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A normofunctioning caged-ball aortic valve prosthesis for 31 years/Otuz bir yildir normal fonksiyonlari olan bir top kafes aort kapak protezi.

Starr-Edwards (S- E) ball cage prosthetic valve was first successfully implanted in mitral position in September 1960 (1). Since then, S-E ball valves have been widely used in all over the world with good results till 2007 when Edwards Lifesciences discontinued production of the S-E valve. Their usage was abandoned because prosthetic valves with better hemodynamics and with less thromboembolic potential were introduced to the market. The S-E ball cage valve was known for its long durability. We report a case with 9 no. S-E aortic caged-ball valve prosthesis, which has been well-functioning for 31 years.

A 50 years old male patient was referred to the echocardiography laboratory after a routine physical examination. He had no complaints. He had undergone aortic valve replacement for rheumatic aortic valve disease with a S-E caged-ball aortic valve (no.9) in 1977. After 15 years of asymptomatic period; his symptoms recurred and he underwent a second surgery and 27 no. Medtronic mechanical monoleaflet mitral valve was implanted in 1995. The prosthetic valve in the aortic position was functioning well at that time. From then, he attended outpatient appointments regularly with no complaints with grade I New York Heart Association (NYHA) functional class. Routine echocardiography and cine-fluoroscopy controls showed normofunctioning aortic and mitral mechanical valves (Fig. 1-2, Video 1. See corresponding video/movie images at

In the past decades; aortic S-E caged-ball valves have been used successfully all over the world. The only Food and Drug Administration (FDA) approved caged-ball valve is the S-E valve. The complications related to S-E caged-ball valves are; thromboembolism, hemolytic anemia, valve failure, cloth wear, endocarditis, and pannus formation (2). Orszulak et al. (3) have reported that survival rate of patients with prosthetic aort valve at 20 years were 31,2 % -including 6,2 % operative mortalityin a series of 1100 S-E caged ball aortic prostheses with a 24.8 years mean follow up time. They found that advanced NYHA class (III or IV), older age (>56 years) and lower ejection fraction (<0.56) were predictive of poor late survival. They did not find any valve failure in 1100 patients and they recommend that especially S-E valves of larger sizes (9A and above) provide an excellent, safe and durable alternative in the aortic position. Godje et al. (4) have reported 16.6 % survival rate in patients with aortic S-E ball valves after 30 years. For the S-E prosthesis, 40-year survival after mitral valve replacement and 41- year survival after aortic valve replacement have been reported (5).



Although natural heart valves allow blood to flow straight through the center of the valve (central flow), caged ball valves completely block central flow and collisions with the occluder ball cause damage to blood cells, stimulate thrombosis and formation of blood clots. The high pressure gradient, less effective orifice area and the absence of a central blood flow with the patient morbidity rates are the factors that leaded scientists to design new mechanical valves (4). Our case demonstrates long durability of caged ball valves. The patient has a normofunctioning S-E caged-ball aortic valve implanted 31 years ago. His functional capacity is classified as NYHA class 1.

Murat Baskurt, Fatma Nihan Turhan, Baris Okcun, Serdar Kucukoglu Department of Cardiology, Institute of Cardiology, Istanbul University, Istanbul, Turkey


(1.) Peterman MA, Donsky MS, Matter GJ, Roberts WC. A Starr-Edwards model 6120 mechanical prosthesis in the mitral valve position for 38 years. Am J Cardiol 2006; 97:756-8.

(2.) Yotsumoto D, Iguro Y, Ueno T, Matsumoto K, Sakata R. Use of the Bentall method for replacement of an aortic Starr-Edwards ball valve prosthesis implanted 32 years previously. Gen Thorac Cardiovasc Surg 2007; 55:331-4.

(3.) Orszulak TA, Schaff HV, Puga FJ, Danielson GK, Mullany CJ, Anderson BJ, et al. Event Status of the Starr-Edwards Aortic Valve to 20 Years: A Benchmark for Comparison. Ann Thorac Surg 1997; 63: 620-6.

(4.) Godje 0, Brenner R Fischlein T, Reichart B. Thirty years survival after double valve replacement with Star-Edwards prostheses in aortic and mitral position. Eur J Card-thor Sur 1997; 11: 391-3.

(5.) Suezawa T Morimoto T, Jinno T, Tago M. Forty-year survival with Smeloff-Cutter and Starr-Edwards prostheses. Ann Thorac Surg 2008; 85: e14-6.

Address for Correspondence/Yazisma Adresi: Dr. Murat Baskurt Department of Cardiology, Institute of Cardiology, Istanbul University, Istanbul, Turkey Phone: +90 212 459 20 00 Fax: +90 212 459 20 69 E-mail:
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Title Annotation:Letters to the Editor/Editore Mektuplar
Author:Baskurt, Murat; Turhan, Fatma Nihan; Okcun, Baris; Kucukoglu, Serdar
Publication:The Anatolian Journal of Cardiology (Anadolu Kardiyoloji Dergisi)
Article Type:Letter to the editor
Date:Jun 1, 2009
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