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Ann Thorac Surg 1998;66:707-713
© 1998 The Society of Thoracic Surgeons

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Original articles: Cardiovascular

Mitral valve replacement: randomized trial of St. Jude and Medtronic Hall prostheses

^a Division of Cardiothoracic Surgery and Cardiology, Saint Louis University Health Sciences Center, St. Louis, Missouri, USA

Address reprint requests to Dr Fiore, Department of Surgery, Saint Louis University Health Sciences Center, 3635 Vista at Grand Blvd, St. Louis, MO 63110-0250

Presented at the Thirty-fourth Annual Meeting of The Society of Thoracic Surgeons, New Orleans, LA, Jan 26–28, 1998.

	Abstract

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 
Background. This study was designed to better define the merits of the bileaflet and tilting-disc valves.

Methods. We prospectively randomized 156 patients (mean age, 59 years) to receive either the St. Jude (n = 80) or the Medtronic Hall (n = 76) mitral valve prosthesis between September 1986 and December 1997. The two groups were not significantly different with respect to preoperative New York Heart Association class, left ventricular ejection fraction, incidence of mitral stenosis or insufficiency, extent of coronary artery disease, completeness of revascularization, or cross-clamp or bypass time.

Results. The operative mortality (11.2% versus 13.1%, St. Jude versus Medtronic Hall, respectively) and late mortality (27% versus 22%, St. Jude versus Medtronic Hall, respectively) were not significantly different. Follow-up was complete in all hospital survivors with a mean of 60.7 months (range, 1 to 133 months). The analysis of 10-year actuarial survival and freedom from valve-related events demonstrated no significant differences between the cohorts. Freedom from reoperation was higher in the St. Jude group (p < 0.01). Comparisons of patient functional status and echocardiographic hemodynamic parameters obtained at the time of follow-up demonstrated no significant differences between the two prostheses.

Conclusions. This study suggests that there is no difference between the St. Jude and Medtronic Hall prostheses with respect to late clinical performance or hemodynamic results and therefore does not support the preferential selection of either prosthesis.

	Introduction

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 
Although heart valve replacement is a safe and commonly performed procedure, all available prostheses are associated with valve-related complications that influence their clinical use. Two commonly used prosthetic valves in the United States are the bileaflet St. Jude and the tilting-disc Medtronic Hall. Both prostheses possess specific mechanical features that appear advantageous. The wide opening angle (70 degrees), upward gliding disc, and monostrut construction are attractive properties of the Medtronic Hall valve, whereas the central flow design of the low-profile bileaflet St. Jude prosthesis is purported to be hemodynamically advantageous. To determine whether one prosthesis has clinical or hemodynamic superiority, we designed a prospective, randomized trial to compare these two valves in patients requiring mitral valve replacement.

	Material and methods

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 
From September 1986 until December 1997, 156 patients undergoing elective valve replacement for mitral valve dysfunction were prospectively randomized to receive either the Medtronic Hall (MH, 76 patients) or the St. Jude (SJ, 80 patients) mitral prosthesis. Patients requiring emergency operations and those requiring simultaneous aortic and mitral valve replacement were excluded from this study. Randomization was accomplished by a blind drawing from randomly distributed envelopes.

The clinical data recorded included age, sex, admitting diagnosis, cardiac risk factors, procedure performed, and postoperative complications. A New York Heart Association functional classification was determined for each patient. Angina was graded using the Canadian Cardiovascular Society Classification.

Cardiac catheterization data noted include left ventricular end-diastolic pressure, pulmonary artery pressure, cardiac index, left ventricular score (regional wall motion scoring as defined by Coronary Artery Surgery Study) [1], number of major coronary vessels diseased (defined as at least 70% luminal obstruction in any angiographic plane), presence of left main coronary artery stenosis (defined as 50% luminal obstruction), mitral valve area (calculated using the Gorlin formula), and the presence and severity (grade 0 to 4) of angiographically determined mitral insufficiency.

