The longest survival after mitral valve replacement with a tilting-disc Lillehei-Kaster prosthesis?

Introduction

Five decades ago, Starr implanted the first mechanical ball-

and-cage prosthesis in the mitral position, starting the era of mitral valve replacement (MVR). Since that time, millions of patients after MVR have been followed-up and reported. However, it is difficult to find reports regarding cases of more than 25-year survival after MVR.

Case report

We present a case of a 83-year-old man who in the late 1940s had a course of rheumatic fever resulting in a heart valvular disease. Through the next three decades, symptoms of heart failure were gradually increasing, and finally he found himself in functional class III of the New York Heart Association (NYHA). In 1979, after cardiac catheterization the diagnosis of combined mitral valve disease (predominantly regurgitation) was established and the patient was referred for the cardiac surgery.

On 14 March 1979, MVR was performed in the Department of Cardiac Surgery, Medical University of Lodz. The patient was operated on through median sternotomy, on standard cardiopulmonary bypass with moderate systemic hypothermia, intermittent aorta cross-clamping and topical cooling. A tilting-disc mechanical prosthesis Lillehei-Kaster

20 (internal diameter of 20 mm, external diameter of

27.5 mm) was implanted using interrupted sutures of 2/0 Ticron (Fig. 1). The early postoperative period was uneventful.

In 1981, the patient was hospitalized due to fever and treated with intravenous penicillin and excessive teeth extraction as a treatment of suspected infective endocarditis. In the following year he had a neurological embolic event with transient hemiparesis and aphasia.

Until 1986 the patient remained in the sinus rhythm and between 1986 and 1994 he had several electric cardioversions because of paroxysmal atrial fibrillation (AF). Since 1994 the patient has had permanent AF and due to slow ventricular rhythm he had the VVI pacemaker implanted.

Throughout all those years the patient experienced several hemorrhagic events usually associated with surgical interventions like re-implantation of the pacemaker (2000), prostatic biopsy (2003) or excision of facial keratoacanthoma (2008). These events were connected with both anticoagulation and previously noticed thrombocytopenia. Considering this fact, he has been ordered an oral anticoagulation with a target INR from 2.0 to 3.0.

During the follow-up period the patient has been also regularly monitored by echocardiography (Fig. 2). The examination performed at the end of 2010 revealed a relatively good function of the mitral prosthesis with an opening angle of tilting disc of about 50 degrees, small effective orifice area of 1.0 cm2 and transvalvular gradient of 13/6 mm Hg (small-size device). The left atrium was significantly enlarged to 6.3 cm. The diastolic dimension of the left ventricle was 5.5 cm with a satisfactory global left ventricular ejection fraction of 40%. Besides, there was moderate tricuspid insufficiency. Systolic pulmonary artery pressure was 38 mm Hg.

The patient worked as a white-collar employee until 2002 and nowadays he continues to be in a good mental condition. Through the observation period he remained in NYHA functional class II on optimized medical therapy regimen.

Discussion

Tilting-disc valvular prostheses replaced ball-and-cage Starr-Edwards devices used in the late 1960s. The Lillehei-Kaster prosthesis was introduced into clinical use in 1970 as one of the first of this type [1]. It was not a perfect valve with a limited opening angle (50°-70°), quite small orifice-to-annular area ratio and turbulent flow. Those disadvantages were to be eliminated in the second-generation devices derived from the Lillehei-Kaster project, called Omniscience and introduced in 1978. Meanwhile, in 1977, the first bi-leaflet mechanical valve, St. Jude Medical (SJM), was implanted. Simultaneously, an alternative branch of heart valve devices was developed: the biological prostheses.

In our patient’s case, the operation was performed in the pre-cardioplegia era, therefore it was more challenging than it is nowadays. Implanting a 20 mm diameter prosthesis (the only available size) into the adult male patient’s heart was indeed changing severe mitral regurgitation into a well-tolerated moderate mitral stenosis. In the first postoperative echocardiography, the mitral valve area was 1.2 cm2. Who could expect that this patient will survive 32 years without re-operation?

