Asian Cardiovasc Thorac Ann 2006;14:333-335
© 2006 Asia Publishing EXchange Ltd
Unusual Structural Valve Degeneration in a Cloth-Covered Starr-Edwards Valve
Manoj Kuduvalli, FRCS,
Sanjay V Ghotkar, FRCS,
Brian M Fabri, FRCS
Department of Cardiothoracic Surgery, Cardiothoracic Center, Liverpool, United Kingdom
For reprint information contact: Manoj Kuduvalli, MD Tel: 44 151 724 1954 Fax: 44 151 724 1954 Email: manojkud{at}hotmail.com, Flat 24, Hawthorne House, Park Avenue, Mossley Hill, Liverpool L18 8BT, United Kingdom.
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ABSTRACT
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Structural valve degeneration in a mechanical ball and cage prosthesis is a well-described entity. Here we describe an unusual case of structural valve degeneration of a cloth-covered composite-seat Starr-Edwards ball and cage valve prosthesis in the mitral position, where degeneration of the cloth covering of the seat of the valve led to significant intravalvular mitral regurgitation.
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CASE REPORT
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A 68-year-old lady presented with progressive dyspnea on exertion over the previous two years, and repeated admissions with heart failure in recent months. She had suffered from rheumatic fever at the age of 10, and this resulted in severe mitral regurgitation. She had a mitral valve replacement performed in January 1972 with a size 4M cloth-covered composite-seat Starr-Edwards ball and cage prosthesis, Model 6310 (Edwards Lifesciences LLC, Irvine, CA, USA). Other medical history in recent years included a myocardial infarction in 1996 and a CVA during the same year, from which she recovered completely. She suffered from non-insulin dependent diabetes mellitus, which was well controlled, and had been in chronic atrial fibrillation for a number of years, treated with digoxin. She was also anemic with a hemoglobin level of 10.8 gm·dL–1.
Transthoracic echocardiography showed evidence of mild left ventricular systolic dysfunction, with a high gradient across the mitral valve of 18 mm Hg. There was some mitral regurgitation, which was classified as mild. The left atrium was dilated at 6.2 cm. The aortic valve was normal and the right heart was of normal size and function.
Cardiac catheter studies showed a left ventricular end diastolic pressure of 13 mm Hg, pulmonary artery pressure of 66/17 mm Hg and a pulmonary capillary wedge pressure trace with an 
; wave of 18 mm Hg, v wave of 14 mm Hg and a mean of 20 mm Hg. The gradient across the mitral valve prosthesis was 9.6 mm Hg at rest, and 12.2 mm Hg with the leg raised. Left ventricular angiogram showed mild global hypokinesia and mild to moderate mitral regurgitation. Selective coronary angiography showed significant sequential stenoses in the left anterior descending (LAD) artery and a 50% stenosis in the mid-circumflex artery. The right coronary artery was dominant with mild plaque disease. A myocardial perfusion scan did not show any evidence of stress-induced ischemia in the LAD or circumflex artery territories.
Elective redo mitral valve replacement was undertaken. Preoperative transesophageal echocardiography showed moderate to severe mitral regurgitation (Figure 1
) that appeared to be intravalvular. The estimated gradient across the mitral prosthesis under general anesthesia was 10 mm Hg. Subsequent to sternotomy and adhesionolysis, routine cardiopulmonary bypass was established using ascending aortic and bi-caval cannulation. Continuous retrograde warm blood cardioplegia was used for myocardial protection. The left atrium, which was moderately enlarged, was opened by a paraseptal incision. There was no evidence of paravalvular leak. However there was some evidence of pannus formation, predominantly around the valve orifice. The cloth covering of the Starr-Edwards valve appeared to have completely eroded away from the valve seat, but not from the cage. A tag of degenerated cloth was hanging out from the valve seat into the left ventricle. The Starr-Edwards valve was explanted, and a 31 mm ATS Medical mechanical bi-leaflet valve (ATS Medical, Inc., Minneapolis, MN, USA) was implanted using interrupted polyester sutures. The patient made a good recovery from her operation, except for some mild transient weakness of her left upper limb, which improved significantly prior to discharge from hospital on the 12th postoperative day.