M-mode, two-dimensional, and Doppler echocardiography were performed preoperatively and 1 to 7 years postoperatively (mean, 2.4 years). Ventricular end-systolic and end-diastolic dimensions were measured, and ejection fraction and prosthetic valve gradient were calculated. In patients with atrial fibrillation, the mean of ten consecutive cardiac cycles was calculated. The ejection fraction was calculated by Simpson’s rule as previously described [2]. Mitral valve areas were calculated by the pressure half-time method with either continuous or pulsed wave recordings [3, 4]. The presence and degree of prosthetic valve regurgitation was qualitatively assessed by pulsed wave, continuous wave, and color Doppler echocardiography from multiple windows. Exercise studies were performed on a treadmill using the Bruce or modified Bruce protocol [5]. The heart rate increased from a mean of 74 to a mean of 123 beats per minute (increase of 46%). The metabolic equivalents increased from 2 to 13 with a mean peak value of 6.76.

Cardiopulmonary bypass was established using ascending aortic and bicaval cannulation with systemic hypothermia and hemodilution. Myocardial protection included the use of cold hyperkalemic blood cardioplegia (6°C). The infusate consisted of a 4:1 dilution of blood with 0.9% normal saline solution that contained 20 mEq/L sodium bicarbonate and 0.1 mg/mL lidocaine hydrochloride (Xylocaine). The initial infusion contained 14 mEq/L of potassium. In patients in whom the aortic valve was competent, an initial dose (15 mL/kg) was given through the aortic root and subsequent doses (7.5 mL/kg) were infused through the coronary sinus. In patients with aortic insufficiency, all doses of cardioplegic solution were given through the coronary sinus. Topical myocardial cooling with Ringer’s lactate slush and a cardiac insulation pad for phrenic nerve protection were used in all patients. Proximal vein graft anastomoses were performed using a partially occlusive aortic clamp while distal anastomoses were constructed with the aorta cross-clamped. Myocardial revascularization was performed before mitral valve replacement to avoid raising the heart after the mitral prosthesis had been inserted, thus decreasing the risk of myocardial rupture.

The operative procedure was performed by the same group of surgeons (A.C.F., H.B.B., L.R.M., G.C.K.) using similar techniques. The mitral prosthesis was inserted with interrupted horizontal mattress sutures of 2-0 Ethibond (Ethicon, Somerville, NJ) placed through the left atrial side so as to evert the mitral annulus. When feasible, the posterior mitral leaflet was left intact. The St. Jude prosthesis was oriented either in the antianatomic axis perpendicular to the mitral commissures or in the anatomic plane parallel to the mitral commissures. The Medtronic Hall valve was generally oriented with the larger orifice opening posteriorly. This prosthesis could be rotated according to the surgeon’s preference to prevent entrapment of the disc by the retained posterior mitral leaflet. Recorded operative variables included cardiopulmonary bypass and cross-clamp times. Prophylactic anticoagulation with sodium warfarin was carried out in all patients. Anticoagulation was instituted within 48 hours after the operation unless clinical contraindications existed. The control of therapy was made by interval analysis of the international normalized ratio, which was kept between 2.5 and 3.5. Antibiotic prophylaxis consisted of cefazolin sodium (Ancef; Smith Kline & French Laboratories, Philadelphia, PA) administered preoperatively and for 48 hours postoperatively.

Follow-up data were collected by a registered nurse using written questionnaires and telephone interviews with the patient, the patient’s physician, or both. All patients enrolled were contacted yearly for the duration of their participation in this prospective randomized trial. Patients surviving the operative period were followed up for a minimum of 1 month and a maximum of 133 months (mean, 60.7 months). The mean follow-up was 4.9 years for SJ and 5.1 years for MH (not significant [NS]). The cumulative follow-up was 394 patient-years for the SJ and 395 patient-years for the MH group. No patient was lost to follow-up.

The definitions of events, their classification, and the analysis of the data follow the recently suggested guidelines for reporting morbidity and mortality after cardiac valve prosthesis insertion [6]. Operative mortality is defined as death in the operating room, in the hospital, or within 30 days of the operative procedure regardless of the patient’s geographic location. Late mortality is defined as death beyond 30 days of the operative procedure regardless of the patient’s geographic location. Operative deaths were all classified as valve-related. Data were analyzed using the Statview for Windows 4.53 statistical software package (Abacus Concepts, Inc, Berkeley, CA). Univariate analysis of discrete variables was performed using the ² analysis or Fisher’s exact test where appropriate. Unpaired Student’s t tests were used for continuous variables. Results are expressed as means ± the standard deviation except as noted. The actuarial curves were constructed using the methods described by Kaplan and Meier and are reported with 95% confidence limits. Actuarial curves were compared using a log-rank analysis as described by Mantel-Cox [7]. Hospital deaths were included in the actuarial survival analysis. A p value of less than 0.05 was considered significant.

