Reoperation for a Starr-Edwards aortic valve implanted 28 years earlier

A 56-year-old man admitted with dyspnea had undergone aortic valve replacement using a Starr-Edwards ball valve to treat aortic regurgitation 28 years earlier. Chest radiography showed moderate cardiomegaly, moderate pulmonary edema, and mild pleural effusion. Echocardiographic examination showed severe mitral regurgitation. The mitral valve was replaced using a St. Jude Medical prosthesis, and the Starr-Edwards aortic valve was replaced using a CarboMedics prosthetic valve. The cloth covering on the Starr-Edwards valve had worn away and pannus had formed. The patient's postoperative course was uneventful, and he was discharged on postoperative day 35.     

Use of the Bentall method for replacement of an aortic Starr-Edwards ball valve prosthesis implanted 32 years previously

We report the case of a 54-year-old woman who, 32 years previously, had undergone replacement of the ascending aorta by the inclusion method with a Starr-Edwards ball valve prosthesis and recently underwent aortic root re-reconstruction by the Bentall method. Routine chest radiography revealed dilatation of the mediastinum, and computed tomography revealed an aneurysm of the ascending aorta. At reoperation, although the cloth covering the cage of the Starr-Edwards ball valve prosthesis appeared worn and some pannus formation was seen, the Starr-Edwards ball valve was functioning normally. The aortic root was replaced with a composite graft that consisted of a 23-mm St. Jude bileaflet prosthesis and a 24-mm Hemashield gold graft. The patient was discharged from the hospital in good condition 25 days after surgery.     

Starr-Edwards valves at the aortic and mitral positions implanted for 39 years

Cloth-covered Starr-Edwards caged ball valves implanted in the aortic and mitral valve positions for 39 years were extracted. Both showed valve dysfunction resulting from pannus overgrowth. The metal cages of the Starr-Edwards valves were covered with worn cloth. This case indicates the extended durability of Starr-Edwards valves and the importance of the design and materials of prosthetic heart valves to avoid pannus overgrowth and prosthetic valve abrasion.     

Reoperation for a Starr-Edwards aortic prosthetic valve 33 years after initial implantation

A 40-year-old woman admitted with heart failure had undergone aortic valve replacement with a Model 2310 Starr-Edwards valve due to aortic regurgitation 33 years previously. She had been followed up for several years, but discontinued follow-up and medication (including Warfarin) for the past 25 years. Echocardiography demonstrated marked dilatation and thickening of the left ventricle, and the peak pressure gradient of the prosthesis was measured as 87.9 mmHg. Under the diagnosis of chronic aortic valve prosthesis-patient mismatch with subsequent severe left ventricular dysfunction, the Starr-Edwards valve was explanted and replaced with a 23 mm St. Jude Medical prosthetic valve. The removed valve showed minimal cloth wear except for a small part of the strut. The postoperative echocardiography demonstrated recovering of left ventricular function. To our best knowledge, this case presents the longest duration for a surgically explanted Starr-Edwards aortic prosthetic valve in Japan.     

Obstruction of the left ventricular outflow tract due to pannus formation after the implantation of a carbomedics aortic valve

Excessive pannus formation after implantation of a prosthetic valve is an infrequent but serious complication. A 69-year-old woman who had received a 19-mm CarboMedics aortic valve 11 years ago was readmitted to our hospital with dyspnea and chest oppression. Cineradiography did not show the restriction of valve movement. The aortic peak pressure gradient was calculated by Doppler echocardiography to be 104 mmHg. Based on the diagnosis of stenosis of the left ventricular outflow tract, the patient underwent reoperation. At reoperation, the pannus had formed circumferentially without disturbing the movement of the leaflet. A 19-mm St. Jude Medical Regent valve was implanted after enlargement of the aortic annulus. The patient’s postoperative course was uneventful. We report this characteristic finding of pannus formation after the implantation of a CarboMedics valve in the aortic position.     

