Aortic Ball-valve Prostheses Research Articles

Ascending aortic aneurysm in a patient with an aortic Starr-Edwards ball valve prosthesis implanted 39 years previously

A 53-year-old man who had undergone aortic valve replacement with a Starr-Edwards ball valve prosthesis 39 years previously was admitted to our hospital under the diagnosis of ascending aortic aneurysm. Operative findings revealed that the ball valve was functioning normally. The markedly dilated ascending aorta was replaced with a 30-mm prosthetic vascular graft, and the ball valve was replaced with a19-mm bileaflet valve prosthesis. The patient's postoperative course was uneventful, and he was discharged from our hospital 19 days after surgery. Dilatation of the ascending aorta in this case might have been caused by the poststenotic dilatation mechanism, which seems to be one of the long-term complications of Starr-Edwards ball valve implantation.

Use of the Bentall method for replacement of an aortic Starr-Edwards ball valve prosthesis implanted 32 years previously

We report the case of a 54-year-old woman who, 32 years previously, had undergone replacement of the ascending aorta by the inclusion method with a Starr-Edwards ball valve prosthesis and recently underwent aortic root re-reconstruction by the Bentall method. Routine chest radiography revealed dilatation of the mediastinum, and computed tomography revealed an aneurysm of the ascending aorta. At reoperation, although the cloth covering the cage of the Starr-Edwards ball valve prosthesis appeared worn and some pannus formation was seen, the Starr-Edwards ball valve was functioning normally. The aortic root was replaced with a composite graft that consisted of a 23-mm St. Jude bileaflet prosthesis and a 24-mm Hemashield gold graft. The patient was discharged from the hospital in good condition 25 days after surgery.

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.

Late ball variance with the Model 1000 Starr-Edwards aortic valve prosthesis: Risk analysis and strategy of operative management

The first generation of aortic ball-valve prostheses, used until 1965, was associated with poppet damage owing to fatty infiltration of the silicone rubber ball, a phenomenon termed ball variance. For the Model 1000 Starr-Edwards valves, almost all cases were discovered before 8 years. However, a review of our patients still at risk with the original valve and poppet, prompted by other recent reports of late ball variance, has shown that severe variance can exist up to 20 years after implantation. There is a relationship between the year of valve implantation and the timing and severity of ball variance for the overall series of patients surviving operation, but for the subgroup currently at risk the sample sizes are too small to detect any difference, if one still exists. Only three of 12 patients in the current subset were found to have severe variance. Simple ball change has been the operation of choice. Prophylactic reoperation is not indicated in the current subset, but patients require careful follow-up and should be considered for reoperation should symptoms develop.

Echocardiographic features of aortic ball valve prosthesis malfunction

A case of aortic ball valve prosthesis malfunction is described in which the poppet became alternately stuck in the open and closed position. The patient experienced chest pain followed by pulmonary edema and cardiac arrest. Malfunction of prosthetic valve was diagnosed on echocardiogram and cardiopulmonary resuscitation was carried out until a Bjork-Shiley valve could be inserted in place of the faulty prosthesis. At the time of the operation, poppet migration had occurred and the poppet could not be found. Subsequent Bjork-Shiley aortic valve prosthesis dysfunction was suggested by variation in the intensity of the aortic opening sound and in the duration of the systolic ejection period. Fluoroscopy revealed the missing poppet in the left ventricle. Following surgical removal of the poppet, "normal" Bjork-Shiley valve function was restored.

Bleeding during acetylsalicylic acid and anticoagulant therapy in patients with reduced platelet reactivity after aortic valve replacement

Bleeding complications were evaluated in 148 patients with single Starr-Edwards aortic ball valve prostheses in a study designed to prevent arterial thromboembolism. They received either one gm. of ASA daily or placebo in combination with anticoagulants, and were observed for two years. Only two embolic episodes occurred in patients on combined therapy, as compared to 12 episodes in the placebo group. Fifteen bleeding complications developed in patients receiving ASA, seven during the first month. Two patients suffered intracranial hemorrhage and one died, the others recovered completely. Six episodes occurred in patients on anticoagulants alone; three intracranial complications caused two deaths. The higher incidence of bleeding induced by the combined therapy was entirely due to gastrointestinal hemorrhage, indicating that irritation of mucosa was important in addition to the ASA-induced inhibition of hemostasis. The intensity of anticoagulation correlated significantly with the occurrence of bleeding, and severe blood loss developed only after intensive therapy. This raises the question whether a slightly less intensive anticoagulation in combination with ASA will maintain a satisfactory antithrombotic effect at a lowered risk of bleeding. Platelet adhesiveness, which is partly responsible for primary hemostasis, was reduced in the ball valve patients, and more in those who bled than in the others. It is concluded that the higher incidence of gastrointestinal bleeding in patients who received ASA and anticoagulants than in those on anticoagulants alone was acceptable when compared to the antithrombotic effect achieved with the combined treatment.

