We present the case of a 72-year-old woman diagnosed with rheumatic fever at the age of 6. In 1972, she was diagnosed with mitral valve insufﬁciency and mitral valve stenosis, then in 1974, a decision was made to perform mitral valve replacement surgery with a 32-mm Braunwald-Cutter ball cage prosthesis. An echocardiogram performed in 2014 revealed normal biventricular systolic function, mechanical prosthesis in mitral position with maximum speed of 1.9 m/s, maximum gradient of 15 mmHg, mean gradient of 6 mmHg, severe tricuspid valve insufﬁciency, inferior vena cava measuring 15 mm with more than 50% collapse and pulmonary artery systolic pressure of 40 mmHg. We report the use of the 32-mm Braunwald-Cutter ball cage prosthesis with the longest longevity that remains functional after more than 43 years of implantation. features was the reduction in thromboembolic complications. INTRODUCTION However, almost a decade later of clinical use, numerous cases In 1960, Drs Nina Starr Braunwald and Andrew Morrow developed reported attrition of the posts in aortic prostheses that resulted in a mitral valve prosthesis with a ﬂexible Dacron-polyurethane escape of the silastic ball and subsequent death. In 1979, the valve compound. Their design used Teﬂon strips to link the chordae was withdrawn from market due to an increased rate of pannus tendinae. When Dr Braunwald identiﬁed the device susceptibility formation reported in animal studies [4, 5]. to ﬁbrous connective tissue inﬁltration, she considered applying Teﬂon to the metal ball could reduce thrombogenesis [1, 2]. Subsequently, Dr Braunwald worked in Dr Cutter’s laboratory CASE REPORT developing a silastic ball designed to minimize ball deformation (Figs 1 and 2). A new design included a Dacron tube around the A 72-year-old woman diagnosed with rheumatic fever at the age titanium struts previously positioned as free posts without dis- of 6 is presented in this report. She remained asymptomatic until tal attachment. She also coated the inlet ring with a thin layer 1962 (17 years old). In 1965, she was referred to our hospital with of polypropylene. It is estimated that around 5000 units were complaints of shortness of breath on exertion. She was diagnosed produced and implanted worldwide . with mitral valve insufﬁciency and mitral valve stenosis though Firstable the valve was developed for mitral valve replacement her symptoms improved with medical therapy. In 1972, she had but subsequently was used in both aortic and mitral positions. her ﬁrst uneventful pregnancy, 4 months after that she began Successful clinical use started in 1968. One of the valve’s main with heart failure symptoms, reporting orthopnea and Received: October 30, 2017. Revised: November 29, 2017. Accepted: December 7, 2017 © The Author(s) 2017. Published by Oxford University Press. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact email@example.com Downloaded from https://academic.oup.com/omcr/article-abstract/2018/2/omx107/4911314 by Ed 'DeepDyve' Gillespie user on 16 March 2018 Normal function of a 43-year-old Braunwald Cutter 71 biatrial dilation, normal biventricular systolic function, normally functioning mechanical prostheses, maximum gradient of 14 mmHg, and a mean gradient of 4 mmHg, In addition, she pre- sented a pulmonary artery systolic pressure of 40 mmHg, leading to severe tricuspid regurgitation, and permanent atrial ﬁbrillation, which was treated with medical therapy with good outcome. Later in 2013, the patient was diagnosed with hairy tubular polyp. She underwent total colectomy, right salpingo-oophorectomy and ileorectal anastomosis with ileostomy for protection. After the procedure, she had and adequate hospital course and was discharged home. In May 2015, a corrective ileostomy was performed. As part of the preoperative surgical protocol, an echocardio- gram performed in 2014 revealed biatrial dilation, no alterations in left ventricular segmental mobility, and normal biventricular systolic function, also, a mechanical prosthesis in mitral pos- ition was disclosed with maximum speed of 1.9 m/s, maximum gradient of 15 mmHg, mean gradient of 6 mmHg, severe tricus- pid valve insufﬁciency, inferior vena cava measuring 15 mm with more than 50% collapse and pulmonary artery systolic Figure 1: In this ﬂuoroscopic image, is shown the main structure of the Braunwald Cutter prosthetic valve. pressure of 40 mmHg (Fig. 3). Echocardiographic results from 2016 reveal a normal mech- anical prosthesis with maximum speed of 1.8 m/s, maximum gradient of 13 mmHg, mean gradient of 6 