Forty-year durability of a Smeloff-Cutter ball valve prosthesis in the mitral position

A rare case requiring replacement of an intact Smeloff-Cutter ball prosthesis in the mitral position 40 years after implantation is presented. The Smeloff-Cutter ball valve prosthesis was designed to have two open cages. It has two potential advantages: a relatively large, effective orifice area and its self-washing effect that prevents thrombus formation. There have been only a few reports of survivors with ball valve prostheses in place for more than three decades especially in the mitral position. This is a valuable report describing the long-term durability of a Smeloff-Cutter ball valve prosthesis in the mitral position.     

Aortic valve replacement with Smeloff-Cutter prosthesis: 1 to 8 year follow-up

Two hundred patients had an aortic valve replacement with the Smeloff-Cutter prosthesis between 1972 and 1980. One hundred and seventy six patients had aortic valve replacement alone (mortality 2.8%) and 24 patients had additional procedures. The overall mortality was 6.5%. One hundred and eighty seven patients have been followed up for from 4 months to 8 years (mean 33 months). The 14 patients who died later are analysed; half of these deaths were prosthesis related. There has been no instance of structural failure, ball variance or massive thrombosis in this series. All but 4 of the survivors showed functional improvement. We consider the Smeloff-Cutter valve a good choice for aortic valve replacement.     

CLINICAL EXPERIENCE WITH THE SMELOFF-CUTTER PROSTHESIS: ONE TO TWELVE YEAR FOLLOW-UP

In order to determine the long-term results of aortic valve replacement with the Smeloff-Cutter prosthesis, the fate of 134 of 139 (96%) consecutive patients was determined one to 12 years after operation. The mean age at operation was 54 years (range 18 to 76 years). Aortic stenosis was the dominant lesion in 77 patients (55%), aortic regurgitation in 36 patients (26%), and 22 (15%) had both aortic stenosis and regurgitation. In addition to aortic valve replacement, 25 patients (18%) had coronary artery bypass, seven (5%) had mitral commis-surotomy, and four (4%) had other procedures. Preoperative status by NYHA Class was: Class I … 3 patients (2%); Class II … 36 (26%); Class III … 67 (48%); Class IV … 33 (24%). Perioperative (30-day) mortality was 7% (10/139). Functional improvement was obtained in all postoperative survivors with 86 (70%) in NYHA Class I,28 (23%) in Class II, and nine (7%) in Class III. A perivalvular leak developed in one patient and subacute bacterial endocarditis in two (2%). There were no cases of prosthesis failure or haemolysis. Actuarial long-term survival was 85% at five years, 75% at eight years. Thromboembolism occurred in eight patients (6%). The incidence of thromboembolism per 100 patient years for patients receiving no anticoagulants was 5·5; taking warfarin 2·4; and taking antiplatelet agents 2·7. Major thromboembolism was uncommon in patients taking warfarin (0·9 episodes per 100 patient years.) The study confirms that the Smeloff-Cutter aortic valve prosthesis is mechanically durable, has good long-term haemodynamic performance, and carries a low incidence of thromboembolism even in patients not receiving anticoagulants.     

A case of aortic prosthetic valve endocarditis with aortic root aneurysm

A 72-year-old male who underwent patch closure of atrial septal defect and aortic valve replacement (AVR) 10 years ago was diagnosed as aortic prosthetic valve endocarditis for recurrent fever, coexisting paravalvular leakage and aortic root aneurysm by transthoracic and transesophageal echocardiography. Operative findings showed mechanical prosthesis was dehiscenced in part and limited subannular aneurysm that was healed macroscopically. The hole of the aneurysm was closed by direct suture. Re-AVR, mitral valve replacement and tricuspid annuloplasty for complicating mitral valve stenosis and regurgitation and tricuspid valve regurgitation was performed. The patient is now doing well for one year after the reoperation.     

