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.     

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.     

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.     

Reoperation for a Starr-Edwards ball valve prosthesis implanted in mitral position 31 years ago

The patient is a 61-year-old woman who had undergone mitral valve replacement with the Starr-Edwards cloth-covered ball valve 31 years ago. She had dyspnea on effort 1 month before admission. The echocardiography revealed mitral and tricuspid regurgitation. Re-replacement of the mitral prosthetic valve with an ATS valve and tricuspid annuloplasty were successfully performed without any complication. The cloth wear of the Starr-Edwards ball valve cage was recognized and no thrombus was found at operation. To our knowledge, there has been no such a reoperative case who underwent so long postoperative period after initial implantation of the Starr-Edwards ball valve in Japan. This experience made us realize again the importance of attention to the complications related to a prosthetic valve like a cloth wear during long-term follow-up for the Starr-Edwards ball valve.     

Reoperation for a patient with starr-edwards aortic valve malfunction due to pannus formation twenty-nine years after implantation

We report a re-do case of severe aortic valve stenosis due to pannus formation 29 years after an aortic Starr-Edwards caged-ball valve implantation. A huge shelf of calcified and thick pannus tissue below the valve had reduced the already small orifice by at least a third in surface area. The explanted Starr-Edwards valve revealed no mechanical or structural failure. Early detection and treatment of pannus outgrowth is essential in order to prevent life-threatening prosthetic valve malfunctions.     

Post hoc patient satisfaction with the choice of valve prosthesis for aortic valve replacement: results of a single-centre survey

Open in a separate window OBJECTIVESOur goal was to examine post hoc patient satisfaction and the decision-making process of choosing a prosthesis for aortic valve replacement (AVR).METHODSWe surveyed 113 patients who were operated on for AVR at 60–70 years of age, including 74 patients with a mechanical valve (MECH) and 39 with a bioprosthesis (BIO). The study focused on quality of life and the decision pathway in relation to prosthesis choice and valve-related complications. Decisional conflict was defined as the post hoc uncertainty perceived by patients regarding their choice of prosthesis.RESULTSThe survey was performed at a median of 5.2 (3.2–8.1) years after the AVR. Patients with a biological valve were older (BIO: 68.4 years [66.2–69.4] vs MECH: 63.9 [61.9–66.7]; P < 0.001). Global post hoc satisfaction with prosthesis choice was high in both groups (MECH: 95.9%; BIO: 100%), and 85.1% (MECH) and 92.3% (BIO) of them would repeat their choice. Conflict about their decision was equal (MECH: 30.3%; BIO: 32.6%) for different reasons: MECH patients experienced more anticoagulation-related inconvenience (25.9% vs 0%), fear of bleeding (31.1% vs 0%) and prosthesis noise (26.2% vs 0%), whereas more BIO patients feared prosthesis failure (39.7% vs 17.4%) or reoperation (43.5% vs 18.1%). Active involvement in the decision (odds ratio 0.37, 95% confidence interval 0.16–0.85; P = 0.029) and adequate information about the prosthesis (odds ratio 0.34, 95% confidence interval 0.14–0.86; P = 0.020) decreased the risk of conflict about the decision.CONCLUSIONSAlthough 30% of the responders showed a decisional conflict related to prosthesis-specific interferences, global patient satisfaction with the prosthesis choice for AVR is excellent. Increasing the patient’s involvement in the prosthesis choice through shared accountability and improved information is recommended to decrease the choice-related uncertainty.     

Isolated aortic valve replacement. Analysis of factors influencing survival after replacement with the Starr-Edwards prosthesis

A review of 104 consecutive patients who underwent isolated aortic valve replacement with the Starr-Edwards prosthesis is reported. All 104 were followed an average of 3.8 years.Operative mortality was 1.8% and late mortality was 12.7%. The importance of continuous coronary perfusion is emphasized as the single most important factor in achieving a low operative mortality. Patients with pure aortic stenosis had the highest cumulative mortality (18%), followed closely by those with “mixed” lesions (aortic stenosis [AS] and aortic insufficiency [AI]) (16%). Patients in Class IV (N.Y. Heart Association classification) had, as expected, the highest mortality. The single category in which there was the highest incidence of deaths consisted of Class IV patients with mixed lesions (57%).There were 89 survivors, 85 of whom achieved excellent rehabilitation (95%), although almost all still require medication.The Starr-Edwards prosthesis seems to function well over several years. Prosthesis complications were uncommon, and the most frequent cause of late mortality seemed to be myocardial disease itself. Accordingly, any improvement in late results will come from earlier operation, before the myocardium reaches a “point of no return.”     

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.     

肥胖对小主动脉瓣人工瓣膜置入术后长期生存的影响

目的 评估肥胖对于小主动脉瓣人工瓣膜(直径≤21 mm)置换术后长期生存率的影响.方法 1998年1月至2008年12月对307例首次接受小号主动脉瓣置换术生存时间超过1个月者进行长期随访.并根据身体质量指数(BMI)划分为3组:BMI＜ 24.0 kg/m2为正常组(185例),BMI 24.0 ～27.9 kg/m2为超重组(94例),BMI≥28 kg/m2为肥胖组(28例).分别在术后第3、6个月,第1、3、5、8年收集NHYA分级,有效瓣口面积指数(EOAI),左心室质量指数(LVMI),左心室射血分数(LVEF)等指标,了解各组中这些指标的变化及组间比较,分析肥胖是否与生存率有关;计算总体死亡率及3组各自死亡率并比较.结果 经过单变量和多变量分析,并通过倾向得分调节,肥胖均为影响生存率的独立危险因子(HR:1.62;P =0.01).长期随访中,肥胖组和超重组生存率较正常组低,而且术后NYHAⅢ/Ⅳ级患者所占比例偏高.3组中肥胖组和超重组EOAI偏小,LVMI偏高,均有统计学意义.但LVEF无明显变化.结论 肥胖和术后长期生存率密切相关,肥胖和超重均可能降低术后的长期生存率.EOAI可能在其中发挥重要作用,提高EOAI会提高术后长期生存率,改善术后长期生存质量.     