	Results

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 
Clinical characteristics
The cohorts were similar with respect to age, sex, hemodynamic and operative parameters, and the degree of mitral stenosis or mitral insufficiency (Table 1). The majority of patients had mild left ventricular dysfunction with moderate pulmonary hypertension. Fifteen percent of patients in both groups had prior valve replacement, and 23% had concomitant myocardial revascularization. Thirty-three percent of the patients in both cohorts had at least one prior cardiac surgical procedure. Before operation, most patients were in New York Heart Association functional class III or IV. After operation, however, the mean New York Heart Association functional class improved significantly in both cohorts (SJ, 1.4 ± 0.63; MH, 1.36 ± 0.75; NS).

The most common cause of operative death was low cardiac output syndrome. Eleven patients died as a result of low cardiac output associated with biventricular failure. In two instances (SJ, 1; MH, 1) operative death was caused by atrioventricular sulcus rupture. The cause of death in 3 additional patients receiving the Medtronic Hall valve included fatal dysrhythmia, massive cerebral hemorrhage on postoperative day 1, and an aortic dissection at the aortic cannulation site in a patient with Ehlers-Danlos syndrome.

Three additional patients (SJ, 2; MH, 1) died of multiorgan system failure. One patient with a history of chronic hepatitis died 13 days postoperatively of liver and renal failure. A second patient remained comatose postoperatively. Renal and respiratory failure developed and the patient died on the fourth postoperative day. The remaining patient had undergone urgent third-time mitral valve replacement. He died of multiorgan system failure after several hypotensive episodes on postoperative day 5.

The patients who died in the hospital had a mean New York Heart Association functional class of 3.1 ± 0.6, and 47% of hospital deaths were in patients with mitral regurgitation as the primary pathologic process. Univariate analysis demonstrated that the presence of left ventricular ejection fraction less than 0.40 correlated with operative mortality (p < 0.05). Coronary artery disease, a history of hypertension, and cardiopulmonary bypass time were marginally significant predictors of operative mortality (p = 0.05 to 0.1). Sex, pulmonary artery systolic pressure, and global ischemic time were not correlated with hospital death. Multivariate analysis failed to demonstrate any predictors of operative mortality.

Late mortality
There were a total of 39 late deaths recorded after mitral valve replacement: 22 in patients receiving the St. Jude valve and 17 in patients receiving the Medtronic Hall valve (SJ, 27%; MH, 22%; NS).

Valve-related complications were the cause of late death in 12 patients (SJ 5, 12.8%; MH 7, 17.9%; NS). The most common cause of valve-related death was cerebrovascular accident, which accounted for five valve-related late deaths (SJ, 4; MH, 1) at 31, 47, 54, 72, and 91 months postoperatively. Sudden death occurred at home in 3 patients (all in the MH group) at 23, 24, and 34 months postoperatively. Two of these patients had known coronary artery disease, an ejection fraction less than 40%, and pulmonary hypertension. Three patients (SJ, 2; MH, 1) died of congestive heart failure at 3.3, 53, and 55 months postoperatively secondary to paravalvular leak. The remaining valve-related late death (MH) was secondary to generalized sepsis from bacterial endocarditis 2.3 months after valve implantation.

Patient survival
The actuarial survival curve for the population is shown in Figure 1. At 5 and 10 years the survival rates were nearly identical for patients receiving either the Medtronic Hall or the St. Jude mitral valve. Patients who underwent mitral valve replacement were found to have a significantly higher 10-year actuarial survival in the absence of coexisting coronary artery disease (63% versus 30%; p < 0.05).

View larger version (16K): [in this window] [in a new window]   Fig 1. Actuarial survival rates after mitral valve replacement with the St. Jude (SJ) and Medtronic Hall (MH) valves. Operative and late deaths are included. (NS = not significant.)