A case of aortic prosthetic valve endocarditis with aortic root aneurysm]

A 72-year-old male who underwent patch closure of atrial septal defect and aortic valve replacement (AVR) 10 years ago was diagnosed as aortic prosthetic valve endocarditis for recurrent fever, coexisting paravalvular leakage and aortic root aneurysm by transthoracic and transesophageal echocardiography. Operative findings showed mechanical prosthesis was dehiscenced in part and limited subannular aneurysm that was healed macroscopically. The hole of the aneurysm was closed by direct suture. Re-AVR, mitral valve replacement and tricuspid annuloplasty for complicating mitral valve stenosis and regurgitation and tricuspid valve regurgitation was performed. The patient is now doing well for one year after the reoperation.     

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.     

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.     

Clinical Experience with the Smeloff-Cutter Prosthesis: 1- to 12-Year Follow-up

To determine the long-term results of aortic valve replacement with the Smeloff-Cutter prosthesis, the fate of 358 of 459 (78%) consecutive patients was determined 1 to 12 years postoperatively. There were 319 male patients (70%). Mean age at operation was 57 years (range, 15 to 84 years). Aortic stenosis was the dominant lesion in 267 patients (58%) and aortic regurgitation in 133 patients (29%). Fifty-nine patients (13%) had both aortic stenosis and regurgitation. In addition to aortic valve replacement, 93 patients (20%) had coronary artery bypass, 30 (6.5%) had mitral commissurotomy, 23 (5%) had mitral valve replacement, and 41 (9%) had other procedures. Preoperative status by New York Heart Association Functional Class was: Class I, 3 (1%); Class II, 39 (8%); Class III, 148 (32%); and Class IV, 269 (59%). Operative (30-day) mortality was 8.5% (39 out of 459).Functional improvement was obtained in all postoperative survivors: 345 (82%), Class I; 63 (15%), Class II; and 12 (3%), Class III. A perivalvular leak developed in 6 patients (1%) and subacute bacterial endocarditis in five (1%). Actuarial long-term survival was 80% at 5 years and 71% at 8 years. Thromboembolism occurred in 34 patients (9.5%). The incidence of thromboembolism per 100 patient-years for patients receiving no anticoagulants was 5.4; antiplatelet agents, 2.9; and Coumadin (sodium warfarin), 2.6. Major thromboembolism was uncommon in patients on a regimen of sodium warfarin but major morbidity from bleeding was significant.     

Immediate hemodynamic response to correction of cardiac valvular lesions

The immediate hemodynamic response to prosthetic replacement of the aortic and mitral valves was evaluated in 50 patients by intraoperative measurement of cardiac output, intracardiac pressures, and other hemodynamic variables. Hemodynamics returned to near-normal immediately after correction of aortic stenosis, aortic regurgitation, and mitral regurgitation. In contrast, little immediate hemodynamic improvement occurred after mitral valve replacement for mitral stenosis. This difference could not be explained by blood volume deficits, the presence of the prosthesis, or residual valvular lesions. The most likely explanation appears to be that pulmonary vascular resistance does not immediately decrease, while an increased mechanical load is placed on the chronically diseased right ventricle. Impairment of left ventricular function may also play a role in the altered hemodynamic state observed early after correction of long-standing mitral stenosis.     

Forty-year survival with Smeloff-Cutter and Starr-Edwards prostheses

This case study describes a 40-year follow-up of a man who had a double valve replacement with Smeloff-Cutter aortic (Cutter Laboratories, Berkeley, CA) and Starr-Edwards mitral prostheses (Edwards Laboratories, Santa Ana, CA) when he was 34 years old. Double valve replacement was performed for aortic and mitral valve stenosis and insufficiency. To date, no surgical treatment has been required except a pacemaker implantation. The patient presented with a New York Heart Association functional class of I to II. Echocardiography revealed intact prostheses.     

Downward displacement of aortic anulus leading to aortic and mitral regurgitation

A rare case of combined aortic and mitral regurgitation resulting from downward displacement of the aortic anulus is reported. The patient was treated successfully with an aortic valve replacement with a Bj?rk-Shiley valve prosthesis, which was anchored at the normal site of the aortic anulus. No procedures were performed on the mitral valve, but mitral regurgitation was not evident postoperatively.     

