Outcome analysis of 245 CarboMedics and St. Jude valves implanted at the same institution

Clinical outcomes of Carbomedics Top Hat valve with a robust follow-up system

AIM

Late failure of bioprosthetic valves may limit their use in patients < 60 years. The superior hemodynamic performance offered by the Carbomedics Top Hat supraannular valve enables greater effective orifice areas to be achieved. The aim of this study was to assess the clinical outcomes of this valve, using a robust follow-up system.

METHODS

Patients who underwent aortic valve replacement with or without coronary artery bypass grafting between July 1997 and January 2010 with Carbomedics supraannular Top Hat valves were identified. Details of readmissions and late deaths were obtained from the National Hospital Episodes Statistics data and the Office of National Statistics, tracked by the Quality and Outcomes Research Unit. Late complications associated with this prosthesis were evaluated.

RESULTS

Of 253 patients identified, 181 underwent isolated aortic valve replacement and 72 had aortic valve replacement with coronary artery bypass grafting. The 30-day mortality was 1.6%, and 5- and 10-year survival rates were 91.4% and 80.5%, respectively. Detailed readmission data were available after 2001 (n = 170). Two (1.2%) patients required reoperation for endocarditis and pannus formation. Of the 17 late deaths in this subset, 4 were attributable to cardiac causes. One patient was treated for heart failure, and 2 developed bleeding complications.

CONCLUSIONS

Implantation of the Carbomedics Top Hat supraannular valve in our unit resulted in satisfactory in-hospital and midterm survival with low incidences of endocarditis and late heart failure.

Choice of echocardiography method for postoperative evaluation of mitral valve replacement with a mechanical prosthesis

OBJECT

The French Cardiology Society (SFC) systematically recommends (Class I) transesophageal echocardiography (TEE) after any mitral valve replacement with a mechanical prosthesis (MMVR). Taking into account the increasing workload of echocardiography laboratories, our attitude was to propose that only post-operative transthoracic echocardiography (TTE) is performed. The purpose of this study was to evaluate the possible risks of this simplified procedure.

METHODS

We performed a precise analysis of one full year of practice of MMVR with exhaustive follow-up for the first 2 years concentrating on thromboembolic complications.

RESULTS

From January to December 2003, 84 MMVRs (46 after rheumatic fever, 22 degenerative disease, 11 infective endocarditis (IE) and 5 ischemia) were conducted in 45 women and 39 men of average age 61 years. Early mortality (<30 days) concerned 5 patients (5.9%). A control TTE to determine normal prosthetic function was performed 7+/-2 days after surgery and this revealed 2 cases of nonobstructive thrombosis which were treated medically, 3 cases of paraprosthetic regurgitation, and 1 vegetation due to underlying IE. Actuarial survival was 90.5% at 1 year and 83.3% at 2 years. After a mean follow-up of 179.3 patient-years, 5 patients were reoperated (5.9%): 1 for IE, 1 for paravalvular regurgitation, 1 for mitral valve insufficiency with haemolysis, and 2 for obstructive prosthetic valve thromboses. In addition there were 2 cases of prosthetic valve thrombosis, 8 ischemic strokes (2 ministrokes, 6 sequelar strokes), and 1 peripheral embolism. The global thromboembolic complication rate was therefore 6.1 per 100 patient-years (n=11). There were 4 hemorrhagic events, i.e. a rate of 2.2 events per 100 patient-years. 63% of the 1193 INR conducted were within the target range (3-4.5), 26% were below 3 and 11% were greater than 4.5. 35% of patients with thromboembolic complications had an INR<3.

CONCLUSION

Morbidity and mortality during the first 2 years after MMVR were relatively high but equivalent to the values of comparable series in the literature. These complications would not have been reduced by a more precise screening based on early TEE. Despite the increasingly litigious nature of the doctor-patient relationship, it would probably be excessive to oppose that this guideline was not followed in a dispute; in particular as it is difficult to apply this measure as echocardiography departments are overworked.

