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An 81-year-old woman was evaluated for prosthetic mitral valve function. She had received a Harken disk mitral valve 29 years earlier due to severe mitral valve disease. This particular valve prosthesis is known for premature disk edge wear and erosion. The patient's 2-dimensional Doppler echocardiogram showed the distinctive appearance of a disk mitral valve prosthesis. Color Doppler in diastole showed a unique crown appearance, with initial flow acceleration around the disk followed by convergence to laminar flow in the left ventricle. Cineradiographic imaging revealed normal valve function and minimal disk erosion. We believe this to be the longest reported follow-up of a surviving patient with a rare Harken disk valve. We present images with unique echocardiographic and cineangiographic features. (Tex Heart Inst J 2003;30:319–21)
An 81-year old woman had a history of rheumatic fever that had occurred many years earlier. At age 52, she had presented at the Rochester General Hospital (New York) with progressive shortness of breath. Clinical evaluation at that time revealed severe mitral stenosis and moderate regurgitation. There was evidence of reduced left ventricular function, probably due to rheumatic myocarditis. She had moderate pulmonary hypertension. The patient underwent successful mitral valve replacement surgery with a large-sized Harken disk prosthesis on 4 February 1971 in Rochester. The prosthesis has a bariumimpregnated silicone rubber disk inside a highly polished titanium cage. The 2 metallic struts of the cage cross each other at 90° angles. The valve was available in small, medium, and large sizes. 1
At the time of presentation in May 2000, the patient had been anticoagulated for the past 29 years without major complication. Recent echocardiography revealed normal Harken valve function without stenosis, and there was no paravalvular or valvular regurgitation. The disk and edge of the cage were clearly visible on the 2-dimensional echocardiogram. Disk motion was normal within the cage. There was a unique diastolic flow pattern with initial flow acceleration around the disk, then convergence of the flow in a laminar state and a “crown” appearance (Fig. 1). This color Doppler pattern is different from that seen with the bileaflet prostheses widely used today. Cineradiography showed normal Harken valve disk motion and minimal disk erosion on 1 edge of the prosthesis (Fig. 2).
When last seen in September 2000, the patient was hospitalized for ischemic cardiomyopathy, nonsustained ventricular tachycardia, small non-Q wave myocardial infarction, pacemaker implantation, and renal insufficiency. She was discharged from the hospital to a nursing home. The patient subsequently died of end-stage cardiomyopathy.
The late Dwight E. Harken (Chief of Thoracic and Cardiac Surgery at the Peter Bent Brigham Hospital in Boston from 1948 to 1970), along with Charles P. Bailey (of Philadelphia), was one of the 1st U.S. surgeons to successfully perform closed mitral valvuloplasty on patients, in 1948. Henry Souttar, in England, performed the 1st transatrial finger fracture valvuloplasty, in 1923. 2 Charles Hufnagel, at Georgetown University Hospital in Washington, DC, was the 1st surgeon to implant a polyethylene ball-valve in a patient with rheumatic fever and severe aortic coarctation, in 1952. He implanted the valve in the descending aorta, and the patient survived for 8 years. This was achieved before the use of the heart-lung machine. 3 Dwight Harken and Albert Starr successfully implanted mitral and aortic caged-ball valves in May and August of 1960. 4 Dr. Harken then designed the caged-disk valve, which improved hemodynamics and decreased valve profiles substantially compared with the early (Starr-Edwards) caged-ball valve. Other early versions of nontilting disk valves included Kay-Suzuki (very similar to Harken), Kay-Shiley, and Beall. 5 The caged-disk valve offered less resistance to blood flow into and out of the left ventricle, occupied less space in the left ventricle, was less prone to cause arrhythmias by septal trauma, and had a greater outflow area during diastole compared with a caged-ball valve of comparable orifice size. The most important hemodynamic finding in patients receiving the caged-disk valves was the association of normal left atrial pressure with cardiac outputs in the normal and high–normal range and marked improvement in pulmonary hypertension. 6
The 1st Harken disk valve was implanted in 1965. 6 The valve was subsequently modified with a Magovern turtleneck sewing ring covered by a Dacron skirt to facilitate easy insertion. 1 An estimated 2,300 patients received Harken mitral disk valves during the late 1960s and early 1970s. 7 Oparah and colleagues 1 probably had the largest experience with Harken mitral valve implantation and long-term follow-up. They reported their 5-year experience in 100 patients who underwent mitral valve replacement from 1968 to 1973. The operative mortality rate was 7%. The incidence of combined early and late thromboem-bolic complications was 7%, which was significantly lower than that of the Starr-Edwards valve.
The Harken disk valve was subject to valve variance and disk wear. Otero-Coto and co-authors 8 reported a retrograde disk escape in a Harken mitral valve prosthesis 21 years after implantation. In response to that report, Berger 9 recommended routine cinefluoros-copy as part of the clinical evaluation in patients with a Harken mitral prostheses, and emphasized that such valves should be promptly replaced upon detection of disk variance. Berger also warned that patients with aortic regurgitation might be at higher risk for excessive stress on the Harken valve. Wann and associates 10 first used M-mode echocardiography to make a correct diagnosis in a patient with a malfunctioning Harken caged-ball mitral valve.
Patients with mitral Harken valves are rarely seen in today's cardiovascular practice. To our knowledge, our patient was the longest reported survivor with a normal functioning Harken valve. There were unique echocardiographic features and color flow pattern on the echocardiogram that are not seen in images of the more common mechanical bileaflet valves. We agree with Berger 9 that cinefluoroscopy, in addition to echocardiography and clinical examination, offers a simple and reliable method to assess disk motion and edge erosion of Harken valve prostheses.
Address for reprints: David H. Hsi, MD, 1561 Long Pond Road, Suite 401, Rochester, NY 14626