Prevention of Calcification of Bioprosthetic Heart Valve Cusp and Aortic Wall With Ethanol and Aluminum Chloride Jocelyn N. Clark, PhD, Matthew F. Ogle,

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Prevention of Calcification of Bioprosthetic Heart Valve Cusp and Aortic Wall With Ethanol and Aluminum Chloride Jocelyn N. Clark, PhD, Matthew F. Ogle, BS, Paul Ashworth, BS, Richard W. Bianco, BS, Robert J. Levy, MD The Annals of Thoracic Surgery Volume 79, Issue 3, Pages 897-904 (March 2005) DOI: 10.1016/j.athoracsur.2004.08.084 Copyright © 2005 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 Inhibition of bioprosthetic heart valve calcification by ethanol-aluminum chloride. Gross pathology photographs of bioprosthetic sheep explants with the valves in situ. (A) group 1 (Carpentier-Edwards control), (B) group 2 (St. Jude Toronto stentless porcine valve control), and (C) group 3A (45 minute aluminum chloride treatment) of inflow photographs. Arrows denote calcium phosphate deposits. The Annals of Thoracic Surgery 2005 79, 897-904DOI: (10.1016/j.athoracsur.2004.08.084) Copyright © 2005 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 Roentgenogram analysis showing inhibition of calcification in bioprosthetic heart valves (sheep explants). (A) group 1 (Carpentier-Edwards control), (B) group 2 (St. Jude Toronto stentless porcine valve control), (C) group 3A (45 minute aluminum chloride treatment), and (D) group 3B (6 hours aluminum chloride treatment) radiographs. Arrows denote calcification, notably absent in (C). The Annals of Thoracic Surgery 2005 79, 897-904DOI: (10.1016/j.athoracsur.2004.08.084) Copyright © 2005 The Society of Thoracic Surgeons Terms and Conditions

Fig 3 Calcium and phosphorus content (mg/g of dry tissue) in bioprosthetic cusps of group 1 (Carpentier-Edwards control), group 2 (Toronto stentless porcine valve control), group 3A (45 minute aluminum chloride treatment), group 3B (6 hours aluminum chloride treatment), and group 3C (8 hours aluminum chloride treatment). Data represented as mean ± standard error. a,bp less than 0.001 compared to groups 2 and 3B, respectively. □ = calcium; ▨ = phosphorus. The Annals of Thoracic Surgery 2005 79, 897-904DOI: (10.1016/j.athoracsur.2004.08.084) Copyright © 2005 The Society of Thoracic Surgeons Terms and Conditions

Fig 4 Von Kossa staining of bioprosthetic cusps for (A) group 3A (original magnification ×100) and (B) early death of group 3B at day 64 with calcification staining red (original magnification ×100). The Annals of Thoracic Surgery 2005 79, 897-904DOI: (10.1016/j.athoracsur.2004.08.084) Copyright © 2005 The Society of Thoracic Surgeons Terms and Conditions

Fig 5 Calcium and phosphorus content (mg/g of dry tissue) in bioprosthetic aortic walls (sheep explants) of group 1 (Carpentier-Edwards control), group 2 (Toronto stentless porcine valve control), group 3A (45 minute aluminum chloride treatment), group 3B (6 hours aluminum chloride treatment), and group 3C (8 hours aluminum chloride treatment). Data represented as mean ± standard error. a,bp less than 0.001 compared to groups 1 and 2, respectively, and cp = 0.02 compared to group 1. □ = calcium; ▨ = phosphorus. The Annals of Thoracic Surgery 2005 79, 897-904DOI: (10.1016/j.athoracsur.2004.08.084) Copyright © 2005 The Society of Thoracic Surgeons Terms and Conditions

Fig 6 Von Kossa calcification staining (red) in bioprosthetic aortic walls for (A) group 2 (original magnification ×100) and (B) group 3A (original magnification ×100). The Annals of Thoracic Surgery 2005 79, 897-904DOI: (10.1016/j.athoracsur.2004.08.084) Copyright © 2005 The Society of Thoracic Surgeons Terms and Conditions

Fig 7 Aluminum content (mg/g of dry tissue) in bioprosthetic cusps of group 1 (Carpentier-Edwards control), group 2 (Toronto stentless porcine valve control), group 3A (45 minute aluminum chloride treatment), group 3B (6 hours aluminum chloride treatment), and group 3C (8 hours aluminum chloride treatment). Data represented as mean ± standard error. The Annals of Thoracic Surgery 2005 79, 897-904DOI: (10.1016/j.athoracsur.2004.08.084) Copyright © 2005 The Society of Thoracic Surgeons Terms and Conditions

Fig 8 Aluminum content (mg/g of dry tissue) in bioprosthetic aortic walls of group 1 (Carpentier-Edwards control), group 2 (Toronto stentless porcine valve control), group 3A (45 minute aluminum chloride treatment), group 3B (6 hours aluminum chloride treatment), and group 3C (8 hours aluminum chloride treatment). Data represented as mean ± standard error. ap less than 0.001 compared to group 1, bp less than 0.001 compared to group 2, cp less than 0.001 compared to group 3A. The Annals of Thoracic Surgery 2005 79, 897-904DOI: (10.1016/j.athoracsur.2004.08.084) Copyright © 2005 The Society of Thoracic Surgeons Terms and Conditions

Fig 9 Aluminum levels (parts per billion, ppb, or ng/mL) in serum of group 3A (45 minute aluminum chloride treatment), group 3B (6 hours aluminum chloride treatment), and group 3C (8 hours aluminum chloride treatment). Data represent mean ± standard error. Preimplant (Preimp), control (cont), and sacrifice (sac) notations represent samples taken approximately 2 weeks before surgery, on the day of surgery, and the day of sacrifice, respectively. □ = 45 minutes; ▨ = 6 hours; ■ = 8 hours. The Annals of Thoracic Surgery 2005 79, 897-904DOI: (10.1016/j.athoracsur.2004.08.084) Copyright © 2005 The Society of Thoracic Surgeons Terms and Conditions