Ann Thorac Surg 2005;79:1395-1397
© 2005 The Society of Thoracic Surgeons
Case report
Reoperation of the Kay-Shiley Disc Valve 35 Years After Replacement
Shogo Nakayama, MD, PhD*,a,
Michihito Nonaka, MDa,
Osamu Ishida, MDa
a Department of Cardiovascular Surgery, Takamatsu Red Cross Hospital, Kagawa, Japan
Accepted for publication September 23, 2003.
* Address reprint requests to Dr Nakayama, Department of Cardiovascular Surgery, Takamatsu Red Cross Hospital, 4-1-3 Bancho, Takamatsu, Kagawa 760-0017, Japan
nakafami{at}ma.akari.ne.jp
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Abstract
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The Kay-Shiley disc valve (Shiley Inc, Irvine, CA) was manufactured in 1965 and is no longer in clinical use due to its high incidence of thromboembolism. We report a case of tricuspid valve replacement with the Kay-Shiley valve 35 years previously. The valve was replaced successfully with a St. Jude Medical valve (St. Jude Medical, Inc, St. Paul, MN). This is the longest interval from implantation to re-replacement with the Kay-Shiley valve that has been reported in the literature.
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Introduction
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Reoperation is sometimes required for dysfunctioning valve prostheses, mechanical or biological. We performed reoperation in a very rare case of a 48-year-old man who had undergone tricuspid valve replacement with the Kay-Shiley disc valve (Shiley Inc, Irvine, CA) 35 years previously.
A 48-year-old Japanese man was referred to our hospital for evaluation of congestive heart failure. He complained of fatigue and dyspnea on effort. Congenital heart disease had been pointed out at birth, and direct closure of an atrial septal defect and a valve replacement with a Kay-Shiley disc valve for tricuspid stenosis were performed at age 13. Echocardiography in the recent visit showed an enlarged right atrium and the inferior vena cava, indicating right-sided heart failure. Aortic regurgitation of a moderate degree was also detected. Cardiac catheterization demonstrated an atrial-wave of 30 mm Hg and a mean right atrial pressure of 18 mm Hg. Right atrial angiogram showed a remarkably dilated right atrium, suggesting that his congenital heart disease may have been Epstein's malformation (Fig 1). The respiratory function was within normal range and no pulmonary embolic episode was recorded. Prosthetic valve malfunction and tricuspid stenosis were suspected.
The patient underwent replacement of the tricuspid prosthesis and the aortic valve. The operation begun with a median sternotomy was performed on the patient. Dissection of the adhesion around the heart was not difficult and aortic and bi-caval cannula were smoothly inserted. After clamping the aorta, the ascending aorta was incised obliquely and selective antegrade cardioplegia was used for myocardial protection. The aortic valve was excised first and replaced with a 23 mm St. Jude Medical valve (St. Jude Medical, Inc, St. Paul, MN). A right atriotomy was made to observe the implanted Kay-Shiley disc valve. Neointimal proliferation was not thick around the valve orifice on the atrial side, but the occluder disc was thickly covered with organized thrombus and had adhered firmly to the disc cage. Excessive neointima and subvalvular apparatus surrounded the whole valve on the ventricular side, making the valve orifice slit-like and narrow. The occluder disc was entrapped in the disc cage mainly due to the overgrowth of the pannus formation. A small amount of fresh thrombus was recognized on the surface of the neointima (Fig 2). The Kay-Shiley valve was excised by cutting the annular cloth between the metal ring and the sawing cuff. Parts of the sawing cuff were left on the annulus in order to reinforce the suture line. The prosthetic valve was replaced successfully with a 27 mm St. Jude Medical valve (St. Jude Medical, Inc).
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Fig 2. An excised Kay-Shiley disc valve; ventricular aspect. The disc and disc cage were covered with the overgrowth of the pannus formation.
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After the operation, the mean value of central venous pressure was decreased to 13 mm Hg and the high atrial-wave disappeared. The patient is now well and continues with follow-ups at the outpatient clinic for anticoagulation therapy of warfarin and aspirin.
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Comment
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The Kay-Shiley disc valve was invented as an alternative to the Starr-Edwards ball valve in 1965 [1]. The Kay-Shiley disc valve was improved through several variations from the K and T series without muscle guard to the MGCD and TGCD series with muscle guard from 1965 to 1980. These modified devices have since been abandoned because of high incidences of thromboembolic complications.
The Kay-Shiley valve in the current report is the model without muscle guard. Previous studies reported high incidences of thromboembolic complications with the Kay-Shiley disc valve. Wellons and colleagues [2] reported complications totaling 55 embolic events in 83 patients over a 6-year period. Bowen and colleagues [3] noted complications in 64% of the operative survivors with an incidence of 28.7 events per 1,000 patient months. Bowen and colleagues [3] recommended elective replacement of the Kay-Shiley mitral prostheses in all patients in whom the risk of operation was reasonable.
Tricuspid valve replacement is seldom done in clinical practice today. It is the last choice of treatment in patients with tricuspid regurgitation or stenosis in which repair is not feasible. The use of mechanical valves or bioprostheses has been controversial. Carrier and colleagues [4] recommended biological prostheses for tricuspid valve replacement in young patients because of their limited life expectancy, which was unrelated to the type of tricuspid prostheses in long-term follow-up. In contrast, Van Nooten and colleagues [5] found no differences over a 7-year postoperative period, whereas the new mechanical prostheses, such as St. Jude Medical's bileaflet valve (St. Jude Medical, Inc) showed better results than the bioprostheses in more than 7 years of follow-up, suggesting degradation of the bioprostheses. Van Nooten and colleagues [5] favored mechanical prostheses for patients with good, long-term prognoses. In our patient, a mechanical valve was selected because he was young, he had normal cardiac function, and he had a long-term life expectancy. Correctly regulated anticoagulation therapy is necessary to maintain the valve function over a long period of time. This case involved the longest interval from the Kay-Shiley valve implantation to re-replacement of a new valve that has been reported in literature.
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References
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- Kay JH, Kawashima Y, Kagawa Y, et al. Experimental mitral valve replacement with a new disc valve. Ann Thorac Surg. 1966;2:485–498[Medline]
- Wellons HA Jr, Strauch RS, Nolan SP, et al. Isolated mitral valve replacement with the Kay-Shiley disc valve: actuarial analysis of the long-term results. J Thorac Cardiovasc Surg. 1975;70:862–868[Abstract]
- Bowen TE, Colonel MC, Zajtchuk R, et al. Isolated mitral valve replacement with the Kay-Shiley prosthesis: long-term follow-up and recommendations. J Thorac Cardiovasc Surg. 1980;80:45–49[Abstract]
- Carrier M, Hebert Y, Pellerin M, et al. Tricuspid valve replacement: an analysis of 25 years of experience at a single center. Ann Thorac Surg. 2003;75:47–50[Abstract/Free Full Text]
- Van Nooten GJ, Case F, Taeymans Y, et al. Tricuspid valve replacement: postoperative and long-term results. J Thorac Cardiovasc Surg. 1995;110:672–679[Abstract/Free Full Text]
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Abstract
Introduction