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Figure 1. Color flow mapping in the transesophageal echocardiogram showing mitral regurgitation across the prosthetic valve.
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DISCUSSION
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The development of cloth-covered Starr-Edwards aortic and mitral prostheses with stellite metal poppets appeared to decrease the incidence of thromboembolism and prosthesis dysfunction caused by thrombus formation or ball variance observed in the earlier model Starr-Edwards valves.1 However, the initial series of cloth-covered valves (Models 2300 aortic and 6300 mitral valves) were found to be functionally stenotic, with pressure gradients considerably in excess of previous Starr-Edwards prostheses.2 The subsequent designs: Models 2310 aortic and 6310 mitral prostheses, were the result of modifications designed to correct this inherent functional stenosis. The valve orifice was widened, and the ratio of orifice to cross-sectional area of the poppet was increased. To accomplish this without producing excessive shearing forces by the poppet on the cloth covering of the valve seat, a composite-seat was designed. This consisted of multiple small metal pegs that protruded through the cloth covering in the valve seat and on which the stellite poppet rested when the valve was in the closed position.3
Closer examination of the explanted valve in this case revealed the etiology of the significant mitral regurgitation that was observed on transesophageal echocardiography. Degeneration of the cloth covering from the seat of the valve had resulted in multiple small orifices being formed between the stellite poppet and the uncovered metal pegs in the valve seat, when the valve was in the closed position (Figure 2). This resulted in multiple small jets of intravalvular mitral regurgitation, which cumulatively resulted in a significant regurgitant volume. Furthermore, the regurgitating jets through these multiple small orifices could also have been causing significant hemolysis, which may have explained her anemia.
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Figure 2. The explanted Starr-Edwards valve showing the multiple small orifices being formed between the stellite poppet and the uncovered metal pegs in the valve seat, when the valve is in the closed position
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Degeneration of the cloth covering of the Starr-Edwards prosthesis has been reported earlier.4,5,6 However, it mostly presented as increased transvalvular gradients with pannus and/or thrombus formation. This case was unusual because degeneration of the cloth covering from the valve seat of the composite-seat Starr-Edwards prosthesis resulted in significant mitral regurgitation, along with some degree of stenosis that was possibly due to pannus formation around the orifice.
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ACKNOWLEDGMENTS
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Our thanks to Dr. Glenn Russell, Consultant Cardiac Anesthetist, Cardiothoracic Center, Liverpool, for his help in producing this case report.
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REFERENCES
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- Hodam R, Starr A, Raible D, Griswold H. Totally cloth-covered prostheses. A review of two years’ clinical experience. Circulation 1970;41:II33–8.
- Kloster FE, Herr RH, Starr A, Griswold HE. Hemodynamic evaluation of a cloth-covered Starr-Edwards valve prosthesis. Circulation 1969;39:I119–25.
- Kloster FE, Farrehi C, Mourdjinis A, Hodam RP, Starr A, Griswold HE. Hemodynamic studies in patients with cloth-covered composite-seat Starr-Edwards valve prostheses. J Thorac Cardiovasc Surg 1970;60:879–88.[Medline]
- Lamberti JJ, Gupta DS, Falicov R, Anagnostopoulos CE. An unusual form of late stenosis after aortic valve replacement with a cloth-covered Starr-Edwards prosthesis. Chest 1977;71:89–90.
- Marbarger JP Jr., Clark RE. The clinical life history of explanted prosthetic heart valves. Ann Thorac Surg 1982;34:22–33.[Abstract]
- Tsukamoto S, Shiono M, Orime Y, Hata H, Yagi S, Okumura H, et al. Macroscopic aspects of cloth-covered Starr-Edwards prostheses at reoperation: what the precursory valve teaches us. J Heart Valve Dis 1998;7:556–60.[Medline]
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ABSTRACT
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