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Starr-Edwards caged ball valve pursuing to astonish us-38 years in mitral position/Starr-Edwards kafesli top kapak bizi sasirtmaya devam ediyor-mitral pozisyonda 38 yil.


Until invention of a caged ball valve prosthesis, rheumatic cardiac valve failure had been a deadly disease with death rate of 12/100.000 in 1958. The first time successful Starr-Edwards caged ball valve implantation performed in 25 August 1960 is accepted as a milestone for cardiac valve surgery (1). Several centers published their experiences with this valve in both aortic and mitral positions. Encountered complications with caged ball valve such as; systemic embolisation, ball variance, high pressure gradient, growth of pannus and chronic hemolysis; lead to new valve designs (2-5). Nowadays these investigations still goes on for perfect valve.

Despite its' old fashion design in some cases impressive durability of Starr-Edwards caged ball valves astonishes investigators and this case is one of them.

Case Report

A 58-year-old male patient with lower extremity edema and dyspnea during minimal exercise admitted to the hospital. 38 years ago the patient had mitral valve replacement with Starr-Edwards Caged Ball prosthesis for severe mitral valve regurgitation. According to New York Heart Association classification, the patient was in class 3. Echocardiography documented severe tricuspid valve regurgitation with right atrial (9.7 cm) and right ventricular (5.4 cm) enlargement. Pulmonary artery peak pressure was 40 mmHg. Left atrium diameter was 8 cm. Left ventricular diastolic diameter was 5.2 cm and systolic function was normal with a 60% ejection fraction rate. Peak and mean gradients were 13 mmHg, 7 mmHg respectively over the mitral valve caged ball prosthesis. Hemolysis or anemia were not observed in laboratory tests. Diuretic medications were prescribed and because of symptoms did not relieve drug doses were progressively increased. Despite intensive medical therapy, echocardiographic and clinical right cardiac symptoms did not improve patient underwent tricuspid ring annuloplasty (Carpentier Edwards) and mitral valve re-replacement (St. Jude mechanical valve) operation. Operation was achieved through median sternotomy with mild hypothermic cardiopulmonary bypass. Operative and postoperative courses were uneventful. Control echocardiography before discharge revealed normal functioning valves. Caged ball mitral valve prosthesis inspected as macroscopically at the end of the operation. Although gradients were reported in preoperative transthoracic echocardiography, there were neither growth of pannus and structural integrity loss nor lipid infiltration over the valve (Fig. 1).


Caged ball valve design was inspired from a wine bottle stopper, which was invented in 1858. Harken-Sorroff, Starr-Edwards, Magovern-Cromie fabricated and implanted caged ball valves in 1960. Only Starr-Edwards valve was designed for mitral position and others were designed for aortic position. Until appearance of tilting disc valve, Edwards laboratories had developed different series of ball valves during next 12 years (1). However, some defects due to the design of the valve such as unacceptable transvalvular gradient in smaller sizes, absence of central flow causing higher transvalvular gradients especially in aortic position and thromboembolic complications associated with the strut clothes had never been solved (2). The incidence of complications related to the Starr-Edwards valve, especially thromboembolism was higher compared with the bileaflet valves (3-5). Regarding these data, even in cases with functioning valves surgeons were tended to replace it with updated versions (6). However, except strut cloth, valve related complications were rare. The loss of structural integrity has only been reported only 2 times for mitral position (2). Recently published results of fifteen years follow-up suggest Starr-Edwards caged ball as a good choice for mitral position (7). Furthermore, several impressive durability case reports are available in the literature. Also Gogje et al. (8) published their thirty year experience with Starr-Edwards prosthesis and they recommend that caged balls after 20 -year durability should not be removed except patients who require additional cardiac operation for other indications.



In our case, patient was suffering from severe tricuspid regurgitation and he did not respond to the medications so operation decision was made. According to literature, we have performed tricuspid valve annuloplasty and mitral valve re-replacement with removing caged ball not to jeopardize patient's rest life.


(1.) Gott VL, Alejo DE, Cameron DE. Mechanical heart valves: 50 years of evolution. Ann Thorac Surg 2003; 76:S2230-9.

(2.) Akins CW. Results with mechanical cardiac valvular prostheses. Ann Thorac Surg 1995; 60: 1836-44.

(3.) Dumanian GA, Dumanian AV. Late embolic phenomena associated with cloth-covered Starr-Edwards aortic valve prostheses. Am J Cardiol 1987; 60:914-5.

(4.) Bonchek LI, Starr A. Ball valve prostheses; current appraisal of late results. Am J Cardiol 1975; 35:843-54.

(5.) Shah A, Dolgin M, Tice DA, Trehan N. Complications due to cloth wear in cloth-covered Starr-Edwards aortic and mitral valve prostheses-and their management. Am Heart J 1978; 96: 407-14.

(6.) Sezai A, Hata M, Niino T, Yoda M, Wakui S, Umeda T, et al. Prophylactic reoperation after mitral valve replacement with the Starr-Edwards ball valve: a report of four cases. Ann Thorac Cardiovasc Surg 2007; 13: 316-21.

(7.) Panda BR, Shankar R, Kuruvilla KT, Philip MA, Thankachen R, Shukla V, et al. Combined mitral and aortic valve replacement for rheumatic heart disease: fifteen-year follow up and long-term results. J Heart Valve Dis 2009; 18:170-9.

(8.) Godje OL, Fischlein T, Adelhard K, Nollert G, Klinner W, Reichart B. Thirty-year results of Starr-Edwards prostheses in the aortic and mitral position. Ann Thorac Surg 1997; 63: 613-9.

Gokhan Gokaslan, Neyyir Tuncay Eren [1]

Department of Cardiovascular Surgery, Faculty of Medicine, Gaziantep University, Gaziantep-Turkey

[1] Department of Cardiovascular Surgery, Faculty of Medicine, Ankara University, Ankara-Turkey

Address for Correspondence/Yazisma Adresi: Dr. Gokhan Gokaslan Gaziantep Universitesi Tip Fakultesi, Kalp ve Damar Cerrahisi Anabilim Dali, 27310, Sehitkamil, Gaziantep-Turkiye

Phone: +90 505 474 25 36 Fax: +90 342 360 30 02


Available Online Date/Cevrimici Yayin Tarihi: 18.09.2012

doi: 10.5152/akd.2012.223
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 2012 Gale, Cengage Learning. All rights reserved.

Article Details
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Title Annotation:Case Reports/Olgu Sunumlari
Author:Gokaslan, Gokhan; Eren, Neyyir Tuncay
Publication:The Anatolian Journal of Cardiology (Anadolu Kardiyoloji Dergisi)
Date:Dec 1, 2012
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