There is limited literature regarding long-term results of MVR with Lillehei-Kaster prosthesis. Olesen et al. [2] presented 185 such patients operated in the 1970s and 1980s. Operative mortality rate was quite high (13%), 10-year survival was 56% as well as 76 ±5% of patients were free from thromboembolic events. A similar group was reported by Milano et al. [3] with a comparable operative mortality rate (15%) and with quite poor 15-year survival of 32 ±6%. In this subset, the rates of thromboembolic, hemorrhagic and infective events per year were 2.7%, 1.8% and 0.3%, respectively. Horstkotte et al. [4] conducted a 5-year follow-up of 50 patients after MVR with Lillehei-Kaster valve with operative mortality of 12%, long-term survival of 76% and late complications rate of 50%. Whereas Teijeira [5] published data on 716 valve-year follow-up of 103 patients after MVR with Omniscience prosthesis and the rates of thromboembolism, valve thrombosis, bleeding and endocarditis per year were 0.71%, 0.42%, 0.99% and 0.14%, respectively.

In the current literature, there are several long-term follow-ups of the patients after MVR with SJM mechanical prosthesis, but none exceeds 25 years. Toole et al. [6] presented a group of 408 such patients with operative mortality of 4.9%, 25-year survival of 23%, a re-do surgery rate of 19%, thromboembolic complication rate of 48%, bleeding rate of 36% and endocarditis rate of 3%. A much bigger group was shown by Emery et al. [7] who followed 1498 patients after MVR with SJM device for 25 years (mean follow-up 7 ±5 years). The operative mortality rate in this population was as much as 9% but long-term survival was satisfactory (63%) and thromboembolic and hemorrhagic events were observed in 19% each. What is interesting, the longest survival of an individual patient was 24.8 years and the oldest patient reached 102 years of age living for

8 years with mitral prosthesis implanted.

The thirty-two years’ survival after MVR with a Lillehei-Kaster prosthesis, in a good clinical condition, covering more than a half of the whole history of this operation, seems to be a very good result. In available literature, no comparable reports were found.

References

1. Grunkemeier GL, Starr A, Rahimtoola SH. Prosthetic heart valve performance: long-term follow-up. Curr Probl Cardiol 1992; 17: 329-406.

2. Olesen KH, Rygg IH, Wennevold A, Nyboe J. Long-term follow-up in 185 patients after mitral valve replacement with the Lillehei-Kaster prosthesis. Overall results and prosthesis-related complications. Eur Heart J 1987; 8: 680-688.

3. Milano A, Bortolotti U, Mazzucco A, Guerra F, Magni A, Stellin G, Gallucci V. Mitral valve replacement with the Hancock, Björk-Shiley and Lillehei-Kaster prostheses. A comparison based on a 15-year follow-up. Eur J Cardiothorac Surg 1989; 3: 312-319.

4. Horstkotte D, Haerten K, Herzer JA, Loogen F, Scheibling R, Schulte HD. Five-year results after randomized mitral valve replacement with Björk-Shiley. Lillehei-Kaster, and Starr-Edwards prostheses. Thorac Cardiovasc Surg 1983; 31: 206-214.

5. Teijeira FJ. Long-term experience with the omniscience cardiac valve.

J Heart Valve Dis 1998; 7: 540-547.

6. Toole JM, Stroud MR, Kratz JM, Crumbley AJ 3rd, Bradley SM, Crawford FA Jr, Ikonomidis JS. Twenty-five year experience with the St. Jude medical mechanical valve prosthesis. Ann Thorac Surg 2010; 89: 1402-1409.

7. Emery RW, Krogh CC, Arom KV, Emery AM, Benyo-Albrecht K, Joyce LD, Nicoloff DM. The St. Jude Medical cardiac valve prosthesis: a 25-year experience with single valve replacement. Ann Thorac Surg 2005; 79: 776-782.