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Ann Thorac Surg 2009;87:628-629. doi:10.1016/j.athoracsur.2008.07.018
© 2009 The Society of Thoracic Surgeons
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Case Reports

A 37-Year-Old Smeloff-Cutter Aortic Valve

Ming-Sing Si, MDa, Alex Zapolanski, MDb,c,*

a Division of Cardiothoracic Surgery, University of Michigan Medical Center, Ann Arbor, Michigan
b Division of Cardiothoracic Surgery, Columbia University, New York City, New York
c Valley Columbia Heart Center, Ridgewood, New Jersey

Accepted for publication July 9, 2008.

* Address correspondence to Dr Zapolanski, Valley Columbia Heart Center, 223 N. Van Dien Ave, Ridgewood, NJ 07450 (Email: azapolanski{at}gmail.com).


   Abstract
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 Abstract
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We describe the case of a 64-year-old woman with mitral insufficiency that had undergone an aortic valve replacement with a Smeloff-Cutoff prosthesis (Cutter Laboratories, Berkeley, CA) 37 years ago. She underwent both aortic and mitral valve replacement. The patient's Smeloff-Cutter aortic valve was unchanged. This case demonstrates the longest durability for the Smeloff-Cutter aortic prosthesis reported in the literature.


   Introduction
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 Abstract
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Comment
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The Smeloff-Cutter aortic valve prosthesis (Cutter Laboratories, Berkeley, CA) was introduced in 1964 and belonged to the first generation ball-cage design. It has three titanium-pronged cages located both upstream and downstream of the valve orifice. Unlike the Starr-Edwards prosthesis (Edwards Laboratories, Santa Ana, CA), the diameter of the Smeloff-Cutter valve poppet is similar to that of the valve orifice, and the poppet sits in the lower ventricular cage during diastole. This valve has been described to be durable up to 28 years after implantation [1]. Here we describe a patient with an intact 37-year-old Smeloff-Cutter aortic valve prosthesis, which we believe is the longest reported follow-up of any type of aortic mechanical valve.

The patient is a 64-year-old woman with a history of rheumatic heart disease who underwent an aortic valve replacement with a Smeloff-Cutter prosthesis in 1968. She had been anti-coagulated with warfarin. She took 10 mg daily for years without any control and no episodes of bleeding. She had been doing well until she began to have increasing dyspnea develop on exertion, as well as at rest. Transthoracic echocardiogram showed a mitral valve with thick and redundant leaflets causing slight stenosis and severe regurgitation. The Smeloff-Cutter aortic valve was described as normal and had a peak gradient of 24 mm Hg and a mean gradient of 5.5 mm Hg. There was no perivalvular leak. The left atrium was enlarged and the left ventricle was of normal size. Coronary angiography showed the presence of a 50% stenosis in the proximal left anterior descending coronary artery.

The patient was brought to the operating room for an aortic and mitral valve replacement and a graft to the left anterior descending coronary artery.

Intraoperatively, the Smeloff-Cutter aortic prosthesis did not show any signs of wear or thrombus (Fig 1). The ball appeared smooth and with no obvious variance or lipid infiltration. The aortic valve was replaced with a No. 21 On-X mechanical valve and the mitral valve (On-X Life Technologies Inc, Austin, TX) was replaced with a No. 27 On-X mechanical valve. The bypass was performed without event, and the patient was easily weaned off cardiopulmonary bypass.


Figure 1
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  		Fig 1. Excised Smeloff-Cutter aortic valve (Cutter Laboratories, Berkeley, CA) and native mitral valve. The 37-year-old valve showed no signs of mechanical wear.

 
Postoperatively atrial fibrillation developed in the patient, and she was discharged on postoperative day 10.


   Comment
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 Abstract
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The Smeloff-Cutter valve was designed and has been demonstrated to have mild regurgitation [2]. This regurgitant flow prevents thrombus formation on the ball and cage of the prosthesis. Indeed, as compared with the Starr-Edwards ball-cage prosthesis (Edwards Laboratories), the Smeloff Cutter valve has a lower thromboembolism rate at 25 years (1.41% vs 2.01% per patient year) [3, 4]. Furthermore, Gometza and Duran [5] described a subset of young patients (n = 29) with an isolated Smeloff-Cutter aortic valve taking dipyridamole and aspirin, but no anticoagulants, at a thromboembolism rate of 0.9% per patient year in their series. Rao and colleagues [6] demonstrated a 2.5% per patient year thromboembolism rate in young patients taking dipyridamole and aspirin, but no anticoagulants.

Several groups have published their long-term follow-up of patients with the Smeloff-Cutter aortic prosthesis. In the largest published experience of 358 patients, Starr and colleagues [7] demonstrated a 5.4%, 2.9%, and 2.6% per patient year thromboembolism rate in patients, respectively, taking no anticoagulation, antiplatelet agents, and warfarin.

We believe that our patient has the oldest, functionally normal aortic mechanical valve described. Previously, a 29-year-old Harken disk mitral valve (Surgitools Inc, Woodvale, WA) has been described [8]. Although preoperative and intraoperative findings showed that in our patient the Smeloff-Cutter valve (Cutter Laboratories) was normal and functioning well, we decided to replace this 37-year-old valve because of the uncertainty of how much longer it would continue to function well.


   References
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 Abstract
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 Comment
 References
 

  1. Naito Y, Nakajima M, Inoue H, et al. Unexpected durability of Smeloff-Cutter aortic ball valve prosthesis Ann Thorac Surg 2003;75:1633-1635.[Abstract/Free Full Text]
  2. Stormer B, Mendling W, Kohler J, et al. Comparative study of in vitro flow characteristics between a human aortic valve and a designed aortic valve and six corresponding types of prosthetic heart valves Eur Surg Res 1976;8:117-131.[Medline]
  3. Lund O, Pilegaard HK, Ilkjaer LB, et al. Performance profile of the Starr-Edwards aortic cloth covered valve, track valve, and silastic ball valve Eur J Cardiothorac Surg 1999;16:403-413.[Free Full Text]
  4. Godje O, Fischlein T, Adelhard K, et al. 25 years follow-up of patients after replacement of the aortic valve with a Smeloff-Cutter prosthesis Thorac Cardiovasc Surg 1996;44:234-238.[Medline]
  5. Gometza B, Duran CM. Ball valve (Smeloff-Cutter) aortic valve replacement without anticoagulation Ann Thorac Surg 1995;60:1312-1316.[Abstract/Free Full Text]
  6. Rao PS, Solymar L, Mardini MK, et al. Anticoagulant therapy in children with prosthetic valves Ann Thorac Surg 1989;47:589-592.[Abstract/Free Full Text]
  7. Starr DS, Lawrie GM, Howell JF, et al. Clinical experience with the Smeloff-Cutter prosthesis: 1- to 12-year follow-up Ann Thorac Surg 1980;30:448-454.[Abstract/Free Full Text]
  8. Hsi DH, Ryan GF, Taft H, et al. A 29-year-old Harken disk mitral valve: long-term follow-up by echocardiographic and cineradiographic imaging Tex Heart Inst J 2003;30:319-321.[Medline]



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