Bentall procedure 39 years after implantation of a Starr-Edwards Aortic Caged- Ball-Valve Prosthesis
© Schmitto et al; licensee BioMed Central Ltd. 2010
Received: 2 November 2009
Accepted: 18 March 2010
Published: 18 March 2010
We report a case of a male patient who received an implantation of a Starr-Edwards-caged-ball-valve-prosthesis in 1967. The surgery and postoperative course were without complications and the patient recovered well after the operation. For the next four decades, the patient remained asymptomatic - no restrictions on his lifestyle and without any complications. In 2006, 39 years after the initial operation, we performed a Bentall-Procedure to treat an aortic ascendens aneurysm with diameters of 6.0 × 6.5 cm: we explanted the old Starr-Edwards-aortic-caged-ball-valve-prosthesis and replaced the ascending aorta with a 29 mm St.Jude Medical aortic-valve-composite-graft and re-implanted the coronary arteries.
This case represents the longest time period between Starr-Edwards-caged-ball-valve-prothesis-implantation and Bentall-reoperation, thereby confirming the excellent durability of this valve.
In January 2006, 39 years after the initial operation, the patient became increasingly symptomatic for six weeks - progressive dyspnea and chest pain (angina-pectoris according to CCS III). Myocardial scintigraphy and coronary angiography were performed and revealed diffuse, but insignificant atherosclerosis (possibly explaining his acute deterioration). An aortic angiogram revealed high grade post-valvular aneurysm of the ascending aorta. This was also proven on computed tomography of the thorax: the dimensions of the aortic aneurysm were 6.0 × 6.5 cm, with normal physiological diameters distally, with no evidence of an aortic dissection. Additionally, echocardiography demonstrated: middle-grade dilatation of the left atrium, high-grade dilatation of the left ventricle and a left ventricular ejection fraction (EF) severely reduced to 30%. The functionality of the prosthesis presented borderline values, but regular flow.
Of note, this coincidentally is the latest Bentall-procedure after 39 years of survival of a Starr-Edwards-valve implantation found in the literature .
The Starr-Edwards caged-ball-valve prosthesis (Edwards Lifesciences, Nyon, Switzerland) was implanted routinely for many years in heart centers worldwide. By 1967, nearly 2000 Starr-Edwards-valves had been implanted  - establishing the caged-ball-valve prosthesis as the standard surgical treatment for aortic and mitral valve disease. Due to the fact that the Starr-Edwards valves showed a high ventriculo-aortic outflow pressure gradient and also a higher incidence of poststenotic dilations of the ascending aorta in long-term follow-up, newer models had to be developed to increase the valve's hemodynamics. Therefore, new valve prostheses were manufactured using several different materials, including: pericardium, fasciae latae, and dura mater. In the 1960s, Binet and colleagues began to develop tissue valves . Then in 1964, Duran and Gunning (Oxford, England) replaced an aortic valve in a patient using a xenograft porcine aortic valve . The early results of the Starr-Edwards-valve were good , however after a few years these patients developed signs of chronic heart failure, due to the poor hemodynamics of the valve. In addition, the caged-ball-valves showed a higher incidence of thrombembolic complications compared to the newer valve developments. However, there is one large series reporting on 2,247 aortic valve replacements with Starr-Edwards prostheses implanted between 1960 and 1997 . In this study, Kaplan-Meier (KM) survival at 10 years was 53% for Aortic Valve Replacement, 23% at 20 years, 8% at 30 years and 4% at 40 years. Even in this study no Bentall operation after such a long time period was presented. We therefore present the longest time period between Starr-Edwards-caged-ball-valve-prothesis implantation and Bentall reoperation of a long-term survivor, thereby confirming the excellent durability of this valve.
Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
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