Prosthetic valve thrombosis with adequate anticoagulation

We report the case of a 41-year-old woman who developed thrombosis of a CarboMedics prosthetic valve in the mitral position despite adequate anticoagulation. This report provides further supportive data to recently published studies suggesting an increased thrombogenicity of the CarboMedics prosthetic valve in the mitral position and it underscores the importance of conducting large prospective, randomized trials for further evaluation of the thromboembolic complications of this valve.

Prospective randomized comparison of CarboMedics and St. Jude Medical bileaflet mechanical heart valve prostheses: Ten-year follow-up

OBJECTIVE

This is the final report of a randomized controlled trial comparing the performance of CarboMedics (CarboMedics Inc., Austin, Tex) and St. Jude Medical (St. Jude Medical Inc, St Paul, Minn) bileaflet mechanical heart valve prostheses 10 years after surgery.

METHODS

Between 1992 and 1996, 485 patients undergoing mechanical heart valve replacement were randomized to receive CarboMedics (n = 234) or St. Jude Medical (n = 251) prostheses for aortic (n = 288), mitral (n = 160), or double (n = 37) valve replacements. Patients were followed annually to the end of 2004.

RESULTS

Demographic, preoperative, and operative characteristics were similar between the 2 groups. The median follow-up was 10 years in both groups (CarboMedics 99% complete, St. Jude Medical 98% complete; 3879 patient-years of follow-up). Overall, 165 patients died, 25 of valve-related causes. Ten-year survivals were 66.4% (95% confidence interval: 59.6%-72.3%) and 64.7% (95% confidence interval: 58.0%-70.6%) in the CarboMedics and St. Jude Medical groups, respectively (P = .94). Freedom at 10 years from valve-related mortality was 95.0% (95% confidence interval: 90.8%-97.3%) in the CarboMedics group and 93.0% (95% confidence interval: 88.3%-95.9%) in the St. Jude Medical group. During follow-up, 34 patients had a thromboembolic event, 79 patients had at least 1 bleeding event, and 14 patients required reoperation. There were no significant differences between the groups with respect to freedom from complications (P > or = .12); freedom from thromboembolism at 10 years (CarboMedics: 91.5%, 95% confidence interval: 86.5%-94.7%; St. Jude Medical: 92.2%, 95% confidence interval: 87.5%-95.2%); freedom from bleeding events (CarboMedics: 83.0%, 95% confidence interval: 76.6%-87.8%; St. Jude Medical: 77.5%, 95% confidence interval: 71.1%-82.7%); and freedom from death or valve-related complication (CarboMedics: 51.6%, 95% confidence interval: 44.7%-58.0%; St. Jude Medical: 46.2%, 95% confidence interval: 39.7%-52.4%). Linearized rates per patient-year were 1.1% in the CarboMedics group and 0.8% in the St. Jude Medical group for thromboembolism; 2.3% in the CarboMedics group and 3.2% in the St. Jude Medical group for bleeding events; and 0.72% in the CarboMedics group and 0.47% in the St. Jude Medical group for nonstructural valve dysfunction. International normalized ratio values were similar between the 2 groups throughout the study period.

CONCLUSION

At 10 years, the clinical outcome was similar with respect to these 2 mechanical bileaflet prostheses.

Eleven-Year Single-Center Experience with the ATS Open Pivot Bileaflet Heart Valve

BACKGROUND

The ATS Open Pivot Heart Valve was first introduced in 1992 and has been implanted routinely at our institution since 1993. Valve selection was based on surgeon preference. The objective of this study is to retrospectively analyze our 11-year clinical results with ATS prostheses.

METHODS

Between January 1993 and December 2003, 601 ATS valves (393 aortic valve replacement [AVR], 168 mitral valve replacement [MVR], 20 aortic plus mitral valve replacement [DVR]) were implanted in 581 patients (377 male, 204 female; mean age, 63.7 years; range 18 to 89). Preoperatively, 47 (8%) were New York Heart Association class I, 212 (36.5%) were class II, 267 (46%) were class III, and 55 (9.5%) were class IV. Preoperative comorbidities were coronary artery disease, 167 (29%); diabetes mellitus, 72 (12%); cerebrovascular disease, 2 (0.3%); endocarditis, 53 (9%); and atrial fibrillation, 115 (20%).