Coronary ostial stenosis: a complication of aortic valve replacement of coronary perfusion.

Coronary ostial stenosis developing after aortic valve replacement is a clinically well-recognized entity. This non-atheromatous intimal proliferation may be limited to the proximal part of the coronary artery, probably as a complication of intra-operative coronary perfusion. It may also occur in association with widespread intimal thickening in the aortic root, presumedly as a reaction to turbulence around aortic ball valve prostheses. We have encountered this process in 2/508 patients (0.4%), who underwent aortic valve replacement with the Björk-Shiley tilting disc valve prosthesis. The coronary perfusion technique was identical in all the operations.

Effects of dipyridamole and acetylsalicylic acid on platelet functions in patients with aortic ball-valve prostheses

The effects of dipyridamole and ASA on platelet functions were studied in patients with aortic ball-valve prostheses. Before ingestion, platelet adhesiveness was markedly reduced and platelet survival time slightly, but insignificantly shortened. ASA prolonged the bleeding time, reduced collagen-induced platelet aggregation, and inhibited secondary aggregation initiated by adrenalin. Similar effects were obtained with 2 Gm. of ASA alone as with 1 Gm. daily in combination with 225 mg. of dipyridamole. Platelet adhesiveness remained low. Dipyridamole alone, 375 mg. daily, did not influence any of these parameters. The mean platelet half-life was prolonged from 3.52 to 3.72 days by each drug and to 4 days by the combined treatment. None of the differences was, however, statistically significant. A clinical study with ASA has been started in a larger series of patients to evaluate the effect on arterial thromboembolism.

CLINICAL CARDIOVASCULAR PHARMACOLOGY OF DOBUTAMINE A SELECTIVE INOTROPIC CATECHOLAMINE

The cardiovascular effects of dobutamine, a new inotropic catecholamine, have been studied in seventeen patients. In a phono-cardiographic study infusions of dobutamine 2·5- 10 μg. per kg. per minute in seven patients with aortic ball-valve prostheses produced increases in the rate of left-ventricular ejection comparable to those produced by isoprenaline in concentrations of 0·02- 0·08 μg. per kg. per minute, but the heart-rate change after isoprenaline was significantly greater. In ten patients with coronary-artery disease or congestive cardiomyopathy these concentrations of dobutamine increased stroke volume, cardiac output, and left-ventricular dp/dt max significantly without significantly changing heart-rate, diastolic arterial pressure, or left-ventricular filling pressure. A separation of the inotropic and chronotropic effects of dobutamine has been demonstrated. This agent therefore has potential therapeutic value in the management of cardiovascular failure associated with low cardiac output after myocardial infarction or open heart surgery, whenever isoprenaline would currently be used.

Postoperative hemodynamic evaluation of a new fabric-covered ball-valve prosthesis.