View larger version (16K): [in this window] [in a new window]   Fig 2. Actuarial freedom from all valve-related events after mitral valve replacement with the St. Jude (SJ) and Medtronic Hall (MH) valves. (NS = not significant.)

Thromboembolism
There were a total of 26 episodes of thromboembolism occurring in 26 patients and 5 were fatal.

Valve thrombosis occurred in 4 patients, 2 in each group. One patient died of metastatic disease with clot on the St. Jude valve at 1.8 months postoperatively. Two patients (SJ, 1; MH, 1) underwent successful reoperation with insertion of a porcine bioprosthesis at 18 and 43 months postoperatively. The remaining patient with valve thrombosis had successful thrombolytic therapy 72 months after implant. These latter 3 patients are long-term survivors. Nine patients who experienced transient ischemic attack (SJ, 4; MH, 5) had presumed embolic events at a mean of 42 months postoperatively in both cohorts. The earliest transient ischemic attack occurred at 0.5 months postoperatively. Seventeen patients experienced a cerebrovascular accident (SJ, 8; MH, 9) of which 4 (SJ, 3; MH, 1) were fatal. The actuarial freedom from thromboembolism was equal in both cohorts (Fig 3).

View larger version (16K): [in this window] [in a new window]   Fig 3. Actuarial freedom from thromboembolism after mitral valve replacement with the St. Jude (SJ) and Medtronic Hall (MH) valves. (NS = not significant.)

View larger version (16K): [in this window] [in a new window]   Fig 4. Actuarial freedom from hemorrhage after mitral valve replacement with the St. Jude (SJ) and Medtronic Hall (MH) valves. (NS = not significant.)

Paravalvular leak
Paravalvular leak developed in eleven patients (SJ, 5; MH, 6). Three patients underwent reoperation with one operative death and 2 long-term survivors. Of the remaining 8 patients, 2 died at 3 and 53 months of congestive heart failure and sudden unexplained death, respectively. The remaining 6 patients are long-term survivors. The 10-year actuarial freedom from paravalvular leak was similar in both cohorts.

Reoperations
Seven patients, all in the Medtronic Hall group, underwent reoperation. The indications for reoperation were paravalvular leak (3), endocarditis (2), valve thrombosis (1), and endocarditis with peripheral emboli in the remaining patient. The operative mortality for reoperation was 28%. The 10-year actuarial freedom from reoperation was significantly higher in the SJ cohort (Fig 5).

View larger version (15K): [in this window] [in a new window]   Fig 5. Actuarial freedom from reoperation after mitral valve replacement with the St. Jude (SJ) and Medtronic Hall (MH) valve.

	Comment

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

Although a number of investigators have reported their clinical and hemodynamic results with these valves, this report represents the only prospective randomized trial comparing these prostheses in the mitral position throughout a 10-year period of observation at a single institution [8, 9]. This is important because referral patterns may vary from one institution to another as may operative techniques and postoperative management, factors that often make comparisons problematic.

The overall operative mortality in this series is similar to that reported by other investigators. Operative mortality rates of 4.7% to 12% have been reported for mitral valve replacement with St. Jude and 7.5% to 13.1% with the Medtronic Hall valve [10, 11]. In our series nearly 50% of the operative deaths were in patients with mitral insufficiency, and the most accurate predictor of operative death was left ventricular dysfunction. It was not unexpected that the leading cause of hospital mortality was perioperative heart failure. Although independent determinants of operative survival for mitral valve replacement from previous studies have included coexisting coronary artery disease and female gender, they were not demonstrated to be predictors in this series.

Patient survival based on 5- and 10-year actuarial estimates was not significantly different between groups. At 5 years our survival estimates (SJ, 65%; MH, 70.5%) compared favorably with those reported in other series, which range from 59% to 78% for the St. Jude and 67% to 74% for the Medtronic Hall [12, 13]. Late survival is dependent on many factors related to the individual patient’s disease and to the complications of the prosthesis. In our study, most late deaths were a result of cardiac failure and were not related to prosthetic valve dysfunction or its attendant complications.