Supravalvular aortic stenosis syndrome with advanced mitral regurgitation requiring extended aortoplasty and mitral valve replacement: a case report

This is a case report of a 28-year-old male, suffering from supravalvular aortic stenosis (systolic pressure gradient 60 mmHg) and severe mitral regurgitation associated with elfin face and mental retardation. Severely prolapsed mitral valve with elongated chordae tendineae was replaced with Bj?rk-Shiley mitral valve prosthesis. Simultaneously, extended aortoplasty was carried out using Doty's method. His postoperative course was uneventful. Catheterization study, carried on one month after surgery, revealed complete disappearance of supravalvular aortic stenosis and mitral regurgitation. In review of the literature, as far as we know, report of successful combined correction for supravalvular aortic stenosis and mitral regurgitation is extremely rare.     

Current surgical treatment for acquired valvular heart disease

We discuss the current status of surgical treatment for acquired valvular heart disease. Mitral valve repair for organic and functional mitral regurgitation is the first choice instead of valve replacement. It is important that surgery for functional mitral regurgitation restores the geometry of the left ventricle and mitral valve. The reduction of mitral valve tethering for functional mitral regurgitation is a current topic of discussion. At present, the surgical procedure for both aortic stenosis and aortic regurgitation is valve replacement in most cases, although aortic valve repair has been attempted for aortic regurgitation in recent years. The early results of aortic valve repair are excellent, but the long-term results have not been clarified. The durability of valve repair in both the mitral and aortic position is a future issue and it may be improved by revising the indications for valve repair and using new surgical techniques.     

Long-term survival after single aortic or mitral valve replacement with the present model of Smeloff-Cutter valves

Two hundred fourteen survivors of single aortic (AVR) or mitral valve replacement (MVR) were evaluated. The present model of the Smeloff-Cutter prosthesis was used in these patients, and the series was started in September, 1966, following the last structural change in the valve. Clinical follow-up ended in September, 1976. Bleeding, thromboembolism, and peristent left ventricular dysfunction were the major complications. Thromboembolism occurred at a rate of 0.13 percent per month of patient follow-up. Late deaths occurred in 19.2 percent of patients, half of these within the first year. Acturarial data indicated a 5 year survival rate of approximately 75 percent after both mitral and aortic replacements. Bleeding and thromboembolism were more frequent causes of death after mitral replacement. Myocardial function was of greatest importance in long-term survival after replacement of either valve. Variations in warfarin dosage significantly affected both bleeding and thromboembolic complications.     

Influence of concomitant mitral valve dysfunction on survival after aortic valve replacement

Aortic valve pathology is the most common acquired valvular heart disease in the adults of western countries, and mitral regurgitation (MR) is often clinically present in patients with degenerative aortic stenosis or insufficiency. Many studies report an incidence of MR between 65-75% in patients evaluated for aortic valve replacement. Severe aortic valve disease may be associated with functional mitral regurgitation (FMR) defined as the failure of mitral valve to prevent systolic backward flow in the absence of any significant structural or intrinsic valvular disease. Increased afterload and left ventricular remodeling have been implicated to explain FMR in patients with aortic valve disease. Moreover, organic mitral valve disease can be associated with aortic stenosis and can be rheumatic or degenerative. We have examined the data of the literature to understand the evolution of MR, the impact of mitral regurgitation on the outcome of patients undergoing aortic valve replacement, and to determine clinical predictors of prognosis in patients with concomitant MR at the time of aortic valve replacement.     

Combined techniques for double valve replacement in the infant

A 6-month-old female infant was seen with heart failure secondary to severe aortic and mitral regurgitation. As a neonate the infant had undergone an aortic valvotomy for congenital aortic stenosis. Subsequently the infant had aortic and mitral regurgitation with an infarcted papillary muscle. Double valve replacement was carried out with the St. Jude valve. The first approach was by the Manouguian procedure with extension of the aortotomy out between the left coronary cusp and the noncoronary cusp. The posterior mitral apparatus was resected, and a 19-mm St. Jude aortic valve was sewn into the mitral position. Because the enlarged aortic valve annulus was still inadequate to accommodate a 19-mm St. Jude valve, a Konno procedure was carried out to enlarge the aortic ring anteriorly. Atrial, septal, and aortic repair and right ventricular outflow tract reconstruction were carried out with bovine pericardium. Bypass was carried out with standard techniques of hypothermia, aortic cross-clamping, and cardioplegia. Postoperative anticoagulation therapy was initially with aspirin and dipyridamole (Persantine); however, clotting of the mitral prosthesis necessitated treatment with urokinase and heparin, which completely resolved the clot. Sodium warfarin (Coumadin) therapy was then begun. One year postoperatively, the child is developing normally.     