RESULTS

Follow-up is 99% complete. Data represent 2,500 cumulative patient-years. Mean follow-up is 4.3 +/- 2.6 years (range, 0.1 to 11.6). Overall hospital mortality is as follows: AVR, 3.8% (15 patients); MVR, 1.8% (3 patients); DVR, 10% (2 patients). Structural valve failure was not encountered. Overall survival at 10 years is AVR, 84.7% +/- 3.1%, AVR plus coronary artery bypass, 67.5% +/- 8.2%; MVR, 59.8% +/- 7.1%, MVR plus coronary artery bypass, 39% +/- 27.8%; and DVR, 74.3% +/- 10%. Freedom from valve-related death at 10 years is AVR, 99.2%; MVR, 94.6%; and DVR, 100%. Linearized rates for postoperative complications are paravalvular leak, 0.6% per patient-year; valve thrombosis, 0.04% per patient-year; thromboembolism, 1.1% per patient-year; major bleeding, 0.5% per patient-year; and de novo prosthesis endocarditis, 0.1% per patient-year. Postoperative mortality risk was significantly elevated by diabetes (p < 0.01), but not by other comorbidities.

CONCLUSIONS

Our 11-year experience demonstrates low rates of adverse events and valve-related complications with the ATS Open Pivot heart valve.

Long-Term Result of 1144 CarboMedics Mechanical Valve Implantations

BACKGROUND

It has been reported that the CarboMedics mechanical valve has acceptable valve-related complication rates. The aim of this study was to evaluate the long-term performance of the CarboMedics valve.

METHODS

Between August 1988 and September 1999, we implanted 1144 CarboMedics valves in 850 patients (aortic, 179; mitral, 385; double-valve, 234; tricuspid, 52). Mean patient age was 44.5 +/- 12.5 years. Follow-up was completed in 95.3% and the median follow-up period was 7.9 years (6753 patient-years). Patients were divided into four groups according to implanted valve location and number (aortic, mitral, double, and tricuspid valve groups).

RESULTS

The overall hospital mortality rate was 3.4%, and the mortality rates in these groups were 1.7% in the aortic, 2.6% in the mitral, 4.7% in the double, and 9.6% in the tricuspid valve. The tricuspid valve group revealed a significantly higher mortality rate than the aortic and mitral valve groups (p < 0.05). Overall 10-year survival was 87.1% +/- 2.6%, 88.9% +/- 1.7%, 82.4% +/- 2.9%, and 77.5% +/- 7.0% in the aortic, mitral, double, and tricuspid valve groups, respectively. Age and tricuspid valve replacement were identified as significant risk factors of long-term survival by multivariate analysis (p < 0.05), and 99.4% +/- 0.6%, 98.2% +/- 0.8%, 99.2% +/- 0.8%, and 87.6% +/- 0.5% in the aortic, mitral, double, and tricuspid valve groups were free of valve thrombosis at 10 years. The tricuspid valve group demonstrated a significantly higher rate of valve thrombosis (p < 0.05).

CONCLUSIONS

This long-term study of patients that received CarboMedics valve implantation demonstrates that the CarboMedics prosthetic valve has an acceptable incidence of valve-related complications. However, it should be noted that tricuspid valve replacement indicated a higher level of overall mortality and valve thrombosis.

A 10-Year Experience With the Carbomedics Cardiac Prosthesis

BACKGROUND

There are few reports on the long-term results of Carbomedics prosthetic heart valves.

METHODS

Five hundred five patients who underwent valve replacement with this prosthesis in the aortic or mitral position were chosen for this study. Patients' mean age was 57 years. There were 173 aortic (AVR), 253 mitral (MVR), and 79 double (DVR) valve implants. The mean follow-up was 5.1 years, and cumulative follow-up was 2,590 patient-years with an overall follow-up rate of 99.2%.

