key: cord-0854565-dkkjcia8
authors: Masiello, Paolo; Citro, Rodolfo; Mastrogiovanni, Generoso; Bellino, Michele; Frunzo, Francesco; Orlando, Michele; Iesu, Ivana; Cafarelli, Francesco; Triggiani, Donato; Iesu, Severino
title: Caged-Ball Mitral Prosthesis Explanted After 50 Years
date: 2021-06-16
journal: JACC Case Rep
DOI: 10.1016/j.jaccas.2021.03.029
sha: 255b64d2cee902cfe91afb27b8a43f6d807f7d2c
doc_id: 854565
cord_uid: dkkjcia8

We report a unique case of a Starr-Edwards prosthesis (model 6310, cloth covered) implanted in the mitral position by Christian Barnard that was successfully explanted and replaced after 50 years, the longest period free from valve dysfunction ever reported. Reoperation also included replacement of the native aortic valve combined with tricuspid valve annuloplasty. (Level of Difficulty: Beginner.)

tion during the past few years, was admitted for the onset of exertional dyspnea and palpitations. She had been febrile (38.2 C) for 2 days. Physical examination revealed an arrhythmic pulse, a mean heart rate of 118 beats/min, regular arterial pressure (systolic blood pressure 110 mm Hg, diastolic blood pressure 70 mm Hg), and normal oxygen saturation. At cardiac auscultation, a holosystolic, rumbling, Levine grade 3 murmur radiating to the left armpit and not described previously was heard. A diastolic, rolling, Levine grade 2 murmur was also detectable at the apex.

Thoracic auscultation revealed basal bilateral pulmonary rales. As a caged-ball Starr-Edwards mitral prosthesis holder, she was on oral anticoagulation therapy. Notably, the international normalized ratio (INR) level was 2.7 on arrival, and the patient maintained good adherence to warfarin. Atrial fibrillation was documented by the electrocardiogram. Echocardiography revealed a normal ejection fraction, no significant variation in the mitral transprosthetic gradient, and a perivalvular leak originating from the postero-medial region of the prosthetic ring.

The woman's past medical history included rheumatic heart disease, diagnosed at the age of 5 years and resulting in the development of severe mitral

To be able to correctly handle follow-up of patients with prosthetic valves characterized by both high durability and non-negligible rates of various complication. To understand the role of echocardiography in the prompt identification of complications and directing the surgical strategy.

stenosis. The 1960s were pioneering for cardiac surgery in Europe, and access to cardiac surgical treatment was very difficult in Italy. Her brother, a navy captain who frequented the routes to Africa, had heard about cardiac surgery in South Africa and of Christian Barnard, who became famous at that time for performing the first heart transplantation. After consult with family members, she conducted a long journey, together with her brother, and was addressed to Barnard's management. She underwent mitral valve replacement with a caged-ball Starr- Edwards mitral prosthesis at the Department of Surgery of the University of Cape Town in South Africa when she was 10 years old. Afterward, the patient enjoyed good health, got married when she was 24 years old, and completed 2 pregnancies. Her subsequent medical history was unremarkable, and she did not even experience one of the most common inconveniences of this type of valve, the noise. The patient scrupulously followed oral anticoagulation therapy, keeping her INR between 2.5 and 3.5.

Taking into account the patient's clinical history and presentation, the following conditions should be considered in the differential diagnosis. to range between 51.0% and 75.0%, 23.0% and 61.0%, and 8.0% and 33% at 10, 20, and 30 years, respectively (3, 4) . Freedom of patients from reoperation for mitral valve replacement was reported to range between 94.3% and 96.4%, 83.0% and 87.0%, and 78.9% and 87.0% at 10, 20, and 30 years, respectively (5).

In the present case, the reason for reoperation was the onset of signs and symptoms of heart failure along with echocardiographic evidence of new perivalvular leak. Intraoperative evaluation confirmed heavy calcification involving the sewing ring and leading to partial mitral prosthetic valve dehiscence.

We hypothesize that late onset of dehiscence is related to the slow development of the bulky calcified lesion.

In this context, echocardiography remains the firstline imaging tool for the assessment of prosthetic valves. If valve dysfunction is detected, closer clinical and echocardiographic follow-up is indicated.

The 6-month follow-up was uneventful. The patient was in atrial fibrillation with good heart rate control under beta-blocker therapy and reported improved exercise tolerance. Transthoracic echocardiography revealed a normal left ventricular ejection fraction.

No paravalvular leaks were detected in both the mitral and aortic prosthetic valves. Transprosthetic gradients were within the normal range. No signs of pulmonary hypertension were detected.

To the best of our knowledge, we describe the latest case ever reported of explantation of a Starr-Edwards valve prosthesis in the mitral position before the onset of complications. Of note, despite its 50-year duration, no structural damage to the cage and ball mechanism was detected, confirming the exceptional durability of this "ancient" mechanical prosthetic valve.

The authors have reported that they have no relationships relevant to the contents of this paper to disclose. 

Mitral valve replacement with ball valve prostheses

A Starr-Edwards model 6120 mechanical prosthesis in the mitral valve position for 38 years

Forty-year survival with the Starr-Edwards heart valve prosthesis

Event status of the Starr-Edwards aortic valve to 20 years: a benchmark for comparison