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.     

Enucleation of calcium core and in-situ valve replacement for massive posterior mitral annular calcification

A 67-year-old female was admitted to our hospital for surgical treatment of the aortic and mitral valvular disease. She had chronic renal failure and dialysis was started 13 years previously. A diagnosis of severe aortic stenosis and regurgitation with severe mitral stenosis was made, and she underwent aortic valve and mitral valve replacement. Because mitral annular calcification had deeply invaded into the subvalvular region, enucleation of calcified core was performed using the ultrasonic aspiration system. The posterior mitral annulus was reconstructed using equine pericardium and aortic and mitral valve replacement was performed. The postoperative course was uneventful.     

A New Modification of Debridement Valvuloplasty for Acquired Aortic Valve Disease

A high speed electric rasp was used to remove fibrous thickening from the aortic valve in conjunction with aortic valve commissurotomy in ten patients. All patients had moderate rheumatic aortic valve disease combined with severe mitral valve disease, and were treated by mitral valve replacement and aortic valve repair. All patients survived the operative procedure. There were no deaths or complications during hospitalization related to the valve repair process. The transaortic valve gradient was relieved from an average of 21.0 ± 8.6 mmHg to 5.6 ± 4.0 mmHg (catheterization), and from moderate to less-than-mild stenosis (echocardiography). Aortic valve regurgitation was reduced from an average of 2.2+ to 0.7+ on a scale of 0 to 4+ (aortography), and from an average of 2.5+ to 1.1+ on a scale of 0 to 4+ (echocardiography). During the follow-up period, no patients were reoperated on because of aortic valve dysfunction. Follow-up echocardiographic study demonstrated that the transaortic pressure gradient and valvular regurgitation had not progressed, and immediate postoperative conditions were maintained. There were two late deaths not related to the aortic valve. One patient died of prosthetic valve endocarditis in the mitral prosthesis 14 months postoperatively, and the other of a cerebrovascular accident 21 months postoperatively. Based on these data, we believe that aortic valve repair with a high speed electric rasp can effectively relieve aortic stenosis, reduce valvular regurgitation, and provide an excellent hemodynamlc result at early and mid-term follow-up. (J Card Surg 1994;9:103–108)     

Mitral valve replacement in the first year of life

From 1973 through 1987 25 patients underwent mitral valve replacement in the first year of life for mitral stenosis and mitral regurgitation. The patients with mitral stenosis included two with mitral arcade, two with supravalvular mitral stenosis with hypoplastic mitral valve, and one with parachute mitral valve. Included in the group of patients with mitral regurgitation were 12 with atrioventricular canal defect, six with chordal and leaflet defects, one with Marfan's syndrome, and one with bacterial endocarditis. Prostheses included 12 Bj?rk-Shiley (17 mm), seven St. Jude Medical (19 mm in four, 21 mm in three), five stent-mounted dura mater valves (12 mm to 16 mm), and one porcine xenograft (19 mm). In four patients the valves were placed in the left atrium in a supraannular location. There were nine operative (atrioventricular canal defect seven, mitral regurgitation two) and five late (atrioventricular canal defect four, mitral stenosis one) deaths, giving actuarial 1- and 5-year survival rates of 52% and 43%, respectively. All 6 patients with tissue valves died; the four with supraannular mitral valve replacement survived. Since 1983 operative mortality has been reduced to 0% (70% confidence limits 0% to 24%). Nine patients required a second mitral valve replacement for prosthetic stenosis 5 to 69 (mean 30) months after the original mitral valve replacement (one operative death). Because of improvements in repair of atrioventricular canal defect in infancy, the need for mitral valve replacement at atrioventricular canal defect repair has decreased. Although valvuloplasty has been advocated for repair of congenital mitral valve disease and is applicable in some infants with mitral regurgitation, mitral valve replacement is frequently unavoidable for congenital mitral disease and can now be accomplished at a low operative risk, even when the prosthesis has to be positioned supraannularly.