Performance profile of the Starr-Edwards aortic cloth covered valve, track valve, and silastic ball valve

Modern concepts from old ideas in manufacture of cardiac valve prostheses

In reviewing the history of mechanical prosthetic valves, it appears evident how many improvements and technical advances have been obtained in this field. Looking to the past, it must also be underlined how some old concepts, which can be considered quite revolutionary for those years, clearly indicate the great skill and ingenuity of those who conceived them. Old ideas have been revitalized by modern concepts, and this is exemplified when considering the developments of bileaflet and sutureless prostheses.

Starr-Edwards aortic valve: 50+ years and still going strong: a case report

The advent of the Starr-Edwards mechanical valve marked the beginning of the modern era for heart valve replacement. Nowadays, this valve has been supplanted by lower profile bileaflet mechanical prostheses that are considered to have better haemodynamics, lesser risk of thrombo-embolic complications, and longer durability without structural prosthesis failure. These assumptions often lead physicians to face with the question of systematically replacing functional Starr-Edwards valves in patients undergoing redo operations on other valves. We report the case of a 67-year-old patient who recently underwent mitral valve replacement for symptomatic rheumatic valve disease with an excellent outcome. During the operation, the Starr-Edwards valve in the aortic position implanted 51 years earlier was found to still functioning normally hence was left in place, thereby breaking a new longevity record for a valve prosthesis.

An old friend is still at work: 34-year-old well functioning Starr-Edwards aortic prosthesis without anticoagulation

The Starr-Edwards caged-ball valve prosthesis is the beginning mark of the valve replacement era, and was used widely in many centers worldwide in the past decades. Despite long term results with this prosthesis have been reported with satisfactory hemodynamic performance, only a few cases have been reported exceeded 30 years of durability. We report the case of a patient with a 34-year-old well-functioning Starr-Edwards ball prosthesis in aortic position using neither antiaggregant nor anticoagulant therapies.

Long-Term Results of the Cloth-Covered Starr-Edwards Ball Valve

BACKGROUND

Between June 1968 and March 1977, Starr-Edwards cloth-covered ball valves were exclusively implanted, in a total of 74 patients at our institution, on a routine basis.

METHODS

The retrospective postoperative follow-up rate was 84.5%, for up to 36 years in mitral valve patients (982.5 patient-years); and 81.3%, for up to 34 years in aortic valve patients (282.0 patient-years). Among 66 operative survivors, 20 patients required reoperation due to valve-related complications. Mortality and morbidity after valve replacement was reviewed, and excised valves were examined.

RESULTS

Survival rates after 10, 20, and 30 years were 74.6%, 64.1%, and 31.2%, respectively, after mitral valve replacement, and 62.5%, 50.0%, and 43.8%, respectively, after aortic valve replacement. Freedom from all valve-related complications, respectively after 10, 20, and 30 years, was 70.5%, 55.9%, and 46.4% after mitral valve replacement, and 56.2%, 37.5%, and 31.2% after aortic valve replacement. Cloth wear or pannus overgrowth was observed in all excised prostheses. Remarkable orifice tear was observed in mitral valves that were more than 20 years old. Pannus overgrowth on the studs contributed to prosthetic regurgitation in the older valves. Concomitant valve procedures were frequently required for valve-related complications or other aggravated valve lesions in the mitral position during the follow-up period.

CONCLUSIONS

Early diagnosis of valve dysfunction and the decision to reoperate are important to improve the long-term results for surviving patients who have received a cloth-covered Starr-Edwards valve, especially in the mitral position.

Valve dysfunction of the cloth-covered Starr-Edwards ball valve

BACKGROUND

Between June 1968 and March 1977, Starr-Edwards cloth-covered ball valves were used for valve replacement on a routine basis.

METHODS AND RESULTS

Among the 66 operative survivors who underwent an isolated aortic or mitral valve replacement, 20 patients required reoperation 22 times because of valve dysfunction, thromboembolic complication, paravalvular leakage, hemolytic anemia, and/or prosthetic valve endocarditis. Reoperation was performed at a mean of 15.9+/-9.8 years after initial replacement. Excised valves were examined and reoperation after initial operation was reviewed. Operative mortality was 10.0%. Freedom from reoperation for aortic valve replacement and mitral valve replacement was 56.2% at 34 years and 61.0% at 37 years after initial operation, respectively. Cloth wear or pannus formation were observed in all excised prostheses. Orifice cloth was more markedly worn in mitral valves than in aortic valves, particularly in mitral valves of more than 20 years old. Pannus overgrowth contributed to valve regurgitation in the older valves.

CONCLUSIONS

Early diagnosis of valve dysfunction and reoperation are recommended as soon as symptoms appear.

