Heart valves

A heart valve normally allows blood to flow through it in only one direction. There
are four in a mammalian heart and they determine the pathway of blood flow through
the heart. A heart valve opens or closes depending on the different pressures on each
side of it.

The four valves in the heart are:

 The two atrioventricular (AV) valves, which are between the atria and the
ventricles, are the mitral valve and the tricuspid valve.
 The two semilunar (SL) valves, which are in the arteries leaving the heart, are
the aortic valve and the pulmonary valve.

A form of heart disease occurs when a valve malfunctions and allows some blood to
flow in the wrong direction. This is called regurgitation.

Atrioventricular valves

These are small valves that prevent backflow from the ventricles into the atrium
during systole. They are anchored to the wall of the ventricle by chordae tendineae,
which prevent the valve from inverting.

The chordae tendineae are attached to papillary muscles that cause tension to better
hold the valve. Together, the papillary muscles and the chordae tendineae are known
as the subvalvular apparatus. The function of the subvalvular apparatus is to keep the
valves from prolapsing into the atria when they close. The subvalvular apparatus have
no effect on the opening and closure of the valves, however. This is caused entirely by
the pressure gradient across the valve.

The closure of the AV valves is heard as the first heart sound (S1).

Mitral valve

Also known as the "bicuspid valve" contains two flaps. The mitral valve gets its name
from the resemblance to a bishop's mitre (a type of hat). It allows the blood to flow
from the left atrium into the left ventricle. It is on the left side of the heart and has two
cusps.

A common complication of rheumatic fever is thickening and stenosis of the mitral

valve.
Tricuspid valve

The tricuspid valve is the three-flapped valve on the right side of the heart, between
the right atrium and the right ventricle which stops the backflow of blood between the
two. It has three cusps

Semilunar valves

These are located at the base of both the pulmonary trunk (pulmonary artery) and the
aorta, the two arteries taking blood out of the ventricles. These valves permit blood to
be forced into the arteries, but prevent backflow of blood from the arteries into the
ventricles. These valves do not have chordae tendineae, and are more similar to valves
in veins than atrioventricular valves.

Aortic valve

The aortic valve lies between the left ventricle and the aorta. The aortic valve has three
cusps. During ventricular systole, pressure rises in the left ventricle. When the
pressure in the left ventricle rises above the pressure in the aorta, the aortic valve
opens, allowing blood to exit the left ventricle into the aorta. When ventricular systole
ends, pressure in the left ventricle rapidly drops. When the pressure in the left
ventricle decreases, the aortic pressure forces the aortic valve to close. The closure of
the aortic valve contributes the A2 component of the second heart sound (S2).

The most common congenital abnormality of the heart is the bicuspid aortic valve. In
this condition, instead of three cusps, the aortic valve has two cusps. This condition is
often undiagnosed until the person develops calcific aortic stenosis. Aortic stenosis
occurs in this condition usually in patients in their 40s or 50s, an average of over 10
years earlier than in people with normal aortic valves.

Pulmonary valve

The pulmonary valve (sometimes referred to as the pulmonic valve) is the semilunar
valve of the heart that lies between the right ventricle and the pulmonary artery and
has three cusps. Similar to the aortic valve, the pulmonary valve opens in ventricular
systole, when the pressure in the right ventricle rises above the pressure in the
pulmonary artery. At the end of ventricular systole, when the pressure in the right
ventricle falls rapidly, the pressure in the pulmonary artery will close the pulmonary
valve.

The closure of the pulmonary valve contributes the P2 component of the second heart
sound (S2). The right heart is a low-pressure system, so the P2 component of the
second heart sound is usually softer than the A2 component of the second heart sound.
However, it is physiologically normal in some young people to hear both components
separated during inhalation.

Power of a Human Heart

Under normal conditions, the heart beats 75 times per minute, delivering about 5 liters
per minute, but its flow can be five times greater under extreme conditions. The peak
blood pressure in the heart is about one-sixth of an atmosphere, and the heart
develops about two watts of mechanical power."

For instance, we can compute the power output of the heart as the product of the
pressure times the flow (volume per unit time). If you have six liters of blood and it
circulates every minute, the flow rate is 100 cm3/s. If the pressure averages
133,000 dynes/cm2 (ignoring pulsatile flow), then the average power output is
13,300,000 ergs/s or 1.33 watts. This may not seem like much, but consider the amount
of energy produced by your heart in a day (86,400 s). This is approximately 115,000 J,
which is the energy the average (70 kg) person would have after falling from a 550
foot tall building!"