RESULTS

The early mortality rate for the total population was 2.8% (AVR 1.2%, MVR 3.6%, DVR 3.8%). Actuarial freedom from thromboembolism at 10 years was 81.8% +/- 5.1%, 85.7% +/- 3.2%, and 88.8% +/- 6.8% for AVR, MVR, and DVR, respectively. At 10 years, 92.7% of AVR, 85.4% of MVR, and 94.7% of DVR patients were free of valve-related death. Overall survival rate at 10 years was 77.6% +/- 4.6%, 71.8% +/- 4.2%, and 81.3% +/- 5.8% for AVR, MVR, and DVR, respectively. The linearized rate of thromboembolism was 1.45%/patient-year, 1.78%/patient-year, 0.67%/patient-year; of major bleeding events, 0.52%/patient-year, 0.85%/patient-year, 0.45%/patient-year; of valve thrombosis, 0%/patient-year, 0.25%/patient-year, 0%/patient-year; of prosthetic valve endocarditis, 0.1%/patient-year, 0.25%/patient-year, 0.22%/patient-year; and of all reoperations, 0.31%/patient-year, 0.93%/patient-year, 1.1%/patient-year for AVR, MVR, and DVR, respectively.

CONCLUSIONS

The Carbomedics prosthetic heart valves showed comparable or even better results than those of other mechanical valves with respect to morbidity and mortality. These results may justify the use of Carbomedics valves as one of the mechanical heart valves.

"Our complication rates are lower than theirs": statistical critique of heart valve comparisons

OBJECTIVES

From the widely differing complication rates published for every heart valve, is it possible to determine a true rate for each valve and to compare the rates of two different valves? We investigated this question for the two most popular bileaflet valves.

METHODS

Aortic valve data were abstracted from 14 St Jude Medical (St Jude Medical Inc, Minneapolis, Minn; 33,125 patient-y) and 11 Carbomedics (Sulzer Carbomedics Inc, Austin, Tex; 19,141 patient-y) series, and mitral valve data were abstracted from 11 St Jude Medical (21,553 patient-y) and 8 Carbomedics (8368 patient-y) series. Regression analysis was used to accommodate heterogeneity among rates with the same valve model, to estimate hazard ratios and 95% confidence intervals for the valve model effect, and to incorporate other series-level risk factors.

RESULTS

Most of the complication rates with both valve models exhibited significant heterogeneity. For thromboembolism and bleeding, the relative risks for valve model were not significantly different from unity. Valve thrombosis rates exhibited less heterogeneity: the Carbomedics valve had a lower rate in the aortic position (hazard ratio 0.2, 95% confidence interval 0.1-0.6) and a higher rate in the mitral position (hazard ratio 1.9, 95% confidence interval 1.0-3.8).

CONCLUSIONS

Unlike simple weighted averages of valve complication rates, regression methods can incorporate heterogeneity related to center effects and allow for inclusion of other risk factors. Thromboembolism and bleeding rates were not significantly different with St Jude Medical and Carbomedics valves. Valve thrombosis appeared to differ between the two valves, but the absolute differences in rates were small. Because of the variability among rates with the same valve, statistical comparisons must be interpreted cautiously.

Ten year clinical experience with the CarboMedics heart valve implants

We reviewed the histories of 144 patients who underwent heart valve replacement with the CarboMedics prosthesis from 1990 to 2000. There were 74 males and 70 females, with a mean age of 52 years, including 69 aortic valve replacements, 48 mitral valve replacements, and 27 double (aortic and mitral) valve replacements. The mean duration of follow-up was 6.5 years. Early mortality was 7.6% (11 patients). Late deaths occurred in 14 patients, including cardiac-related late deaths in 9 and valve-related deaths in 3. The survival rate including early deaths was 84.7 +/- 3.2% at 5 years and 78 +/- 4.1% at 10 years. Preoperative New York Heart Association Class IV (p = 0.0001) was found to be a significant predictor of cardiac-related late death. Freedom rate from complications at 10 years were embolism 84.7 +/- 4.2% (linearized rate 1.8% per patient year), valve thrombosis 92.7 +/- 2.7% (linearized rate 0.8% per patient year), bleeding 95.6 +/- 2.6% (linearized rate 0.4% per patient year), reoperation 85.9 +/- 4% (linearized rate 1.5% per patient year), valve endocarditis 98.7 +/- 1.3% (linearized rate 0.1% per patient year), and nonstructural dysfunction 90 +/- 3.5% (linearized rate 1% per patient year). There was no structural deterioration. The early and long-term results with the CarboMedics heart valve implantation were acceptable, but valve thrombosis remains a concern in the present study. Further investigation for optimal anticoagulation therapy is necessary to reduce the incidence of valve thrombosis as well as embolic and bleeding complications.

