The Starr–Edwards caged ball valve is one of the oldest cardiac valve prostheses and was widely used all around the world in the past decades . Few patients are reported to have lived with Starr–Edwards prosthesis for 30 years or longer. A 64-year-old woman was admitted to our hospital with complaints of dyspnea on exertion (NHYA Class III), abdominal distention, peripheral swelling, and diminished appetite. She underwent mechanical mitral replacement with Starr–Edwards caged ball valve prosthesis due to rheumatic mitral valve disease (predominantly severe mitral regurgitation) at age 34. She underwent DDD-R pacemaker implantation 5 years ago due to syncope resulting from sick sinus syndrome. On resting ECG basic rhythm was atrial fibrillation. The patient was well anticoagulated with INR value of 3.7. On transthoracic echocardiogram, the silicon ball was free to travel along the cage over a distance of 1 cm, although high peak velocity (2.5 m/s) accompanied with 8 mmHg of mean gradient and 130 ms of pressure half time was observed on transthoracic echocardiography examination. The latter also demonstrated a giant left atrium with dimensions of 15×12 cm, severe tricuspid insufficiency associated with pulmonary hypertension (systolic pulmonary arterial pressure=75 mmHg), and reduced right ventricular systolic functions. Occluder motion was normal, and no evidence of prosthetic valve thrombosis (despite the presence of spontaneous echo contrast) or pannus formation was observed on transesophageal echocardiogram. On cinefluoroscopy, the movements of the silicon ball were relatively diminished. On thorax computed tomography (CT), 3D colored volume rendered and axial images gave the best overview of the Star–Edwards prosthesis and the giant left atrium which measured 129×154×185 mm with an estimated left atrial volume of 1870 ml ( Fig. 1 A and B). Although severe pulmonary hypertension might have increased surgical risk, we decided to perform mitral valve reimplantation accompanied with left atrial volume reduction plus maze procedure and tricuspid annuloplasty. Unfortunately, the patient did not want to undergo surgery. Since then she was discharged with a single daily dose of 0.25 mg digoxin, 5 mg of warfarin sodium, 100 mg of spironolactone, and 20 mg of furosemide. Her functional capacity was NYHA Class II 6 months later.
