A Perfectly Functioning Magovern-Cromie Sutureless Prosthetic Aortic Valve 42 Years After Implantation
A 65-year–old man was admitted with recurrent pulmonary edema. At the age of 23, 42 years before his admission, he had had an aortic valve replacement with a “ball-and-cage” valve for severe aortic stenosis. He had suffered a postoperative hemorrhagic stroke with right hemiparesis but had been doing well on warfarin for 42 years. Echocardiography demonstrated a perfectly functioning prosthetic aortic valve with peak transvalvular gradient of 23 mm Hg and mean gradient of 13 mm Hg with no aortic regurgitation (Figure 1, Movie I). There was also severe rheumatic mitral valve stenosis. Coronary angiography showed insignificant coronary disease, and on fluoroscopy an unusual ball-and-cage prosthetic valve, with an incomplete cage and multiple spikes protruding from its base, was seen (Figure 2, Movie II).
The patient underwent mitral valve replacement via midline sternotomy, and the mitral valve was approached through a left atrial incision parallel to the interatrial groove. Because of the bulkiness of the prosthetic aortic valve, the anterior aspect of the new prosthetic mitral valve could not be sewn. The aorta was opened and the prosthetic aortic valve exposed. While the cage was being held, the valve completely dislodged from the annulus, leaving a large crater. No sewing ring or sutures were seen (Figure 3). A new prosthetic valve was implanted in the aortic position.
In the early 1960s, after the establishment of cardiopulmonary bypass, several mechanical ball-and-cage heart valves with different designs and materials were developed. Concerned about the long time it took to suture the valve to the heart, Dr George Magovern approached the development of the valve from a different angle. Together with Harry Cromie, “to simplify the method of fixation, lessen bypass time and reduce thrombus formation,”1 he developed a valve for “both the aortic and mitral position utilizing a rapid nonsuture, mechanical fixation …which requires only a few seconds …, eliminating the need for prolonged cardiopulmonary bypass ….” Magovern and colleagues wrote, “The essential feature of this fixation is the use of multiple curved pins to hold the valve in position.”1
The valve was first implanted in 1962. Several hundred of its various models were implanted in both aortic and mitral positions.2 Although production ceased in 1980, Dr Magovern continued to implant this valve for several more years.3 The recent development of transapical and percutaneous sutureless aortic valve replacement is an example of history repeating itself.
The valve we explanted after 42 years is the original model, with an all-metal titanium cage. To our knowledge, this is the longest functioning prosthetic valve of any kind documented.
The online-only Data Supplement, which contains Movies I and II, can be found at http://circ.ahajournals.org/cgi/content/full/117/1/e1/DC1.