Previous in vitro and in vivo experimental studies have indicated that insertion of the Braun-wald-Cutter fabric-covered ball-valve prosthesis results in negligible thromboembolic complications and hemodynamic performance comparable to that of noncovered mitral and aortic ball-valve prostheses. To assess the clinical efficacy of this fabric-covered valve prosthesis, 35 patients have been followed for 4 to 26 months (540 patient-months) after mitral and/or aortic valve replacement, and 13 have had extensive hemodynamic re-evaluation. In eight patients with the mitral valve prosthesis, the mean diastolic gradient averaged 4.8 mm Hg (range 0 to 8) and the end-diastolic gradient 0.8 mm Hg (range 0 to 2) at a time when the mean heart rate was 75 beats/min (range 50 to 100) and the cardiac output averaged 5.1 L/min (range 3.4 to 8.0). The calculated effective mitral valve orifice size averaged 2.68 cm 2 (range 1.92 to 3.46). In six patients with the aortic valve prosthesis, the average peak systolic gradient was 13 mm Hg (range 0 to 22), and the mean systolic gradient averaged 14.5 mm Hg (range 0 to 24) when the mean heart rate was 82 beats/min (range 64 to 120) and the cardiac output averaged 6.2 L/min (range 3.2 to 9.3). The average effective aortic valve size in the five patients with a mean systolic transvalvular gradient was 1.41 cm 2 (range 1.26 to 1.62). Only one postoperative thromboembolic complication has been observed, and this occurred in a patient with atrial fibrillation and a large left atrium three weeks after discontinuing anticoagulant therapy because of gingival bleeding. These data indicate that use of the fabric-covered Braunwald-Cutter ball prosthesis produces few thromboembolic complications and a satisfactory hemodynamic result.

Red Blood Cell Osmotic Fragility After Aortic Valve Replacement

Red blood cell osmotic fragility and autohemolysis studies were performed on 35 patients with aortic ball-valve prostheses. Osmotic fragility on fresh heparinized blood was normal. After 24 hours' incubation, it was increased in 17 patients. The most common abnormality was a tail of cells with increased fragility indicative of a heterogeneous population of cells. Sixteen patients with increased fragility had cloth-covered Starr-Edwards prostheses; the majority had intravascular hemolysis. Nine patients with normal fragility had Cutter or Magovern prostheses; the majority had minimal hemolysis. Autohemolysis after 48 hours' incubation with glucose was normal in all patients. Increased incubated osmotic fragility frequently reflects damage to red blood cells by prosthetic heart valves, and increased osmotic fragility is often associated with increased rates of hemolysis in vivo. The damage is greater with cloth-covered Starr-Edwards than with Magovern or Cutter prostheses.

Displacement and fracture of pacemaker electrode during physical exertion. Report on three cases.

Abstract Three patients with electrode failure arising during permanent pacemaker treatment for AV block are discussed. The physical capacity of all three was improved after pacemaker implantation. In patients 1 and 3 electrode displacement took place during apple picking and lobster fishing. In patient 2 pacemaker implantation was carried out in connection with the insertion of an aortic ball valve prosthesis. He has later been in functional class I. Electrode fracture took place while he was carrying a 50‐kg flour sack, the central fragment of the electrode being displaced to the right ventricle, where it has remained coiled up for 2 years, the battery and peripheral fragment of the electrode having been removed. Patients with good cardiac function after pacemaker implantation should therefore be warned against vigorous physical exertion which may directly affect the pacemaker system.

Chronic intravascular hemolysis after aortic valve replacement. Long-term study comparing different types of ball-valve prostheses.

To assess the severity of hemolysis and to determine whether severity of hemolysis was related to type of prosthesis, hematocrit readings (Hct), schistocyte counts (S), reticulocyte counts (R), and determinations of haptoglobin (Hp), lactic acid dehydrogenase (LDH), bilirubin, urinary hemoglobin, and urinary hemosiderin (Hs) were performed on 54 patients who had three different types of aortic ball-valve prostheses. Hemolysis, as determined by absence of haptoglobins or hemosiderinuria or R>3.5% in the absence of bleeding, was detected in 39 of the 54 patients (72%). S, R, LDH, and bilirubin were higher in patients without haptoglobins than in those with haptoglobins ( P < 0.005). Hematocrits of less than 32% were found in 13 of the 34 patients (38%) with Starr-Edwards valves compared to none of the 11 with Magovern valves ( P < 0.001) and one of the nine with Cutter ( P < 0.05) valves. The combination of S>10 per 1,000 cells, R>5%, and LDH>500 mU was observed only with Starr-Edwards valves (16 of the 34 patients) and was not seen in patients with Magovern or Cutter valves ( P < 0.005). All patients with S>10, R>5%, and LDH>500 mU had hemosiderinuria, and five had hemoglobinuria. Hemoglobinuria was always indicative of severe hemolysis. Hemosiderinuria was rarely detected less than 3 months after operation but was found in 32 of 47 patients so tested (68%) more than 3 months after operation. Hemosiderinuria was found in 25 of 30 patients with Starr-Edwards valves compared to two of the 11 with Magovern valves ( P < 0.001). Hemosiderinuria was also detected in five of six patients with Cutter valves tested, but in three of these the test was only faintly positive. It is concluded that hemolysis is more severe in the presence of Starr-Edwards valves than Magovern or Cutter valves. Based on these observations, the following criteria for rapid clinical evaluation of cardiac hemolysis are suggested: Mild: Hs or absence of Hp but S<10, R<5, LDH<500; moderate: Hs or absence of Hp but S>10, R>5, LDH>500; severe: all of above plus hemoglobinuria.