Premeditated reoperation after mitral valve replacement with a Starr-Edwards ball valve for young women who desire to bear a child: Report of two cases

There are many difficulties for young women with a Starr-Edwards ball valve who want to attempt pregnancy. There is no consensus regarding whether they should maintain anticoagulation therapy throughout pregnancy with the risk of a thromboembolism or to undergo a reoperation with bioprosthetic heart valves, followed by a third operation when the valve deteriorates. This report presents two cases of young women who underwent mitral valve replacement (MVR) with Starr-Edwards ball valves (model 6120: 1M) during their childhood. Although they did not have any cardiac symptoms, transthoracic echocardiography and cardiac catheterization data demonstrated that both the patients had asymptomatic mild relative mitral stenosis. They both wished to bear a child. After the patients and their family provided thorough informed consent, redo MVRs were preformed safely with biological prostheses. The presence of significant pannus formation along the strut and sewing ring of the excised valves could also have a positive impact on the decision to undergo reoperation.     

Early cusp tear of the second-generation Trifecta valve with Glide Technology

We herein report a case of early cusp tear of the second-generation Trifecta valve with Glide Technology. A 69-year-old woman underwent aortic valve replacement with a Trifecta valve with Glide Technology and partial arch replacement for severe aortic valve stenosis caused by a bicuspid valve and ascending aortic and aortic arch aneurysms 2 years previously. During follow-up, she suddenly developed dyspnoea and a heart murmur. Echocardiography revealed severe aortic valve regurgitation caused by structural valve deterioration. We performed re-aortic valve replacement with a mechanical valve through re-median sternotomy. Intraoperative examination revealed a bottom tear of the left coronary cusp without infection or pannus formation.     

Thrombotic phenomena with nonanticoagulated, composite-strut aortic prostheses.

Twenty-nine patients received no anticoagulant therapy after aortic valve replacement with a Starr-Edwards Model 2400 prosthesis. Hemodynamic studies were performed at 3 to 26 months (average 12 months) in 18 of 29 patients. Mean aortic valve gradients ranged from 14 to 62 mm. Hg and averaged 34 mm. Hg. Calculated aortic valve area varied from 0.20 to 1.75 sq. cm. and averaged 0.98 sq. cm. Thirteen of 18 patients had critically stenotic valve orifices. At reoperation or autopsy, examination of the prostheses consistently revealed pannus and thrombus which narrowed the inflow orifice and usually extended to the struts. Of the remaining 11 patients, 3 have died (2 suddenly and one after a cerebrovascular accident), 2 have had embolic episodes, and 6 have refused a repeat study but are being given anticoagulant therapy. Clinical examination, serum lactic dehydrogenase (LDH) levels, phonocardiography, echocardiography, and fluoroscopy of the prosthesis were often unrevealing. Cardiac catheterization was the only reliable method for critically evaluating prosthetic function. In conclusion, close follow-up, preferably with cardiac catheterization, is recommended in any patient who received a Starr-Edwards Model 2400 aortic valve prosthesis without anticoagulation. Long-term anticoagulation with sodium warfarin is indicated in all patients with a Model 2400 aortic valve prosthesis unless there is a contraindication to such therapy.     

Pannus Resection Through the Tilting Disc Prosthesis: Successful Treatment Preserving the Prosthesis

Abstract: A 59-year-old woman was admitted to our hospital because of heart failure. In 1988, she underwent aortic valve replacement with an Omnicarbon valve and mitral valve replacement with a bioprosthetic valve. She was doing well until July in 1996 when she developed heart failure. Echocardiography revealed massive mitral valve regurgitation, and cinefluoroscopy showed implanted Omnicarbon valve dysfunction with a leaflet opening angle of 35 degrees. At reoperation, it was revealed that pannus formation prevented the valve from functioning well. The pannus was resected through the major orifice, and the leaflet was rotated toward the right anterolateral orientation. The worn bioprosthetic valve was replaced with a mechanical one. Postoperative cinefluoroscopy of the rotated Ominicarbon valve showed the opening angle to be 61 degrees.     

Prophylactic reoperation after mitral valve replacement with the Starr-Edwards ball valve: a report of four cases.

