Aortic ball-valve (Starr-Edwards) prostheses. A follow-up evaluation

Results of reoperation for periprosthetic leakage

Between 1961 and 1978, 6,602 valves were replaced in 5,660 patients. Reoperation for periprosthetic leakage was performed in 105 patients (1.6% of the valves); early mortality was 5.7%. At reoperation, 52% of patients were in New York Heart Association Classes III and IV, whereas 72% had been in Classes III and IV prior to the primary valve replacement. Seventy-five patients had aortic periprosthetic leaks, which were distributed equally around the annulus. Among these patients, 41 (55%) had aortic valve rereplacement and 34 (45%) had suture repair. At 5 years, the survival was 94% and the event-free survival was 71%. Seventeen patients had multiple aortic valve reoperations. Hospital mortality for the second reoperation was 5.8%. At late follow-up, 19 patients had murmurs of residual or recurrent aortic periprosthetic leakage. Twenty-nine patients had mitral periprosthetic leaks, most often near the anterior leaflet. Eight patients had mitral valve rereplacement, and 21 had suture repair. At 5 years, the survival was 75% and the event-free survival was 52%. Four patients underwent multiple reoperations. At late follow-up, 5 of the 29 patients in the mitral valve group had murmurs of residual or recurrent periprosthetic leakage. One patient had tricuspid valve rereplacement. The low hospital mortality and the good late results have encouraged us to recommend an aggressive approach in the correction of periprosthetic leakage in all symptomatic and selected asymptomatic patients.

Retrograde left ventricular catheterization in patients with an aortic valve prosthesis

Twenty-seven consecutive patients with an aortic valve prosthesis were evaluated with retrograde left ventricular catheterization. The prosthesis was successfully crossed, permitting hemodynamic and angiographic evaluation of function of the prosthetic valve, left ventricle and mitral valve in all 27 cases. No complications were encountered. In patients with active endocarditis or recent embolization, the retrograde technique was avoided when possible, and attempts were made to utilize other techniques for study. However, three such patients were evaluated with the retrograde technique without complication. Examination of pressure tracings and cineangiographic films suggested only minor interference with valve poppet movement induced by the catheter transversing the valve. In three cases, hemodynamic data were recorded with the catheter crossing the prosthesis at one time and a paraprosthetic valve defect at another time. Identical gradients were recorded. This series documents the safety and efficacy of the retrograde approach, which is proposed as an alternative to the transseptal technique and left ventricular puncture.

Cineradiographic evaluation of prosthetic cardiac valves

Forty-nine patients whose clinical symptoms suggested a leaking cardiac prosthetic valve were studied by both cineradiography and angiocardiography. We found a wider range of tilting motion of the nonleaking mitral valve than has been previously shown. An angle of tilt greater than 6° for the prosthetic aortic valve strongly suggests separation of the prosthesis from its bed with a paravalvular leak, while the angle of tilt suggestive of a paravalvular leak for a prosthetic mitral valve is 12°. However, a tilt of less than these values does not entirely exclude the existence of a leak. We strongly suggest that routine cineradiography be done in each patient shortly after surgery, as a basis for comparison if the patient later develops a murmur or congestive heart failure.

Ultrasonic decalcification of calcified cardiac valves and annuli

Heavily calcified annuli increase the incidence of complications after prosthetic valve replacement-heart block, separation of the aorta or the atrium from the ventricle, late aneurysm formation, paravalvular leak, and haemolysis. An ultrasonic calculus-disintegrator has been developed to remove calcific deposits. The instrument is portable, robust, easily sterilized, inexpensive, and provides nebulized water at the ultrasonic tip which keeps the tissues cool, helps to break up the calculus by cavitation, and washes the calcific debris into the sucker. Preliminary trial on excised calcific valves showed the ultrasound instrument to be capable of removing most forms of calcification. In clinical prosthetic replacement of valves it enabled good clearance of the annulus to be performed in six out of seven cases, in one of which earlier operation had been unsuccessful because of calcification. Two elderly patients with pure calcific aortic stenosis were successfully treated by debridement of the aortic valve with ultrasound.

Survival after Starr-Edwards aortic valve replacement

A series of 507 patients who underwent Starr-Edwards aortic valve replacement is reported. Four hundred fifty-five of these patients were adequately followed an average of 36 months. Of this number, 339 patients (75%) are alive, and 116 (25%) have died. There was an operative mortality of 10.8% and a late mortality of 13.4%. Patients with mixed aortic stenosis and regurgitation had a significantly lower cumulative mortality than patients with pure stenosis or regurgitation. Complications related to the valvular prosthesis itself were frequent. Although the great majority were minor, prosthetic complications caused a significant number of deaths and considerable morbidity. Myocardial disease was the other significant limiting factor in survival. Preoperative cardiac index and functional classification were valuable in predicting long-term survival, but age at time of surgery and type of preoperative symptoms were of lesser prognostic value.

Major detachment of aortic prosthetic valves

The clinical and investigatory findings in five instances of major detachment of an aortic valve prosthesis in four patients are described. This situation was associated with auscultatory and peripheral signs of aortic regurgitation and, in addition, a mid-diastolic murmur in the mitral area. From the haemodynamic and operative findings it was postulated that, in addition to severe aortic regurgitation, disturbance of mitral valve function occurred both in systole and diastole caused by the pivoting of the prosthesis attached to the base of the aortic leaflet of the mitral valve. Cardiac fluoroscopy confirmed the diagnosis.