The mechanical power of the human heart is ~1.3 watts. It takes a much higher rate of
energy turnover (~13 watts) to provide this mechanical power, since the mechanical
efficiency of the heart is very low (less than 10%)"

A normal heart in an average sized person will pump 4 to 5 liters of blood per minute.
And the average heart will beat almost 4 million times per year [sic, they probably
mean 40 million -- ed.]. It is estimated that the energy required to continuously pump
blood at these rates is almost 5 watts of power per hour [sic, watts of power is fine,
watts of power per hour is a non sequitur -- ed.]."

How much energy does the heart need? Use the following equations and numbers:
Mechanical Power = Pmax(C,O)
Chemical Power = Mechanical Power/nth
Systolic Pressure: 16 kN/m2
Cardiac Output: 107 × 10-6 m3/s
nth = 0.2
Answer:
Pmech = (16 kN/m2)(107 × 10-6 m3/s) = 1.71 (Nm)/s [W]
Pchem = 1.71 (Nm)/s = 8.6 (Nm)/s"

The human heart is a pump that is made of muscle tissue. It has four chambers: the
right atrium and the left atrium, which are located at the top, and the right ventricle
and left ventricle, which are located at the bottom. A special group of cells called the
sinus node is located in the right atrium. The sinus node generates electrical stimuli
that make the heart contract and pump out blood. Each contraction represents a
heartbeat. When the heart contracts it is in a systolic phase and when it rests it is in a
diastolic phase. It takes blood about a minute to circulate through the cardiovascular
system and pump oxygenated blood throughout the body.

The power of the heart can be calculated by multiplying the pressure by the flow rate.
An average person has six liters of blood that circulates every minute, making the flow
rate 10-4 m3/s (cubic meters per second). The pressure of the heart is about 10 4 pascal,
making the heart's power about one watt. This is the power of a typical human heart,
but it's different for everyone.

The average heart beats about 75 times per minute, which is about five liters of blood
per minute. Although this isn't much, it enables the heart to complete a tremendous
amount of work in a person's lifetime. The human heart beats about 40 million times
a year, which adds up to more than 2.5 billion times in a 70-year lifetime. This results
in approximately 2 to 3 billion joules of work in a lifetime, which is a huge amount.

Prosthetic heart valves

An artificial heart valve is a device implanted in the heart of a patient with heart
valvular disease. When one of the four heart valves malfunctions, the medical choice
may be to replace the natural valve with an artificial valve. This requires open-heart
surgery.

Valves are integral to the normal physiological functioning of the human heart.
Natural heart valves are evolved to forms that perform the functional requirement of
inducing unidirectional blood flow through the valve structure from one chamber of
the heart to another. Natural heart valves become dysfunctional for a variety of
pathological causes. Some pathologies may require complete surgical replacement of
the natural heart valve with a heart valve prosthesis.

There are two main types of artificial heart valves: the mechanical and the biological
valves.
 Mechanical heart valves
o Percutaneous implantation
 Stent framed
 Not framed
o Sternotomy/Thoracotomy implantation
 Ball and cage
 Tilting disk
 Bi-leaflet
 Tri-leaflet
 Biological heart valves
 o Allograft/isograft
o Xenograft

Mechanical valves

Mechanical heart valves (MHV) are prosthetics designed to replicate the function of
the natural valves of the human heart. The human heart contains four valves: tricuspid
valve, pulmonic valve, mitral valve and aortic valve. Their main purpose is to
maintain unimpeded forward flow through the heart and from the heart into the
major blood vessels connected to the heart, the pulmonary artery and the aorta. As a
result of a number of disease processes, both acquired and congenital, any one of the
four heart valves may malfunction and result in either stenosis (impeded forward
flow) and/or backward flow (regurgitation). Either process burdens the heart and may
lead to serious problems including heart failure. A mechanical heart valve is intended
to replace a diseased heart valve with its prosthetic equivalent.

There are two basic types of valves that can be used for aortic valve replacement,
mechanical and tissue valves. Modern mechanical valves can last indefinitely (the
equivalent of over 50,000 years in an accelerated valve wear tester). However, current
mechanical heart valves all require lifelong treatment with anticoagulants (blood
thinners), e.g. warfarin, which requires monthly blood tests to monitor. This process
of thinning the blood is called anticoagulation. Tissue heart valves, in contrast, do not
require the use of anticoagulant drugs due to the improved blood flow dynamics
resulting in less red cell damage and hence less clot formation. Their main weakness
however, is their limited lifespan. Traditional tissue valves, made of pig heart valves,
will last on average 15 years before they require replacement (but typically less in
younger patients).

