In 1967, a 23-year-old male presented with severe aortic valve regurgitation. Given the symptoms were refractory to medical management, the decision was made to replace the dysfunctional aortic valve. At that time, 39 years ago, standard care was to implant a Starr-Edwards-caged-ball-valve-prosthesis in aortic position (Figure ). The surgery and post-operative course were without complications and the patient recovered well after the operation. However, four years later, the ball was damaged and contained thromboembolic formations. Therefore, the decision was made to replace the elastic ball with a structurally similar silicone ball. For the next four decades, the patient remained asymptomatic - no restrictions on his lifestyle and without any complications.
Pre-operative chest X-ray with the Starr-Edwards-caged-ball-valve in aortic position.
In January 2006, 39 years after the initial operation, the patient became increasingly symptomatic for six weeks - progressive dyspnea and chest pain (angina-pectoris according to CCS III). Myocardial scintigraphy and coronary angiography were performed and revealed diffuse, but insignificant atherosclerosis (possibly explaining his acute deterioration). An aortic angiogram revealed high grade post-valvular aneurysm of the ascending aorta. This was also proven on computed tomography of the thorax: the dimensions of the aortic aneurysm were 6.0 × 6.5 cm, with normal physiological diameters distally, with no evidence of an aortic dissection. Additionally, echocardiography demonstrated: middle-grade dilatation of the left atrium, high-grade dilatation of the left ventricle and a left ventricular ejection fraction (EF) severely reduced to 30%. The functionality of the prosthesis presented borderline values, but regular flow.
Operative intervention was once again indicated. In February, we decided to perform a Bentall-Procedure: therefore, we explanted the 39-year-old Starr-Edwards-aortic-caged-ball-valve-prosthesis (Figure ) and replaced the ascending aorta with a 29 mm St. Jude Medical aortic-valve-composite-graft and re-implanted the coronary arteries. Postoperatively, the patient developed AV-block III°, therefore a DDD-pacemaker was implanted four days later (Figure ). The remainder of the postoperative course was uneventful and he was discharged home on postoperative day 12 with stable hemodynamics. On histological analysis of the aortic wall, a large calcification, bulky mucoid degeneration and destruction of elastic fibres was found.
Explanted Starr-Edwards-caged-ball-valve 39 years after implantation.
Post-operative chest X-ray after successfully performed Bentall- and Pacemaker-implantation.
Of note, this coincidentally is the latest Bentall-procedure after 39 years of survival of a Starr-Edwards-valve implantation found in the literature [1