Up to 8-year follow-up of valve replacement with carbomedics valve

BACKGROUND

The aim of this study was to report midterm valve replacement (VR) results with the Carbo-Medics valve (Sulzer Carbomedics, Austin, TX).

METHODS

From 1991 to 1999, 468 patients aged 13 to 76 years (mean 56 years) underwent VR with CarboMedics valve: 239 aortic (A), 167 mitral (M), and 62 A+M or double valve replacement (DVR). Mean follow-up time was 4.4 years; follow-up was 99.1% complete for 2,016 patient-years (PY). The anticoagulation level was targeted to an international normalized ratio of 1.47 to 2.8.

RESULTS

The hospital mortality rate was 1.2%. Actuarial analysis for the entire group at 7 years for survival was 87%+/-2.3%. Freedom from valve-related death was 94%+/-1.9%. Freedom from thromboembolic and bleeding events, respectively, were as follows: for AVR, 82%+/-4.9% (2.4%/PY) and 88%+/-2.9% (1.6%/PY); for MVR, 95%+/-2.1% (0.8%/PY) and 91%+/-3.1% (1.3%/PY); and for DVR, 96%+/-3.2% (0.7%/PY) and 85%+/-9.7% (1.0%/PY). Actuarial freedom from reoperation was 98%+/-1.4%.

CONCLUSIONS

The CarboMedics valve can be implanted with satisfactory early mortality and a low incidence of valve-related events even under low-intensity anticoagulation, as shown in a Japanese population.

Prospective randomized comparison of CarboMedics and St Jude Medical bileaflet mechanical heart valve prostheses: an interim report

OBJECTIVE

This is a midterm report of a study comparing the clinical performance of CarboMedics and St Jude Medical heart valve prostheses through a projected 10-year period.

METHODS

Between 1992 and 1996, a total of 485 patients undergoing mechanical valve replacement were prospectively randomly assigned to receive either CarboMedics (n = 234) or St Jude Medical (n = 251) prostheses for aortic (n = 288), mitral (n = 160), or double (n = 37) valve replacements and were followed up annually.

RESULTS

Baseline and operative characteristics were similar between the two groups with respect to major demographic characteristics, preoperative clinical status, and operative data. Mean follow-up was 50 +/- 22 months for the CarboMedics group (97% complete) and 47 +/- 20 months for the St Jude Medical group (96% complete), yielding a total of 1959 patient-years. The 30-day mortality, and 5-year actuarial survival, and linearized survival were 6.0%, 82.4% +/- 2.6%, and 4.3% per patient-year in the CarboMedics group and 4.4%, 79.9% +/- 2.8%, and 4.7% per patient-year in the St Jude Medical group (log-rank P =.7). Freedom at 5 years from valve-related mortality, major thromboembolism, hemorrhage, and other nonstructural valve dysfunction was, respectively, 96.7% +/- 1.4% (0.7% per patient-year), 90.9% +/- 2.1% (2.2% per patient-year), 87.3% +/- 2.5% (3.6% per patient-year), and 96.1% +/- 1.4% (0.7% per patient-year) in the CarboMedics group and 95.9% +/- 1.5% (1.0% per patient-year), 92.5% +/- 1.8% (2.0% per patient-year), 82.6% +/- 2.8% (4.3% per patient-year), and 96.0% +/- 1.3% (0.6% per patient-year) in the St Jude Medical group, with no overall intergroup differences. No statistically significant intergroup differences in international normalized ratio values were detected during the study period.

CONCLUSIONS

This study shows no significant differences in the early and midterm clinical outcomes between patients who received CarboMedics valve prostheses and those who received St Jude Medical mechanical prostheses. Choices with respect to valve type can be based on considerations other than patient outcome.