PURPOSE: The Starr-Edwards ball valve was first applied clinically in 1960. In our hospital, this valve has been used since 1963, and some patients have been followed up for 30 years or more. Based on our experience, therapeutic strategies included revalve replacement as a preventive procedure in the absence of valve-related complications. In this study, we investigated whether prophylactic reoperation after valve replacement with the Starr-Edwards ball valve is appropriate. PATIENTS AND METHODS: Of 58 patients in our institute who underwent mitral valve replacement with the Starr-Edwards ball valve, 12 underwent revalve replacement. Of these 12, the subjects of the present study were 4 patients who underwent prophylactic revalve replacement. RESULTS: The mean postoperative follow-up of the 4 patients was 31.0+/-3.7 years. There were no operative deaths or postoperative complications. On examination of the extirpated Starr-Edwards valves, cloth wear was observed in all 4 patients. Although there was no influence on the range of ball motion, they showed the entity of "thrombus/pannus." CONCLUSION: In this study, all of the patients showed cloth wear in the absence of complications. Therefore we consider that prophylactic reoperation after valve replacement with the Starr-Edwards valve should be performed to prevent complications.     

THIRTY YEARS EXPERIENCE WITH HEART VALVE SURGERY: ISOLATED AORTIC VALVE REPLACEMENT

Background: Thirty years have elapsed since the commencement of open-heart surgery in South Australia. A retrospective study was performed to evaluate mortality and complication rates and to identify factors associated with poor outcomes in all patients who underwent prosthetic aortic valve replacement during this period. Methods: Questionnaires and personal contact have been used to generate a combined database of pre-operative and postoperative information and long-term follow-up on 1322 patients who underwent isolated prosthetic aortic valve replacement at the Cardio-Thoracic Surgical Unit of the Royal Adelaide Hospital between 1963 and 1992. Results: Complete survival follow-up data were obtained for 94% (1241) of the patients. The Bjork-Shiley valve was used in 668 (875) of the patients, a Starr-Edwards prosthesis in 31% (412). a St Jude prosthesis in 2% (26). and only 0.7% (9) bioprosthetic valves were inserted. The hospital mortality rate for the 30-year period was 2.9%. Progressively older and less fit patients have undergone surgery in recent years. The long-term survival of patients with aortic stenosis and aortic incompetence was not significantly different. Long-term survival was significantly shorter for patients with higher New York Heart Association (NYHA) functional classifications, and for patients in pre-operative atrial fibrillation. Pre-operative dyspnoea was significantly improved following aortic valve replacement. The rates of postoperative haemorrhagic and embolic complications were low by comparison with other published series. Conclusions: Aortic valve replacement can be performed with low hospital mortality and complication rates, and significant symptomatic improvement can be expected. Aortic valve recipients have a favourable prognostic outcome compared with an age- and sex-matched population, and risk factors that determine long-term survival can be identified pre-operatively.     

Extended (31 years) durability of a Starr-Edwards prosthesis in mitral position

A 62-year-old man underwent mitral valve replacement with a Starr-Edwards caged-ball prosthesis in 1974. He was asymptomatic until February 2005 when he underwent a new cardiac evaluation because of increasing dyspnea and peripheral edema. The echocardiogram showed a severe aortic regurgitation and a mitral valve prosthesis well functioning. At reoperation, the mitral prosthesis and the aortic valve were replaced with St. Jude Medical((R)) bileaflet mechanical prostheses. At macroscopic and radiographic inspection the Starr-Edwards was free from signs of structural valve degeneration. This case demonstrates the impressive durability of a Starr-Edwards prosthesis in mitral position.     

St. Jude Medical prosthetic aortic valve malfunction due to pannus formation.

According to the literature, the incidence of pannus formation with the St. Jude Medical prosthetic aortic valve has been reported at 0.03% and 0.14% (per patient-year), with no case report of St. Jude Medical prosthetic aortic valve malfunction due to pannus formation. Between 1980 and 1999, 1,186 patients underwent aortic valve replacement at our institute. We encountered 2 aortic valve malfunctions due to pannus formation, including the case of a 53-year-old woman who suffered a St. Jude medical aortic valve malfunction 13 years after the initial operation. A second aortic valve replacement was successful and the postoperative course was uneventful. The possibility of pannus formation on St. Jude Medical aortic valves must thus be considered and its mechanism clarified.     

