc valves, they carry a lower risk of blood clots. They are, however, vulnerable to blood backflow.
Advantages of mechanical valves
The major advantage of mechanical valves over bioprosthetic valves is their greater durability.
Made from metal and/or
pyrolytic carbon
Pyrolytic carbon is a material similar to graphite, but with some covalent bonding between its graphene sheets as a result of imperfections in its production.
Pyrolytic carbon is man-made and is thought not to be found in nature.Ratner, Buddy D. ...
,
they can last 20–30 years.
Disadvantages of mechanical valves
One of the major drawbacks of mechanical heart valves is that they are associated with an increased risk of
blood clots
A thrombus (plural thrombi), colloquially called a blood clot, is the final product of the blood coagulation step in hemostasis. There are two components to a thrombus: aggregated platelets and red blood cells that form a plug, and a mesh of cr ...
. Clots formed by red blood cell and platelet damage can block blood vessels leading to
stroke
A stroke is a medical condition in which poor blood flow to the brain causes cell death. There are two main types of stroke: ischemic, due to lack of blood flow, and hemorrhagic, due to bleeding. Both cause parts of the brain to stop functionin ...
. People with mechanical valves need to take anticoagulants (blood thinners), such as
warfarin
Warfarin, sold under the brand name Coumadin among others, is a medication that is used as an anticoagulant (blood thinner). It is commonly used to prevent blood clots such as deep vein thrombosis and pulmonary embolism, and to prevent strok ...
, for the rest of their life.
Mechanical heart valves can also cause
mechanical hemolytic anemia
Mechanical hemolytic anemia is a form of hemolytic anemia due to mechanically induced damage to red blood cells. Red blood cells, while flexible, may in some circumstances succumb to physical shear and compression.Dan L. Longo, ''Harrison's Hematol ...
, a condition where the
red blood cell
Red blood cells (RBCs), also referred to as red cells, red blood corpuscles (in humans or other animals not having nucleus in red blood cells), haematids, erythroid cells or erythrocytes (from Greek ''erythros'' for "red" and ''kytos'' for "holl ...
s are damaged as they pass through the valve.
Cavitation
Cavitation is a phenomenon in which the static pressure of a liquid reduces to below the liquid's vapour pressure, leading to the formation of small vapor-filled cavities in the liquid. When subjected to higher pressure, these cavities, cal ...
, the rapid formation of microbubbles in a fluid such as blood due to a localized drop of pressure, can lead to mechanical heart valve failure, so cavitation testing is an essential part of the valve design verification process.
Many of the complications associated with mechanical heart valves can be explained through
fluid mechanics
Fluid mechanics is the branch of physics concerned with the mechanics of fluids ( liquids, gases, and plasmas) and the forces on them.
It has applications in a wide range of disciplines, including mechanical, aerospace, civil, chemical and bio ...
. For example, blood clot formation is a side effect of high shear stresses created by the design of the valves. From an engineering perspective, an ideal heart valve would produce minimal pressure drops, have small regurgitation volumes, minimize turbulence, reduce prevalence of high stresses, and not create flow separations in the vicinity of the valve.
Implanted mechanical valves can cause foreign body rejection. The blood may coagulate and eventually result in a hemostasis. The usage of anticoagulation drugs will be interminable to prevent thrombosis.
Bioprosthetic tissue valves
Bioprosthetic valves are usually made from animal tissue (heterograft/
xenograft
Xenotransplantation (''xenos-'' from the Greek meaning "foreign" or strange), or heterologous transplant, is the transplantation of living cells, tissues or organs from one species to another. Such cells, tissues or organs are called xenograft ...
) attached to a metal or polymer support.
Bovine (cow) tissue is most commonly used, but some are made from porcine (pig) tissue. The tissue is treated to prevent rejection and
calcification
Calcification is the accumulation of calcium salts in a body tissue. It normally occurs in the formation of bone, but calcium can be deposited abnormally in soft tissue,Miller, J. D. Cardiovascular calcification: Orbicular origins. ''Nature Mat ...