Fifteen-Year Experience with Shanghai Disc Valve Prosthesis

Between 1983 and 1998, 168 Shanghai prosthetic heart valves were implanted in 122 patients (57 males, 65 females) aged 14 to 57 years (mean, 34 years). There were 69 mitral, 7 aortic, and 46 double valve replacements. Early mortality in each group was 8.7%, 14.3%, and 6.5%, respectively. Mean follow-up was 7.9 years (87.5% complete). There were 7 late deaths (5.7%); 2 in the mitral group, 5 in the double valve group. Five late deaths were considered valve-related. The 5-year actuarial survival rates were 96.8% for mitral, 100% for aortic, and 88% for double valve replacement. Preoperatively, 77.9% of patients were in New York Heart Association functional class III or IV, whereas postoperatively, 90.2% were in class I or II. No structural failure was observed. There were 3 cases of systemic and cerebral embolism, and 2 cases of valve thrombosis in patients who had ceased taking anticoagulants. Hemorrhage was the most frequent complication; 1 of 6 events was fatal. The very affordable Shanghai valve provided good hemodynamic performance with low thrombogenicity in patients receiving anticoagulants.

Intermediate-term results with 1,019 carbomedics aortic valves

BACKGROUND

A retrospective study was conducted to evaluate the intermediate-term outcome in patients with the Carbomedics aortic valve prosthesis.

METHODS

The study included 1,019 primary valve replacements between 1989 and 1997. Seventy-two percent of patients were men; mean (standard deviation) age was 61 (10) years. The preoperative New York Heart Association functional class was III or IV in 70% of patients. Follow-up at 9 years was 99.6% complete, comprising 2,730 patient-years (mean, 2.7 years).

RESULTS

Patient survival, including operative deaths, was 80% at 7 years. The linearized death rate was 2.9%/year. Statistically significant risk factors for mortality were diabetes, pure valve insufficiency, advanced age at operation, and advanced preoperative functional class. Linearized rates were thrombosis, 0.1%/year; thromboembolism, 1.0%/year; hemorrhage, 1.7%/year; endocarditis, 0.1%/year; paravalvular leak, 0.1%/year; reoperation, 0.1%/year; and all events, 3.0%/year. The 7-year estimates of freedom from complications were thrombosis, 99%; thromboembolism, 93%; hemorrhage, 89%; endocarditis, 99%; paravalvular leak, 99.7%; reoperation, 99%; and all events, 82%. No structural valve failure was observed.

CONCLUSIONS

The low incidence of valve-related complications favors the continued use of the Carbomedics valve in the aortic position.

Isolated mitral valve replacement with St. Jude medical prosthesis: long-term results: a follow-up of 19 years

BACKGROUND

In this retrospective study, approximately 440 patients received mitral valve replacements with the St Jude Medical prosthesis. The last patient was operated on 10 years before the beginning of the follow-up. The extended follow-up was 19 years.

METHODS AND RESULTS

Four hundred forty patients (sex ratio, 1.32 [men to women]; age, 60+/-11.4 years; age range, 7 to 75 years) were operated on from 1979 to 1987. All patients underwent isolated mitral valve replacement. Tricuspid plasty was the only associated procedure. The follow-up at 19 years was 98% complete. The overall actuarial survival rate was 63+/-3.3% at 19 years, and the actuarial survival rate (only valve related) was 83+/-2.7%. The operative mortality rate (0 to 30 days) was 4.09%. We found that 89.4% of the patients alive at 19 years were in NYHA class I/II. Multivariate analysis showed that age and sex were significantly correlated with valve-related mortality and that age, sex, NYHA class, and atrial fibrillation were significantly correlated with overall mortality. The linearized rates (percent patient-years) of thromboembolism, thrombosis, and hemorrhage were 0.69, 0.2, and 1, respectively. At 19 years, freedom from endocarditis and reoperation was 98.6+/-1% and 90+/-3%, respectively.

CONCLUSIONS

In this study, the very-long-term results confirm the excellent durability of the St Jude Medical prosthesis in the mitral position and show the difficulty of adjusting the anticoagulation protocol, even after long-term treatment.