Introduction of a flexible polymeric heart valve prosthesis with special design for aortic position

Objective: Current prosthetic heart valves necessitate permanent anticoagulation or have limited durability and impaired hemodynamic performance compared to natural valves. Recently a polymeric valve prostheses with special design for mitral position demonstrated excellent in vitro and in vivo results with improved durability and no need for permanent anticoagulation. In this study, a respective flexible polymeric aortic valve is presented and in vitro and in vivo results are reported. Methods: The aortic prosthesis (ADIAM^® lifescience AG, Erkelenz, Germany) is entirely made of polycarbonaturethane. The tri-leaflet flexible prosthesis mimicks the natural aortic valve and has a diminished pressure loss and reduced stress and strain peaks at the commissures. The valve underwent long-term in vitro testing and in vivo-testing in a growing calve animal model (20 weeks, 7 aortic valves) and was compared to two different commercial bioprostheses. Results: The polymeric aortic heart valve substitute demonstrated excellent in vitro and in vivo hemodynamics. Five/seven animals with aortic PCU-prostheses had an excellent clinical long-term course. The explanted valves showed a variable degree of calcification. Two of the seven animals died at 27 and 77 days due to pannus overgrowth causing severe LVOTO without degeneration of the valve itself. Both animals with commercial bioprostheses had to be sacrificed because of congestive heart failure related to structural degeneration of the bioprosthesis after 10 and 30 days of implantation. There was no increased thrombogenity of the PCU valves compared to bioprostheses. Conclusion: The new flexible polymeric aortic valve prosthesis is superior to current bioprostheses in animal testing.     

Isolated replacement of the aortic valve with the Starr-Edwards prosthesis. A 9 year review.

A 9 year review of patients who underwent replacement of the aortic valve with the Starr-Edwards prosthesis indicates that the operative mortality rate for aortic valve replacement continues to decline. Thromboembolic complications have been markedly lessened in newer model valves. Surgical therapy is no longer seriously questioned as the appropriate management for symptomatic aortic valvular disease. The large majority of patients who survive surgery can expect to be rehabilitated to a highly functional existence, with longevity not unlike that of the general population. The Starr-Edwards prosthesis is a very satisfactory prosthesis for replacement of the aortic valve.     

Obstruction of the left ventricular outflow tract due to pannus formation after the implantation of a carbomedics aortic valve

Excessive pannus formation after implantation of a prosthetic valve is an infrequent but serious complication. A 69-year-old woman who had received a 19-mm CarboMedics aortic valve 11 years ago was readmitted to our hospital with dyspnea and chest oppression. Cineradiography did not show the restriction of valve movement. The aortic peak pressure gradient was calculated by Doppler echocardiography to be 104 mmHg. Based on the diagnosis of stenosis of the left ventricular outflow tract, the patient underwent reoperation. At reoperation, the pannus had formed circumferentially without disturbing the movement of the leaflet. A 19-mm St. Jude Medical Regent valve was implanted after enlargement of the aortic annulus. The patient’s postoperative course was uneventful. We report this characteristic finding of pannus formation after the implantation of a CarboMedics valve in the aortic position.     

Ascending aortic aneurysm in a patient with an aortic Starr-Edwards ball valve prosthesis implanted 39 years previously

A 53-year-old man who had undergone aortic valve replacement with a Starr-Edwards ball valve prosthesis 39 years previously was admitted to our hospital under the diagnosis of ascending aortic aneurysm. Operative findings revealed that the ball valve was functioning normally. The markedly dilated ascending aorta was replaced with a 30-mm prosthetic vascular graft, and the ball valve was replaced with a19-mm bileaflet valve prosthesis. The patient’s postoperative course was uneventful, and he was discharged from our hospital 19 days after surgery. Dilatation of the ascending aorta in this case might have been caused by the poststenotic dilatation mechanism, which seems to be one of the long-term complications of Starr-Edwards ball valve implantation.     

