Dynamic in vitro calcification of bioprosthetic porcine valves: Evidence of apatite crystallization Elena Pettenazzo, PhDa, Michael Deiwick, MDb, Gaetano.

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Dynamic in vitro calcification of bioprosthetic porcine valves: Evidence of apatite crystallization Elena Pettenazzo, PhDa, Michael Deiwick, MDb, Gaetano Thiene, MDa, Gianmario Molin, BScc, Birgit Glasmacher, PhDd, Fedora Martignago, BScc, Tomaso Bottio, MDa, Helmut Reul, PhDd, Marialuisa Valente, MDa The Journal of Thoracic and Cardiovascular Surgery Volume 121, Issue 3, Pages 500-509 (March 2001) DOI: 10.1067/mtc.2001.112464 Copyright © 2001 American Association for Thoracic Surgery Terms and Conditions

Fig. 1 Pulsatile accelerated testing device. a, Mounted bioprosthetic on the cylinder; b, test chamber containing the calcification fluid; c, housing; d, bypass; e, choke; f, rotating swash plate with adjustment of plate inclination; α, angle of inclination. The Journal of Thoracic and Cardiovascular Surgery 2001 121, 500-509DOI: (10.1067/mtc.2001.112464) Copyright © 2001 American Association for Thoracic Surgery Terms and Conditions

Fig. 2 Case 4. A, Gross view: diffuse calcium deposition with eggshell cusp fragmentation. B, X-ray view: massive mineralization (score 4). The Journal of Thoracic and Cardiovascular Surgery 2001 121, 500-509DOI: (10.1067/mtc.2001.112464) Copyright © 2001 American Association for Thoracic Surgery Terms and Conditions

Fig. 3 Case 4. A, Cuspal intrinsic calcium deposits at histologic examination. (Von Kossa stain; original magnification, 12×.) B, Higher magnification of A. (Von Kossa stain; original magnification, 36×.) C, Calcium deposits in the aortic wall tunica media. (Von Kossa stain; original magnification, 36×.) D, Higher magnification of C. Calcification involves smooth muscle cells. (Von Kossa stain; original magnification, 240×.) The Journal of Thoracic and Cardiovascular Surgery 2001 121, 500-509DOI: (10.1067/mtc.2001.112464) Copyright © 2001 American Association for Thoracic Surgery Terms and Conditions

Fig. 4 Case 3. TEM with calcification involving collagen fibers. Note the plate-like features. (Original magnification, 24,000×.) The Journal of Thoracic and Cardiovascular Surgery 2001 121, 500-509DOI: (10.1067/mtc.2001.112464) Copyright © 2001 American Association for Thoracic Surgery Terms and Conditions

Fig. 5 Case 1. A, XRPD (CuKα1,2) patterns of an in vitro tested sample in the 2θ range of 24° to 55°. Step-by-step data collection is shown, with a step width of 0.02° and a counting time of 2 seconds per step. The presence of the peaks is consistent with apatite. B, At scanning electron microscopy, platelike aggregates up to 8 μm in size are clearly visible. The aggregates reveal a tabular hexagonal shape consistent with crystals of apatite. (Original magnification, 30,000×.) The Journal of Thoracic and Cardiovascular Surgery 2001 121, 500-509DOI: (10.1067/mtc.2001.112464) Copyright © 2001 American Association for Thoracic Surgery Terms and Conditions

Fig. 6 St Jude Medical Bioimplant xenograft in place in human mitral position for 84 months. A, Gross view of the inflow surface with coarse calcification. B, Score 4 calcification at x-ray examination. C, Intrinsic calcification at histology. (Von Kossa stain; original magnification, 12×.) D, Close up of C. (Von Kossa stain; original magnification, 36×.) The Journal of Thoracic and Cardiovascular Surgery 2001 121, 500-509DOI: (10.1067/mtc.2001.112464) Copyright © 2001 American Association for Thoracic Surgery Terms and Conditions

Fig. 7 TEM of the same human porcine xenograft shown in Fig 6. Note calcification mostly involving collagen fibers. (Original magnification, 24,000×.) The Journal of Thoracic and Cardiovascular Surgery 2001 121, 500-509DOI: (10.1067/mtc.2001.112464) Copyright © 2001 American Association for Thoracic Surgery Terms and Conditions

Fig. 8 XRPD (CuKα1,2) patterns (2θ range, 24°-55°) of the same human porcine xenograft as shown in Fig 6. Step-by-step data collection is shown, with a step width of 0.02° and a counting time of 2 seconds per step. The presence of the sharp peaks is consistent with massive well-crystallized apatite. The Journal of Thoracic and Cardiovascular Surgery 2001 121, 500-509DOI: (10.1067/mtc.2001.112464) Copyright © 2001 American Association for Thoracic Surgery Terms and Conditions