mmHg, severe tricus- pid valve insufﬁciency, inferior vena cava measuring 15 mm with more than 50% collapse (Fig. 4). Our patient remains in NYHA Class II, with a normal hepatic function even in the pres- ence of tricuspid regurgitation; without evidence of hemolysis, ball deformation, and cerebral embolism or to any other organ. She is being treated with metroprolol 50 mg twice a day, furose- mine 40 mg twice a day, spironolactone 25 mg once a day, cholecalciferol 600 IU once a day, and acenocoumarol 12 mg per week as anticoagulant agent. DISCUSSION The Braunwald-Cutter prosthesis was removed from market in 1979. In 1977, around 1450 prophylactic valvular replacements were performed in patients with the device in the aortic pos- ition . Multiple cases of early (3 months post-implant) pan- nus formation were reported, as well as cases of ball embolism and death. Therefore, it was recommended that surgical change be performed after 4.5–5 years of implant in prosthesis found in the aortic position [6, 7]. In 1974, Karp et al. reported a study following a cohort of 278 patients with as long as 15 months follow-up undergoing aortic valve replacement with the following prostheses: Barunwald- Cutter (BC), Starr-Edwards (SE) and homograft prosthesis (HP). The group found a higher incidence of thromboembolism in patients with BC (10.7%, average 6.8 months follow-up) and SE (9%, average 9.6 months follow-up). It is worth noting that no Figure 2: A 3D reconstruction of the prosthesis. anticoagulation therapy for patients with the SE was used. Intrahospital death for the three prostheses was reported as paroxysmal nocturnal dyspnea secondary to double valvular follows: 7/44 patients for the BC (15.9%); 5/72 patients for the SE injury. After a cardiac catheterization identiﬁed Pulmonary (6.9%); 13/307 patients for the HP (4.2%). Meanwhile, the 12-year Capillary Wedge Pressure of 20 mmHg, V wave of 37 mmHg with survival rate was 88% for BC, 83% for SE, 94% for HP . maximum gradient of 9 mmHg, a decision was made to perform Tandon et al. published a comparative analysis in 1978 for mitral valve replacement surgery on 17 September 1974 with a the following prostheses in the mitral position: lonescu-Shiley 32-mm Braunwald-Cutter ball cage prosthesis. Two years later, pericardial xenograft (n = 126), Bjork-Shiley (n = 42) and the patient had a second pregnancy without complications. Braunwald-Cutter (n = 52). The 7-year mean survival rates were Since then, her follow-up was at our hospital treated with oral reported as 89 ± 9.3%, 81.9 ± 12.8% and 41.7 ± 22.9%, respect- anticoagulation based on acenocumarol. ively. An elective change of prosthesis was suggested because In 2011, she reported to the emergency department with dys- of the high risk of embolism and death, in contrast to values pnea on moderate exercise. Echocardiographic ﬁndings reported reported in other studies . Downloaded from https://academic.oup.com/omcr/article-abstract/2018/2/omx107/4911314 by Ed 'DeepDyve' Gillespie user on 16 March 2018 72 G.M. Jiménez-Rodríguez et al. Figure 3: Right atrial enlargement and severe tricuspid regurgitation a case reported of the Starr-Edwards valve lasting 37 years that required prosthetic change due to endocarditis . Another Italian report in 2008 described a patient in NYHA Class II with a functioning Starr-Edwards prosthesis after 39 years of implant- ation . Here, we report the use of the 32-mm Braunwald-Cutter with the longest longevity that remains functional after 43 years of implantation. Upon literature review, we found a Braunwald-Cutter lasting 33 years in a patient who presented valvular dysfunction and paravalvular leak that had to undergo valve replacement. It has been suggested that the reason for the increased duration of prostheses in the mitral position in comparison to the aortic position is due to the decreased blood ﬂow through the prosthesis in the mitral position, which pro- motes endothelialization of struts and minimizes ball deform- ation . Figure 4: Normal mechanical prosthesis gradients with maximum speed of 1.8 m/s, maximum gradient of 13 mmHg, mean gradient of 6 mmHg. ACKNOWLEDGEMENTS The researchers would like to thank the patient described for A 1982 retrospective study with 234 patients that received her willingness to participate in this case report. 