Tricuspid valve replacement with the St. Jude Medical valve

A study was conducted on 20 patients who underwent tricuspid valve replacement (TVR) with the St. Jude Medical (SJM) valve. Isolated TVR was performed on 9 patients, and additional mitral, or mitral and aortic valve replacements were performed on 11 patients. Four patients (20%) died in the early postoperative period, but there were no deaths related to the SJM valve in the tricuspid position. The mean follow-up period of the 16 survivors was 74.4 months, and there have been no deaths during the follow-up period. The postoperative actuarial survival rate was 80%, 10 years after surgery. Three patients, representing 0.25%/patient-months, developed valve thrombosis, the valve thrombosis-free rate being 72.8%, 10 years after surgery, while entrapment of a leaflet by endothelial pannus was found in one patient, representing 0.08%/patient-months. Thus, the incidence of all prosthetic valve-related complications was 0.34%/patient-months, and the postoperative complication-free rate was 65.3%, 10 years after surgery. The medium-term follow-up study of TVR with the SJM valve revealed no prosthetic valve-related deaths and a relatively low incidence of prosthetic valve-related complications. However, as with other mechanical valves, valve thrombosis was a major risk posed by the SJM valve in the tricuspid position.     

Valve Replacement with the Starr-Edwards and Hancock Prostheses: Comparative Analysis of Late Morbidity and Mortality

Although the Starr-Edwards caged-ball valve remains a standard of comparison for more recently introduced prostheses, a substantial incidence of thromboembolic and hemorrhagic complications prompted our evaluation of the Hancock glutaraldehyde-fixed porcine xenograft. We have compared the results of 435 aortic valve replacements using the Starr- Edwards valve (SE-AVR), 515 mitral valve replacements (SE-MVR), and 121 double-valve replacements (SE-AVRMVR) with 251 aortic valve replacements using the xenograft aortic valve (X-AVR), 338 mitral valve replacements (X-MVR), and 88 double-valve replacements (X-AVR-MVR). The Starr- Edwards valves were used during the period 1963 through 1973 and the xenograft valves between 1971 and 1976. No significant differences in patient age, sex, or preoperative hemodynamic data were noted between comparable groups. All patients with Starr-Edwards valves received long-term anticoagulation while anticoagulants were used only for specific indications in patients with xenograft valves. Total follow up was 3944 patient years for the Starr-Edwards patients and 947 patient years for the xenograft patients. Hospital mortality was not significantly different for comparable groups: SE-AVR 6.9% vs. X-AVR 6.4%, SE-MVR 9.7% vs X-MVR 8.6%, and SE-AVR-MVR 7.5% vs. X-AVR-MVR 10.2%. Linearized mortality and morbidity data expressed as percent per patient- year are tabulated below. Pairs which differ significantly (p < .05) are italicized.     

Reoperation for a patient 25 years after a Starr-Edwards ball mitral valve was installed.

A 45-year-old female suffered from increasing dyspnea during exercise and edema of lower extremities from January 2000. She had undergone mitral valve replacement with Starr-Edwards ball prosthesis (model 6320) due to mitral valve regurgitation 25 years ago. The cardiac catheterization and echocardiography documented mitral, aortic and tricuspid valves regurgitation grade III. Left ventricular ejection fraction rate was 49% and the pressures of CVP, RA, RV and PA were also increased. Laboratory examination showed slight hemolytic anemia. Double valve replacement (ATS valve) and tricuspid annuloplasty were carried out in April 2000. Strut cloth wear was confirmed at operation. Her postoperative course was uneventful. We hereby review the published paper of all cases with an implanted Starr-Edwards ball valve who required redo valve replacement with over 15 years follow-up. We consider that cloth injury is the main cause for reoperation and it usually associated with hemolytic anemia; cloth wear not only involves the aortic position but also frequently involves the mitral position for over 15 years follow-up patients and can be corrected by reoperation. Cloth wear should be concerned for those surviving patients who have received the Starr-Edwards ball valve during long-term follow-up.