Bioprosthetic Valves

Key Points

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Most bioprostheses can be identified on and localized by chest radiography. The lateral chest radiograph often assists with obviating the projection of a bioprosthesis onto the spine, particularly in large hearts, which otherwise diminishes the depiction of a bioprosthesis on the frontal radiograph.
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The appearance of bioprostheses varies depending on the amount and design of radiopaque elements (stent wires and rings) within them. Not all bioprostheses contain radiopaque material, and therefore some bioprostheses are not apparent on the chest radiograph.

Bioprostheses

Bioprostheses may be inserted into any cardiac valve position (aortic, mitral, tricuspid, and pulmonic), and may also be included within extracardiac conduits (usually from the right ventricle to the pulmonary artery) ( Table 10-1 ). Most, but not all, bioprostheses contain a network of wires, the stents, that provide support to the commissures of the porcine aortic valve or of the constructed aortic valve made of pericardial tissue. Wire stents are radiographically evident ( Fig. 10-1 ). However, some bioprostheses contain plastic stents that are not radiopaque, and other models of bioprosthetic valves (the Toronto Stentless Porcine valve and the Medtronic Freestyle valve) are essentially preserved porcine aortic valves and roots, and they contain absolutely no radiopaque material. The Medtronic Solo valve is also radiographically inapparent.

TABLE 10-1

Bioprosthetic Heart Valves

ValVe	Leaflet Material	Stents	Ring/Sewing Ring
Sorin
MORE	Pericardial tissue	Polymer stents; low profile; radiopaque wire marker	Nonradiopaque polyester sewing ring/supra-annular
Pericarbon Freedom (stentless)	Pericardial tissue	Stentless	No sewing ring or mesh
Freedom Solo (stentless)	Pericardial tissue	Stentless	NA
Soprano	Pericardial tissue	Nonradiopaque polymer stents	Sewing cloth; no ring
Mitroflow	Pericardial tissue	Radiopaque polymer stents	Radiopaque (tungsten-impregnated silicone ring)
Medtronic
Mosaic	Porcine aortic valve	Nonradiopaque polymer stent; low profile	Nonradiopaque sewing ring/supra-annular
Mosaic Ultra	Porcine aortic valve	Nonradiopaque polymer stent; low profile	Nonradiopaque sewing ring/supra-annular
Freestyle Stentless	Porcine aortic valve and root	Stentless	Nonradiopaque/sewing cuff, not sewing ring
Hancock II	Porcine aortic valve	Nonradiopaque polymer stent; low profile	Nonradiopaque sewing ring/supra-annular
Advantage
Melody	Bovine jugular stented, percutaneous pulmonic valve replacement, “Bonnhoeffer”	Stented	NA
	Supported and non-supported	NA	NA
VenPro Contegra (unsupported)	Bovine jugular vein valve conduit	Stentless	NA
VenPro Contegra (supported)	Bovine jugular vein valve conduit	Stentless	With two plastic rings— sometimes seen on fluoroscopy; seldom seen on chest radiography
Carpentier-Edwards
Perimount (aortic and mitral bioprostheses)	Bovine pericardial tissue	Radiopaque wire (Elgiloy) stent frame	Sewing ring is not radiopaque; partially supra-annular position slightly increases available orifice
Perimount Magna (aortic bioprosthesis)	Bovine pericardial tissue; different fixation/ preservation technique	Radiopaque wire (Elgiloy) stent frame	Redesigned Perimount valve, fully supra-annular/sewing ring is not radiopaque
Perimount Magna (mitral bioprosthesis)	Bovine pericardial tissue; different fixation/ preservation technique	Radiopaque wire (Elgiloy) stent frame	Redesigned Perimount valve; saddle-shaped ring/sewing ring is not radiopaque
Perimount Plus (mitral bioprosthesis)	Different fixation/ preservation technique	Radiopaque wire (Elgiloy) stent frame	Redesigned Perimount valve/sewing ring is not radiopaque
Perimount Theon (mitral replacement)	Different fixation/ preservation technique	Radiopaque wire (Elgiloy) stent frame	Redesigned Perimount valve/sewing ring is not radiopaque
S.A.V.	Porcine aortic valve	Radiopaque wire (Elgiloy) stent frame; low profile	Sewing ring is not radiopaque; supra-annular position increases available orifice
Duraflex Low-Pressure	Porcine aortic valve; asymmetric orifice (includes muscle shelf); low-pressure fixation to lessen stiffening of leaflets	Radiopaque wire (Elgiloy) stent frame	Larger sewing ring to fit the mitral orifice
Prima Plus (stentless porcine prosthesis)	Porcine aortic valve and root	No stent frame	No separate sewing ring
BioPhysio (pericardial aortic bioprosthesis)	Bovine pericardial tissue	Radiopaque wire (Nitinol) stent frame	Supra-annular position; nonradiopaque silicone sewing ring
St. Jude Medical Biocor
Porcine (bioprosthesis)	Porcine aortic valve	Nonradiopaque plastic stents	Nonradiopaque (polyester) sewing ring
Supra Porcine (bioprosthesis)	Porcine aortic valve	Nonradiopaque plastic stents	Nonradiopaque (polyester) sewing ring; supra-annular position
Epic Porcine (bioprosthesis)	Porcine aortic valve	Nonradiopaque plastic stents; low profile	Nonradiopaque (polyester) sewing ring
Epic Supra Porcine (bioprosthesis)	Porcine aortic valve	Nonradiopaque plastic stents; low profile	Nonradiopaque (polyester) sewing ring; supra-annular position
Toronto (stentless porcine bioprosthesis)	Porcine aortic valve and root	NA	Nonradiopaque sewing mesh, not sewing ring; subcoronary
Toronto (stentless root porcine bioprosthesis)	Porcine aortic valve and root	NA	Nonradiopaque sewing mesh, not sewing ring
Biocor	Bovine pericardial tissue	Nonradiopaque plastic stents	Nonradiopaque (polyester) sewing ring; supra-annular position
Biocor Stentless	Composite porcine aortic valve/pericardial conduit mount	Stentless	NA
Trifecta	Pericardial tissue	Stents	Sewing ring; supra-annular position
Others
CryoValve aortic valve/conduit	Human cadaveric	Stentless	No sewing ring or mesh
CryoValve pulmonary valve/conduit	Human cadaveric	Stentless	No sewing ring or mesh
CryoValve mitral valve	Human cadaveric	Stentless	No sewing ring or mesh
Cryolife-O’Brien (stentless)	Porcine aortic valve	Stentless	No sewing ring or mesh
Shelhigh Skeletonized Super-Stentless	Porcine aortic valve	Stentless	NA
Shelhigh Skeletonized Super-Stentless	Porcine aortic valve	Stentless	NA
Shelhigh BioMitral	Porcine mitral valve	NA	NA
Shelhigh porcine pulmonic valve conduit	Porcine pulmonic valve and conduit	NA	NA
Koehler Aspire porcine bioprosthesis	Porcine aortic valve	NA	NA
Koehler Elan stentless porcine aortic valve	Porcine aortic valve	Stentless	No sewing ring or mesh
Koehler Elan stentless porcine root prosthesis	Porcine aortic valve and root	Stentless	Sewing mesh