Replacement of an aortic Starr-Edwards ball valve prosthesis 28 years after implantation

A 53-year-old woman who had undergone aortic valve replacement with a Starr-Edwards (S-E) valve (Model 1260) and open mitral commissurotomy 28 years previously was hospitalized with cardiac failure. Echocardiography showed mitral stenosis, mitral regurgitation, and a normally functioning S-E prosthesis. At reoperation, the mitral and aortic valves were replaced with St Jude bileaflet mechanical prostheses. Examination of the explanted S-E prosthesis revealed no structural abnormality other than lipid infiltration of the silastic ball.

Unexpected durability of Smeloff-Cutter aortic ball valve prosthesis

We report a case in which replacement of a Smeloff-Cutter aortic ball prosthesis was required 28 years after initial implantation. A 57-year-old woman underwent aortic valve replacement with a 21-mm Smeloff-Cutter ball prosthesis and open mitral commissurotomy for aortic stenosis, aortic regurgitation, and mitral stenosis in 1973. Severe aortic regurgitation occurred in April 2001, and aortic valve reoperation combined with mitral valve replacement was successfully performed. The patient's aortic ball valve was nearly intact with perivalvular leakage probably causing the aortic regurgitation. Our experience documents longer durability for the Smeloff-Cutter prosthesis than has been reported to date.

Repeated thromboembolic and bleeding events after mechanical aortic valve replacement

BACKGROUND

The choice of a valve substitute in young adults requires a decision balancing the risks of long-term anticoagulation versus reoperation(s). This article analyzes the long-term risk and determinants of thromboembolic (TE) and bleeding (BLE) complications after mechanical aortic valve replacement (AVR).

METHODS

From December 1963 to January 1974, 249 patients survived a mechanical AVR at our institution. Mean age was 41.8+/-12.4 years and 81% (n = 202) were male. Ball valves were implanted in 24% (n = 61) and disc valves in 76% (n = 188). Patients were anticoagulated with vitamin K antagonists and dipyridamole. A total of 4,855 patient-years was available for analysis. Mean follow-up was 19.5+/-9.4 years and was 100% complete. Analyses were performed with Kaplan-Meier and multivariable Cox regression methods.

RESULTS

One hundred and two patients had one TE or BLE postoperative event and 58 patients had two postoperative events. Six patients had more than five postoperative events. Freedom from a first postoperative event was 74.8%+/-2.9%, 55.3%+/-3.5%, and 46.8%+/-4.0% at 10, 20, and 30 years, respectively. Freedom from a second postoperative event was 45.4%+/-5.4%, 29%+/-6.0%, and 23.2%+/-7.1% at 10, 20, and 30 years, respectively. Multivariate predictors for TE or BLE complications were ball valve (Odds Ratio (OR) = 2.9), postoperative endocarditis (OR = 2.2), and any surgery (OR = 2.2). The incidence of events was highest the first 5 postoperative years.

CONCLUSIONS

The risk of adverse events is highest the first 5 postoperative years. Once an event has occurred, the risk for a second event is increased. The incidence and frequency of events is substantial and should be considered in the choice of a valve substitute.

Standard aortic St. Jude valve at 18 years: performance profile and determinants of outcome

BACKGROUND

The standard St. Jude disc valve has been in use for 20 years and remains the dominant mechanical valve of today. With nearly 19 years of follow-up, the present large series could indicate the performance profile and its determinants in the very long term.

METHODS

A detailed follow-up was performed to a maximum of 18.6 years in 694 patients aged 15 to 83 years who undervent aortic valve replacement (AVR) with the standard St. Jude valve during 1980 to 1993. The Cox regression analysis was used to identify independent determinants of outcome in the aortic stenosis (n = 490) and regurgitation (n = 204) groups.

RESULTS

Overall survival was 58%, 39%, and 37% at 10, 15, and 18 years, respectively. Only 12% of deaths (0.60%/ patient-year) were related to the valve with a 15-year freedom of 91%. Embolism (1.18%/patient-year) and anticoagulant-related bleeding (2.24%/patient-year) were the dominant complications with 10-year/15-year freedoms of 90%/80% and 85%/72%, respectively. Only 24% of bleeding events were classified as major. Valve thrombosis occurred in 2 patients (0.04%/patient-year): 1 did not receive vitamin K antagonist treatment and International Normalized Ratio was below target level in the other. There were no mechanical failures. Endocarditis (0.42%/patient-year) and paravalvular leak (0.42%/ patient-year) occurred with 15-year freedoms of 92% and 96%, respectively, with a relation between the latter (but not the former) and preoperative endocarditis in the regurgitation group. Freedom from serious complications (2.33%/patient-year) and all complications joined (4.33%/ patient-year) were 72% and 54%, respectively, at 15 years with a 96% freedom from redo AVR (0.36%/patient-year). Age- and heart-related variables were independent risk factors for mortality, thromboembolism, bleeding, serious complications, and all complications joined. Small valve (19 and 21 mm) adversely affected serious and all complications in the regurgitation group.

CONCLUSIONS

With a follow-up approaching 2 decades and exhibiting a low rate of valve-related deaths, acceptable low thrombogenicity, and absence of mechanical failure, the standard aortic St. Jude disc valve sets the standard for contemporary mechanical valves.