Roentgenographic method for measurement of the cross-sectional area of the aortic valve

The aortic valve in living subjects can be viewed as if looding directly into the valvular orifice by obtaining roentgenograms directed through the heart on a line approximately from the right shoulder to the left iliac crest. This roentgenographic projection (45 degree superior elevation, 0 degree anterior elevation) was determined by trigonometrical calculations based upon the spacial orientation of aortic ball-valve prostheses in 31 patients. Calculations based on data from these patients indicated that the aortic valve can be shown on roentgenograms taken in this projection with less than 10 per cent distortion of the cross-sectional area of the valve orifice in 8 of 10 patients. Consequently, it was feasible to measure the cross-sectional area of the aortic valve by planimetry of the projected image on the roentgenograms. The method was tested in 18 patients with aortic ball-valve prostheses because in such patients the precise cross-sectional area of the valve orifice was known. The roentgenographic method was at least 80 per cent accurate in 15 of 18 patients. During cardiac catheterization in 21 patients, roentgenographic measurements of the cross-sectional area of the aortic valve, using this same projection, were made on serial films obtained during the injection of contrast material in the supra-aortic region. Roentgenographic measurements correlated well with clinical and hemodynamic data and direct measurements at surgery. These results indicate that the cross-sectional area of the aortic valvular orifice frequently can be measured in a meaningful fashion with this method. Orifice area can be measured roentgenographically in patients in whom hydraulic equations would not be applicable. Obviously, roentgenographic measurements are subject to interpretation in spite of theoretical considerations based upon trigonometrical calculations. Incomplete opening of the aortic valve, due to a low stroke volume, can simulate an apparently small orifice. Eddies of contrast in the sinus of Valsalva can simulate a larger than actual orifice. In the majority of patients, this roentgenographic method of visualization of the aortic valve gives useful information regarding the cross-sectional area of the valvular orifice and the configuration of the valvular leaflets.

Roentgenographic method for measurement of the cross-sectional area of the aortic valve

Abstract The aortic valve in living subjects can be viewed as if looding directly into the valvular orifice by obtaining roentgenograms directed through the heart on a line approximately from the right shoulder to the left iliac crest. This roentgenographic projection (45 degree superior elevation, 0 degree anterior elevation) was determined by trigonometrical calculations based upon the spacial orientation of aortic ball-valve prostheses in 31 patients. Calculations based on data from these patients indicated that the aortic valve can be shown on roentgenograms taken in this projection with less than 10 per cent distortion of the cross-sectional area of the valve orifice in 8 of 10 patients. Consequently, it was feasible to measure the cross-sectional area of the aortic valve by planimetry of the projected image on the roentgenograms. The method was tested in 18 patients with aortic ball-valve prostheses because in such patients the precise cross-sectional area of the valve orifice was known. The roentgenographic method was at least 80 per cent accurate in 15 of 18 patients. During cardiac catheterization in 21 patients, roentgenographic measurements of the cross-sectional area of the aortic valve, using this same projection, were made on serial films obtained during the injection of contrast material in the supra-aortic region. Roentgenographic measurements correlated well with clinical and hemodynamic data and direct measurements at surgery. These results indicate that the cross-sectional area of the aortic valvular orifice frequently can be measured in a meaningful fashion with this method. Orifice area can be measured roentgenographically in patients in whom hydraulic equations would not be applicable. Obviously, roentgenographic measurements are subject to interpretation in spite of theoretical considerations based upon trigonometrical calculations. Incomplete opening of the aortic valve, due to a low stroke volume, can simulate an apparently small orifice. Eddies of contrast in the sinus of Valsalva can simulate a larger than actual orifice. In the majority of patients, this roentgenographic method of visualization of the aortic valve gives useful information regarding the cross-sectional area of the valvular orifice and the configuration of the valvular leaflets.