Types of mechanical heart valves

Starr-Edwards-Mitral-Valve. (Caged ball valve).

1. Starr-Edwards Herzklappe 2. Starr-Edwards Herzklappe 3. Smeloff-Cutter
Herzklappe

There are three major types of mechanical valves - caged-ball, tilting-disk and bileaflet -
with many modifications on these designs.

The first artificial heart valve was the caged-ball, which utilizes a metal cage to house
a silicone elastomer ball. When blood pressure in the chamber of the heart exceeds
that of the pressure on the outside of the chamber the ball is pushed against the cage
and allows blood to flow. At the completion of the heart's contraction, the pressure
inside the chamber drops and is lower than beyond the valve, so the ball moves back
against the base of the valve forming a seal. In 1952, Dr. Charles A. Hufnagel
implanted caged-ball heart valves in ten patients (six survived the operation), marking
the first long-term success in prosthetic heart valves. A similar valve was invented by
Miles "Lowell" Edwards and Albert Starr in 1960 (commonly referred to as the Starr-
Edwards Silastic Ball Valve). The first human implant was on Sept 21, 1960. It
consisted of a silicone ball enclosed in a cage formed by wires originating from the
valve housing. Caged ball valves have a high tendency to forming blood clots, so the
patient must have a high degree of anti-coagulation, usually with a target INR of 2.5-
3.5. Edwards Lifesciences discontinued production of the Starr-Edwards valve in
2007.
Soon after came tilting-disc valves. The first clinically available tilting disk valve was
the Bjork-Shiley valve and has undergone several significant design changes since its
introduction in 1969. Tilting disk valves have a single circular occluder controlled by
a metal strut. They are made of a metal ring covered by a ePTFE fabric, into which the
suture threads are stitched in order to hold the valve in place. The metal ring holds,
by means of two metal supports, a disc which opens and closes as the heart pumps
blood through the valve. The disc is usually made of an extremely hard carbon
material (pyrolytic carbon), in order to allow the valve to function for years without
wearing out. The Medtronic-Hall model is the most common tilting-disc design in the
US. In some models of mechanical valves, the disc is divided into two parts, which
open and close as a door..

St. Jude Medical is the leader in bileaflet valves, which consist of two semicircular
leaflets that rotate about struts attached to the valve housing. This design was
introduced in 1979 and while they take care of some of the issues that were seen in the
other models, bileaflets are vulnerable to backflow and so they cannot be considered
as ideal. Bileaflet valves do, however, provide much more natural blood flow than
caged-ball or tilting-disc implants. One of the main advantages of these valves is that
they are well tolerated by the body. Only a small amount of blood thinner is needed
to be taken by the patient each day in order to prevent clotting of the blood when
flowing through the valve.

These bileaflet valves have the advantage that they have a greater effective opening
area (2.4-3.2 square cm c.f. 1.5-2.1 for the single-leaflet valves). Also, they are the least
thrombogenic of the artificial valves.

Mechanical heart valves are today very reliable and allow the patient to live a normal
life. Most mechanical valves last for at least 20 to 30 years..

Durability

Mechanical heart valves have been traditionally considered to be more durable in

comparison to their bioprosthetic counterparts. The struts and occluders are made out
of either pyrolytic carbon or titanium coated with pyrolytic carbon, and the sewing
ring cuff is Teflon, polyester or dacron. The major load arises from transvalvular
pressure generated at and after valve closure, and in cases where structural failur1e
does happen, it is usually as a result of occluder impact on the components.

impact wear and friction wear dictate the loss of material in MHV. Impact wear
usually occurs in the hinge regions of bileaflets, between the occluder and ring in
tilting-discs, and between the ball and cage in caged-ball valves. Friction wear occurs
between the occluder and strut in tilting-discs, and between the leaflet pivots and
hinge cavities in bileaflets.
MHV made out of metal are also susceptible to fatigue failure owing to the
polycrystalline characteristic of metals, but this is not an issue with pyrolytic carbon
MHV because this material is not crystalline in nature.

Cavitation should also be considered when studying degradation of MHV.