.
Alternatives to animal tissue valves are sometimes used, where valves are used from human donors, as in aortic
homograft
Allotransplant (''allo-'' meaning "other" in Greek) is the transplantation of cells, tissues, or organs to a recipient from a genetically non-identical donor of the same species. The transplant is called an allograft, allogeneic transplant, o ...
s and pulmonary
autograft
Autotransplantation is the transplantation of organs, tissues, or even particular proteins from one part of the body to another in the same person ('' auto-'' meaning "self" in Greek).
The autologous tissue (also called autogenous, autogene ...
s. An aortic homograft is an aortic valve from a human donor, retrieved either after their death or from a heart that is removed to be replaced during a heart transplant.
A pulmonary autograft, also known as the
Ross procedure
The Ross procedure, also known as pulmonary autograft, is a heart valve replacement operation to treat severe aortic valve disease, such as in children and young adults with a bicuspid aortic valve. It involves removing the diseased aortic valv ...
, is where the aortic valve is removed and replaced with the patient's own
pulmonary valve
The pulmonary valve (sometimes referred to as the pulmonic valve) is a valve of the heart that lies between the right ventricle and the pulmonary artery and has three cusps. It is one of the four valves of the heart and one of the two semilunar va ...
(the valve between the right ventricle and the pulmonary artery). A pulmonary homograft (a pulmonary valve taken from a cadaver) is then used to replace the patient's own pulmonary valve. This procedure was first performed in 1967 and is used primarily in children, as it allows the patient's own pulmonary valve (now in the aortic position) to grow with the child.
Advantages of bioprosthetic heart valves
Bioprosthetic valves are less likely than mechanical valves to cause blood clots, so do not require lifelong anticoagulation. As a result, people with bioprosthetic valves have a lower risk of bleeding that those with mechanical valves.
Disadvantages of bioprosthetic heart valves
Tissue valves are less durable than mechanical valves, typically lasting 10–20 years. This means that people with bioprosthetic valves have a higher incidence of requiring another aortic valve replacement in their lifetime.
Bioprosthetic valves tend to deteriorate more quickly in younger patients.
In recent years, scientists have developed a new tissue preservation technology, with the aim of improving the durability of bioprosthetic valves. In sheep and rabbit studies, tissue preserved using this new technology had less
calcification
Calcification is the accumulation of calcium salts in a body tissue. It normally occurs in the formation of bone, but calcium can be deposited abnormally in soft tissue,Miller, J. D. Cardiovascular calcification: Orbicular origins. ''Nature Mat ...
than control tissue. A valve containing this tissue is now marketed, but long-term durability data in patients are not yet available.
Current bioprosthetic valves lack longevity, and will calcify over time.
When a valve calcifies, the valve cusps become stiff and thick and cannot close completely.
Moreover, bioprosthetic valves can't grow with or adapt to the patient: if a child has bioprosthetic valves they will need to get the valves replaced several times to fit their physical growth.
Tissue-engineered valves
For over 30 years researchers have been trying to grow heart valves ''in vitro''.
These tissue‑engineered valves involve seeding human cells on to a scaffold.
The two main types of scaffold are natural scaffolds, such as decellularized tissue, or scaffolds made from degradable polymers.
The scaffold acts as an
extracellular matrix
In biology, the extracellular matrix (ECM), also called intercellular matrix, is a three-dimensional network consisting of extracellular macromolecules and minerals, such as collagen, enzymes, glycoproteins and hydroxyapatite that provide stru ...
, guiding tissue growth into the correct 3D structure of the heart valve.
Some tissue-engineered heart valves have been tested in clinical trials,
but none are commercially available.
Tissue engineered heart valves can be person-specific and 3D modeled to fit an individual recipient
3D printing is used because of its high accuracy and precision of dealing with different biomaterials.
Cells that are used for tissue engineered heart valves are expected to secrete the extracellular matrix (ECM).