239 these prostheses in both mitral (n = 130) and aortic (n = 109) positions. The patients were followed an average of 44 (range: 1–92) and 52 (range: 2–96) months, respectively. For patients CONFLICT OF INTEREST STATEMENT with prophylactic valvular change, early pannus formation was None declared. found in 9% (1/11 patients) for valves in the mitral position, and 93% (43/46 patients) for valves in the aortic position. For patients with the prosthesis in the mitral position, ball embol- FUNDING ism was not reported, and a 71% survival rate was observed at No sources of funding. 5 years. Reduction of the ball occurred in 4% of patients and 4 of them experienced ball embolism (all in aortic position). The incidence of endocarditis was reported in 5 and 4% in the mitral ETHICAL APPROVAL and aortic positions, respectively. For patients with multiple prostheses, endocarditis was reported as 4%. Monitoring of Aside from informed consent, ethical approval was not patients with prosthesis in the mitral position was satisfactory required for this case report. and no elective change was recommended . A second report by Abdulali et al. in 1984 produced similar results in 80 patients with mean follow-up of 84.6 months (range: CONSENT 72–120). Ball damage was reported as 29% (5/17 patients). No Written informed consent was obtained directly from the cases of ball embolism were reported . Yakirevich reported patient for publication of this case report and any accompany- early ball embolism after 8 years when the Braunwald-Cutter ing images. valve is found in the mitral position . In the case of the Smeloff-Cutter prosthesis, the longest duration reported was 43.3 years. After that, ball deformation and pannus develop- GUARANTOR ment was observed, which prevented adequate ball mobility. These were signs that the valve must be replaced . There is S.C.V is the guarantor of this article. Downloaded from https://academic.oup.com/omcr/article-abstract/2018/2/omx107/4911314 by Ed 'DeepDyve' Gillespie user on 16 March 2018 Normal function of a 43-year-old Braunwald Cutter 73 pericardial xenograft and the Braunwald-Cutter and Bjork- REFERENCES Shiley prostheses in the mitral position. J Thorac Cardiovasc 1. Morse D, Steiner RM, Fernandez J. Surgical aspects of valve Surg 1978;76:763–70. implantation. In: Morse D, Sa JF, eds. Guide to Prosthetic 10. Abdulali SA, Silverton P, Schoen FJ, Saunders NR, Ionescu Cardiac Valves. New York: Springer-Verlag, 1985,1113–20. MI. Late outcome of patients with Braunwald-Cutter mitral 2. Waldhausen JA. In Memoriam: Nina S. Braunwald, valve replacement. Ann Thorac Surg 1984;38:579–85. 1928–1992. Ann Thorac Surg 1993;55:1055–6. 11. Yakirevich V, Miller HI, Shapira I, Ostzjega E, Gueron M, 3. Gott VL, Alejo DE, Cameron DE. Mechanical heart valves: 50 Vanderman AY, et al. Intermittent poppet dislodgment in a years of evolution. Ann Thorac Surg 2003;76:2230–9. Braunwald-Cutter prosthesis: noninvasive diagnosis and 4. Blackstone EH, Kirklin JW, Pluth JR, Turner ME, Parr GVS. successful surgical treatment. J Am Coll Cardiol 1984;3: The performance of the Braunwald-Cutter aortic prosthetic 442–6. valve. Ann Thorac Surg 1977;23:302–18. 12. Head SJ, Ko J, Singh R, Roberts WC, Mack MJ. 43.3-Year dur- 5. Braunwald NS. It will work: the ﬁrst successful mitral valve ability of a Smeloff-Cutter ball-caged mitral valve. Ann replacement. Ann Thorac Surg 1989;48:S1–3. Thorac Surg 2011;91:606–8. doi:10.1016. 6. Schoen FJ, Goodenough SH, Ionescu MI, Braunwald NS. 13. Ozkokeli M, Ates M, Ekinci A, Akcar M. Thirty-seven-year Implications of late morphology of Braunwald-Cutter mitral durability of a Starr-Edwards aortic prosthesis case report heart valve prostheses. J Thorac Cardiovasc Surg 1984;88:208–16. and brief review of the literature. Tex Heart Inst J 2005;32: 7. Jonas RA, Barratt-Boyes BG, Kerr AR, Whitlock RML. Late 99–101. follow-up of the Braunwald-Cutter Valve. Ann Thorac Surg 14. Scardi S, Pinamonti B, Moretti M, Sinagra G. Thirty-nine- 1982;33:554–61. year survival with the Starr-edwards mitral valve pros- 8. Karp RB, Kirklin JW, Kouchoukos NT, Paciﬁco AD. thesis. Monaldi Arch Chest Dis 2008;70:34–7. Comparison of three devices to replace the aortic valve. 15. Luk A, Lim KD, Siddiqui R, Gupta S, Gilbert BW, Fremes SE, Circulation 1974;50(2 Suppl):II163–9. et al. A Braunwald-Cutter valve: a mitral prosthesis at 33 9. Tandon AP, Sengupta SM, Lukacs L, Ionescu MI. Long-term years, Case report. Cardiovasc Pathol 2010;19:E39–42. clinical and hemodynamic evaluation of the Ionescu-Shiley Downloaded from https://academic.oup.com/omcr/article-abstract/2018/2/omx107/4911314 by Ed 'DeepDyve' Gillespie user on 16 March 2018
Oxford Medical Case Reports – Oxford University Press
Published: Feb 1, 2018
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