Late results after Starr-Edwards valve replacement in children

Selection of types of prosthetic heart valves for children remains controversial. The case histories of 50 children surviving valve replacement with Starr-Edwards prosthesis between 1963 and 1978 were reviewed to evaluate the long-term performance of mechanical valves. The 31 boys and 19 girls ranged from 6 months to 18 years in age (mean 10.4 years); 19 patients had had aortic valve replacement, 24 patients had had mitral valve replacement, and one patient had had both. Among the six patients who had had tricuspid valve replacement, four had corrected transposition, so that the tricuspid valve was the systemic atrioventricular valve. Mean (± standard deviation) follow-up interval was 7.9 ± 4.9 years (maximum 17 years). For all patients, the 5 year survival rate was 86% ± 6%. At 10 years postoperatively, the survival rate (± standard error) was 90% ± 7% after aortic valve replacement and 76% ± 8% after systemic atrioventricular valve replacement. At follow-up, 39 patients were alive, and 38 were in New York Heart Association Class I or II. Of the 11 deaths, four were valve-related. Seven patients had major (requiring hospitalization) thromboembolic events, and five patients had minor transient neurological symptoms suggesting thromboembolism; 50% of these patients were not taking warfarin (Coumadin) at the time of the thromboembolic event. The incidence of late (>30 days) thromboembolism was 5.3 per 100 patient-years after aortic and 2.0 per 100 patient-years after systemic atrioventricular valve replacement. At 10 years postoperatively, 66% ± 15% of patients who had had aortic valve replacement and 91% ± 6% of those who had had systemic atrioventricular valve replacement were free of thromboembolism. The excellent long-term survival, absence of mechanical failure, and relatively low rate of thromboembolism with this prosthesis contrast with our experience with biological valves, in which 41% of children required reoperation in 5 years. Currently, mechanical valves, such as the Starr-Edwards prosthesis, are our preferred valves for pediatric patients.