Extracellular matrix provides support to maintain the shape of the valves and determines the cell activities.
Scientists can follow the structure of heart valves to produce something that looks similar to them, but since tissue engineered valves lack the natural cellular basis, they either fail to perform their functions like natural heart valves, or function when they are implanted but gradually degrade over time. An ideal tissue engineered heart valve would be non‐thrombogenic, biocompatible, durable, resistant to calcification, grow with the surrounding heart, and exhibit a physiological hemodynamic profile.
To achieve these goals, the scaffold should be carefully chosen—there are three main candidates: decellularized ECM (xenografts or homografts), natural polymers, and synthetic polymers.
Differences between mechanical and tissue valves
Mechanical and tissue valves are made of different materials. Mechanical valves are generally made of titanium and carbon.
Tissue valves are made up of human or animal tissue. The valves composed of human tissue, known as allografts or homografts, are from donors' human hearts.
Mechanical valves can be a better choice for younger people and people at risk of valve deterioration due to its durability. It is also preferable for people who are already taking blood thinners and people who would be unlikely to tolerate another valve replacement operation.
Tissue valves are better for older age groups as another valve replacement operation may not be needed in their lifetime. Due to the risk of forming blood clots for mechanical valves and severe bleeding as a major side effect of taking blood-thinning medications, people who have a risk of blood bleeding and are not willing to take warfarin may also consider tissue valves. Other patients who may be more suitable for tissue valves are people who have other planned surgeries and unable to take blood-thinning medications. People who plan to become pregnant may also consider tissue valves as warfarin causes risks in pregnancy.
Functional requirements of artificial heart valves
An artificial heart valve should ideally function like a natural heart valve.
The functioning of natural heart valves is characterized by many advantages:
* Minimal
regurgitation – This means that the amount of
blood
Blood is a body fluid in the circulatory system of humans and other vertebrates that delivers necessary substances such as nutrients and oxygen to the cells, and transports metabolic waste products away from those same cells. Blood in the c ...
leaking backwards through the valve as it closes is small. Some degree of valvular regurgitation is inevitable and natural, up to around 5 ml per beat. However, several heart valve pathologies (e.g. rheumatic
endocarditis
Endocarditis is an inflammation of the inner layer of the heart, the endocardium. It usually involves the heart valves. Other structures that may be involved include the interventricular septum, the chordae tendineae, the mural endocardium, or the ...
) may lead to clinically significant valvular regurgitation. A desirable characteristic of heart valve prostheses is that regurgitation is minimal over the full range of
physiological
Physiology (; ) is the scientific study of functions and mechanisms in a living system. As a sub-discipline of biology, physiology focuses on how organisms, organ systems, individual organs, cells, and biomolecules carry out the chemical ...
heart function.
* Minimal transvalvular pressure gradient – Whenever a
fluid
In physics, a fluid is a liquid, gas, or other material that continuously deforms (''flows'') under an applied shear stress, or external force. They have zero shear modulus, or, in simpler terms, are substances which cannot resist any shear ...
flows through a restriction, such as a valve, a
pressure
Pressure (symbol: ''p'' or ''P'') is the force applied perpendicular to the surface of an object per unit area over which that force is distributed. Gauge pressure (also spelled ''gage'' pressure)The preferred spelling varies by country and e ...
gradient
In vector calculus, the gradient of a scalar-valued differentiable function of several variables is the vector field (or vector-valued function) \nabla f whose value at a point p is the "direction and rate of fastest increase". If the gradi ...
arises over the restriction. This pressure gradient is a result of the increased resistance to flow through the restriction. Natural heart valves have a low transvalvular pressure gradient as they present little obstruction to the flow through themselves, normally less than 16 mmHg. A desirable characteristic of heart valve prostheses is that their transvalvular pressure gradient is as small as possible.