Hemolysis during acute exercise in patients with aortic ball valve prostheses.

Abstract. Physical exercise may provoke increased erythrocyte destruction in patients with severe hemolytic anemia following the insertion of intracardiac prosthetic materials. The relationship between physical exercise and intravascular hemolysis has, however, previously not been studied in non‐anemic patients with properly functioning ball‐valve prostheses or in unoperated patients with valvular disease. Therefore, intravascular hemolysis was studied before and after a graded exercise test of 15 min duration in three groups of patients: 16 cases with aortic ball valves, 13 cases with unoperated aortic valvular disease and a control group of ten subjects. Serial measurements of plasma heme concentration and serum lactic dehydrogenase activity (SLDH) were made during a two‐hour period. Hemodynamic parameters were recorded during the exercise. All patients with ball valve prostheses showed an increase of SLDH averaging 33 U/l, corresponding to a destruction of red cells in about 20 ml of whole blood during the exercise. Hemolysis of this order of magnitude was not detected by plasma heme measurements, but the average heme concentration was significantly elevated in the patients with ball valves. In controls and unoperated patients neither plasma heme nor SLDH changed consistently following exercise. The discrepancy between the changes in plasma heme and SLDH is discussed; red cell destruction by the ball valves is the most probable cause of the SLDH increment. There was no significant correlation between the SLDH increase during exercise and the ball valve size, heart rate, cardiac output or the SLDH level in the resting slate. Probably individual factors are more important determinants of hemolysis than hemodynamic parameters.

Traumatic Hemolysis with Hemoglobinuria Due to Ball Variance

Abstract A patient with an aortic ball valve prosthesis who had traumatic hemolysis, hemoglobinuria and iron deficiency secondary to ball variance has been reported. Hemolysis and urinary iron loss decreased when activity was restricted. A diurnal pattern of urinary iron excretion was observed. This was reversed when the patient was placed on bed rest during the day and ambulated at night. Hemolysis ceased and urinary iron loss slowly subsided after outflow tract obstruction was corrected by replacement of the swollen poppet.

Traumatic hemolysis with iron deficiency anemia in patients with aortic valve lesions.

Abstract Twelve patients with symptomatic aortic valve disease and 12 patients with aortic ball-valve prostheses were studied for evidence of traumatic hemolysis. Low or absent haptoglobins suggest...

Replacement of the aortic valve with the Starr-Edwards and sutureless (Magovern) prosthesis: Comparative recatheterization results

1. 1. Data obtained in 35 patients, 25 male and 10 female, in whom postoperative catheterization studies on the aortic and ventricular side of the artificial valve were made 6 to 18 months following the replacement of a diseased aortic valve, have been reviewed. 2. 2. The Starr-Edwards prosthesis was used in 17 patients, 11 male and 6 female. Eight of these patients had resting systolic gradients ranging between 15 and 50 mm. Hg. 3. 3. The Magovern-Cromie valve was used in 18 patients, 14 male and 4 female. Only 3 had abnormal resting systolic gradients. These were 15, 25 and 35 mm. Hg, respectively. 4. 4. While obstructing gradients over the aortic ball-valve prostheses are due to many factors, the presence or absence of gradients in either of these two groups of patients seemed primarily related to the proximity of the aortic wall to the artificial valve cage. The lack of gradients with the Magovern-Cromie valve appeared to result from the use of this valve when a small aortic annulus and poststenotic dilatation exist, therefore allowing extra room about the prosthesis. 5. 5. Mild aortic insufficiency about the prosthetic rim was more common in the group in whom the Magovern-Cromie valve was used (5 of 18 cases) but was of no clinical significance in any patient in either group. 6. 6. The important lesson from this study for surgeons is the following: In choosing a ballvalue prosthesis at the operating table it is far more important in obviating morbidity and mortality to select a smaller size and leave adequate outflow room between the cage and the aortic wall than to choose the reverse.

Sound, apex cardiogram and electrocardiogram correlated with cinefluorographic and ultrasonic records of mitral and aortic ball valve prosthesis

Sound, apex cardiogram and electrocardiogram correlated with cinefluorographic and ultrasonic records of mitral and aortic ball valve prosthesis