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.     

Long-term follow-up of cardiac valve replacement using bioprosthesis in patients 70 years old and older

Good long-term results with the bioprosthetic valves for patients 70 years old and older have been reported. However, because the average lifespan is increasing, we aimed to clarify whether patients older than 70 may still be candidates for valve re-replacement. Seventy-one patients 70 years old and older, who received a total of 81 bioprosthetic valve replacements during 73 procedures between 1988 and 2000, were reviewed. There were 8 hospital and 7 late deaths. Ten-year actual survival after valve replacement was 73.5%, and 82.8% when hospital deaths were excluded. During the follow-up period, 2 patients received mitral valve re-replacement. Ten years of freedom from reoperation were found in 66.7% for all valves and in 50.0% for mitral valves. The average lifespan in Japan is currently 77.64 years for men and 84.62 years for women; therefore, valve degeneration in patients who receive bioprosthesis replacement in their early 70s should be anticipated.     

Results of prosthetic valve replacement for aortic stenosis

Background: Aortic valve replacement with mechanical valves is associated with a small but constant risk of valve thrombosis and thromboembolic and hemorrhagic complications. The surgical outcome of patients with Aortic Stenosis who had aortic valve replacement with mechanical valves is reported here. Methods: Between January 1990 and October 1999, 275 patients underwent prosthetic valve replacement for isolated aortic stenosis. The age ranged between 13 years and 75 years and 230 were males. The cause of aortic stenosis was rheumatic in 185 patients (67.3%), followed by bicuspid aortic valve in 75 patients (27.3%) and degenerative in 15 patients (5.4%). Results: The early mortality was 1.5%. The follow up was 96% complete and ranged from 1 to 104 months (mean 54±24.5months). Six patients (2.2%) developed prosthetic valve endocarditis. Paravalvular leak occurred in 3 (0.9%) patients. Valve thrombosis occurred in 10 patients (1.0% per patient year). The actuarial survival was 81±7% at 5 years and 64±13% at 8 years. Event free survival was 40±14% at 8 years. Conclusion: With current operative techniques and myocardial preservation aortic stenosis patients are at low risk for surgery. However, long term survival is limited due to prosthesis related complications.     

Late ball variance with the Model 1000 Starr-Edwards aortic valve prosthesis. Risk analysis and strategy of operative management

The first generation of aortic ball-valve prostheses, used until 1965, was associated with poppet damage owing to fatty infiltration of the silicone rubber ball, a phenomenon termed ball variance. For the Model 1000 Starr-Edwards valves, almost all cases were discovered before 8 years. However, a review of our patients still at risk with the original valve and poppet, prompted by other recent reports of late ball variance, has shown that severe variance can exist up to 20 years after implantation. There is a relationship between the year of valve implantation and the timing and severity of ball variance for the overall series of patients surviving operation, but for the subgroup currently at risk the sample sizes are too small to detect any difference, if one still exists. Only three of 12 patients in the current subset were found to have severe variance. Simple ball change has been the operation of choice. Prophylactic reoperation is not indicated in the current subset, but patients require careful follow-up and should be considered for reoperation should symptoms develop.     

TAVI and the future of aortic valve replacement

Aortic valve stenosis (AS) is the most common valvular pathology and has traditionally been managed using surgical aortic valve replacement (SAVR). A large proportion of affected patient demographics, however, are unfit to undergo major surgery given underlying comorbidities. Since its introduction in 2002, transcatheter aortic valve implantation (TAVI) has gained popularity and transformed the care available to different‐risk group patients with severe symptomatic AS. Specific qualifying criteria and refinement of TAVI techniques are fundamental in determining successful outcomes for intervention. Given the successful applicability in high‐risk patients, TAVI has been further developed and trialed in intermediate and low‐risk patients. Within intermediate‐risk patient groups, TAVI was shown to be noninferior to SAVR evaluating 30‐d mortality and secondary endpoints such as the risk of bleeding, development of acute kidney injury, and length of admission. The feasibility of expanding TAVI procedures into low‐risk patients is still a controversial topic in the literature. A number of trials have recently been published which demonstrate TAVI as noninferior and even superior over SAVR for primary study endpoints.     

Long-term results of valve replacement with the CarboMedics prosthetic heart valve

This study examined the long-term results of the CarboMedics prosthetic heart valve. Between July 1990 and May 2000, 256 CarboMedics valve prostheses (120 single aortic, 62 single mitral, and 34 double aortic/mitral) were implanted into 216 patients (mean age 57.8 years). The mean follow-up was 57.7 +/- 36 months (maximum 133 months) with a total of 1,038.4 patient years. Patient survival, including operative deaths, was 85.1% at 10 years. Linearized rates for various complications were thromboembolism 0.39% per patient year, bleeding events 0.39% per patient year; prosthetic valve endocarditis 0.29% per patient year, nonstructural dysfunction 0.87% per patient year, and reoperation 0.39% per patient year. There were no valve thrombosis or structural valve failures in this series. The probabilities of freedom from thromboembolism and reoperation at 10 years were 96.3% and 93.1%, respectively. In conclusion, the CarboMedics valve can be used satisfactorily with a low incidence of thromboembolism and valve thrombosis.