* Non-
thrombogenic – Natural heart valves are lined with an
endothelium
The endothelium is a single layer of squamous endothelial cells that line the interior surface of blood vessels and lymphatic vessels. The endothelium forms an interface between circulating blood or lymph in the lumen and the rest of the vessel ...
comparable with the endothelium lining the heart chambers, so they are not normally thrombogenic (i.e. they don't cause blood clots). Blood clots can be hazardous because they can lodge in, and block, downstream
arteries
An artery (plural arteries) () is a blood vessel in humans and most animals that takes blood away from the heart to one or more parts of the body (tissues, lungs, brain etc.). Most arteries carry oxygenated blood; the two exceptions are the pul ...
(e.g.
coronary arteries
The coronary arteries are the arterial blood vessels of coronary circulation, which transport oxygenated blood to the heart muscle. The heart requires a continuous supply of oxygen to function and survive, much like any other tissue or organ of ...
, leading to heart attack
myocardial_infarction">nowiki/>myocardial_infarction.html" ;"title="myocardial_infarction.html" ;"title="nowiki/>myocardial infarction">nowiki/>myocardial infarction">myocardial_infarction.html" ;"title="nowiki/>myocardial infarction">nowiki/>myocardial infarction or cerebral arteries, leading to
stroke
A stroke is a medical condition in which poor blood flow to the brain causes cell death. There are two main types of stroke: ischemic, due to lack of blood flow, and hemorrhagic, due to bleeding. Both cause parts of the brain to stop functionin ...
). A desirable characteristic of artificial heart valves is that they are non- or minimally thrombogenic.
* Self-repairing – Valve leaflets retain some capacity for repair thanks to regenerative
cells
Cell most often refers to:
* Cell (biology), the functional basic unit of life
Cell may also refer to:
Locations
* Monastic cell, a small room, hut, or cave in which a religious recluse lives, alternatively the small precursor of a monastery w ...
(e.g.
fibroblasts
A fibroblast is a type of biological cell that synthesizes the extracellular matrix and collagen, produces the structural framework ( stroma) for animal tissues, and plays a critical role in wound healing. Fibroblasts are the most common cells o ...
) in the
connective tissue
Connective tissue is one of the four primary types of animal tissue, along with epithelial tissue, muscle tissue, and nervous tissue. It develops from the mesenchyme derived from the mesoderm the middle embryonic germ layer. Connective tiss ...
from which the leaflets are composed. As the human heart beats approximately 3.4×10
9 times during a typical human lifespan, this limited but nevertheless present repair capacity is critically important. No heart valve prostheses can currently self-repair, but tissue-engineered valves may eventually offer such capabilities.
Artificial heart valve repair
Artificial heart valves are expected to last from 10 to 30 years.
The most common problems with artificial heart valves are various forms of degeneration, including gross billowing of leaflets, ischemic mitral valve pathology, and minor chordal lengthening.
The repairing process of the artificial heart valve regurgitation and stenosis usually requires an open-heart surgery, and a repair or partial replacement of regurgitant valves is usually preferred.
Researchers are investigating catheter-based surgery that allows repair of an artificial heart valve without large incisions.
Additional images
File:Blausen 0056 ArtificialHeartValve.png, 3D Rendering of Mechanical Valve
File:Blausen 0057 ArtificialHeartValve StFrancis.png, 3D Rendering of Mechanical Valve (St. Francis model)
See also
*
Artificial heart
An artificial heart is a device that replaces the heart. Artificial hearts are typically used to bridge the time to heart transplantation, or to permanently replace the heart in the case that a heart transplant (from a deceased human or, experi ...
*
Mitral valve replacement
Mitral valve replacement is a procedure whereby the diseased mitral valve of a patient's heart is replaced by either a mechanical or tissue (bioprosthetic) valve.
The mitral valve may need to be replaced because:
* The valve is leaky (mitral val ...
*
Aortic valve replacement
Aortic valve replacement is a procedure whereby the failing aortic valve of a patient's heart is replaced with an artificial heart valve. The aortic valve may need to be replaced because:
* The valve is leaky (aortic insufficiency, also known as ...
References
Further reading
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External links
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