Explantation of a 44-year-old Starr–Edwards mitral valve for delayed hemolysis

Abstract

FIGURE 1. Starr–Edwards 44-year-old explanted mitral valve, model 6120, with sewing ring removed. Valve is intact, with yellowing of ball. CLINICAL SUMMARY A 68-year-old woman was admitted 44 years after undergoing mitral valve replacement with a Starr–Edwards (SE) prosthesis (Edwards Lifesciences, Irvine, Calif) for rheumatic mitral valve stenosis. Since implantation of the prosthesis in 1965 via thoracotomy, the patient had done well and maintained her anticoagulation with warfarin sodium (Coumadin). She now had fatigue and anemia. Of note, 2 years earlier the patient had had third-degree heart block necessitating the implantation of a dual-chamber pacemaker. A full workup including upper and lower endoscopy did not reveal a source of bleeding. Hematologic testing showed decreased haptoglobin, a high lactic dehydrogenase value, and increased reticulocyte count, consistent with a hemolytic anemia. Bone marrow biopsy was performed, which showed erythroid hyperplasia, normocellular bone marrow, normal megakaryocytes, and absent iron, indicative of iron deficiency anemia. Despite iron replacement therapy she continued to become increasingly transfusion dependent. She received 9 units of blood in 1 month alone. Echocardiogram revealed normal prosthetic mitral valve function with a mitral valve mean gradient of 6 mm Hg, a severely calcified aortic valve with an aortic valve mean gradient of 58 mm Hg, and an aortic valve area of less than 1.0 cm. Aortic and mitral valve replacements were performed with bioprosthetic valves. Reoperative median sternotomy was performed. After standard cannulation, Sondergaard’s groove was used to expose the mitral valve. The SE valve was in good condition without paravalvar leak. The mitral valve was explanted. The SE ball and cage were undamaged (Figure 1). There was no evidence of cloth tears or pannus overgrowth. The color of the ball had changed, presumably from lipid infiltration, but the ball was otherwise without pitting or defects. The patient underwent successful aortic valve replacement with a 21-mm Edwards Magna Thermafix bovine pericardial valve (Edwards) and mitral valve replacement with a 25-mm St Jude Epic porcine valve (St Jude Medical, Inc, St Paul, Minn). The patient was discharged