A more sensitive measure of valve performance is thromboembolism, which is a major risk factor for patients with prosthetic valves. Thromboembolism was the most common valve-related complication in this series. The incidence of thromboembolic complications in the third-generation valvular devices has decreased dramatically. This has been because of improved hemodynamic design resulting in better flow velocity profile, less turbulence, and reduction of stagnant areas. In the Medtronic Hall valve, a more central position of the disc in the open position enlarged the minor orifice, thus reducing stagnation of blood and turbulence in this area. The central flow design of the bileaflet St. Jude prosthesis may contribute to its low incidence of thromboembolism. In this report, the 5-year actuarial freedom from thromboembolism was slightly better for the Medtronic Hall group (SJ, 87%; MH, 94%) but by 10 years the actuarial freedom was identical in both cohorts. These figures compare favorably with those reported by other investigators whose five-year actuarial estimates have ranged between 85% and 92% for the St. Jude valve and 85% and 94% with the Medtronic Hall valve [14, 15]. There were four cases of valve thrombosis. Noncompliance with sodium warfarin anticoagulation in the presence of atrial fibrillation was believed to have contributed to thrombus formation in 3 patients. The fourth case was a patient with metastatic lung cancer in whom valve thrombosis developed despite an international normalized ratio of 3.0. He was not thought to be a candidate for thrombolytic therapy or reoperation. All patients with thromboembolic complications had dipyridamole (300 mg daily) or aspirin (5 grains) added to their anti-coagulant regimen to reduce the recurrent risk of thromboembolism.

Hemorrhage was the second most common valve-related complication. This complication was fatal in 1 hypertensive patient in whom an intracerebral hemorrhage developed. The actuarial freedom from hemorrhage was similarly low in both cohorts and compared favorably with that reported in other series for the Medtronic Hall and St. Jude valves.

As in most previous reports, we noted a low rate of endocarditis with little difference between the two valves [16].

In this report, we measured the mean transvalvular gradient at rest and after treadmill stress testing between 12 and 62 months postoperatively using Doppler echocardiography. No significant difference in the resting or stress-induced mean gradient could be demonstrated when both prostheses were compared in each valve size. Improved hemodynamic performance has been associated with symptomatic improvement. In this series, the St. Jude and Medtronic Hall valves achieved equal improvement in patient symptoms as evidenced by the low postoperative NYHA functional score observed in both cohorts.

The results of this study indicate that in the first 10 years after implantation, the performance of the St. Jude and Medtronic Hall prostheses are comparable. These two valves are among the best of the modern generation of prostheses, and either may be confidently recommended for valve replacement. The choice of valve should be based on the surgeon’s experience and preference, which may be linked to other factors such as ease of insertion, availability, and cost. Clearly, this study suggests that neither valve can claim superior performance or safety.

	Acknowledgments

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 
We thank Terri Wriley for preparation of the manuscript and gratefully acknowledge the participation of Karen Powers, RN, and Debbie Moroney, RN, in obtaining accurate follow-up data.

	References

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 

1. Principal investigators of CASS and their associates. The National Heart, Lung and Blood Institute Coronary Artery Surgery Study. Circulation 1981;63(Suppl 1):1-81.[Free Full Text]
2. Mehdirad A.A., Williams G.A., Bryg R.J., et al. Evaluation of left ventricular function with upright exercise: correlation of exercise Doppler with post-exercise wall motion and single plane echocardiographic ejection fraction. Circulation 1987;75:413-419.[Abstract/Free Full Text]
3. Hatle L., Angelsen B., Tromsdal A. Non-invasive assessment of atrioventricular pressure half-time by Doppler ultrasound. Circulation 1969;60:1096-1104.
4. Bryg R.B., Williams G.A., Labovitz A.J., Aker U., Kennedy H.L. Effect of atrial fibrillation and mitral regurgitation on calculated mitral valve area: comparison of Doppler, two-dimensional echocardiography and cardiac catheterization. Am J Cardiol 1986;57:634-638.[Medline]
5. Edmunds L.H., Jr, Clark R.E., Cohn L.H., Grunkemeier G.L., Miller D.C., Weisel R.D. Guidelines for reporting morbidity and mortality after cardiac valvular operations. Ann Thorac Surg 1996;62:932-935.[Abstract/Free Full Text]
6. Mantel N., Haenszel W. Statistical aspects of the analysis of data from retrospective studies of disease. J Natl Cancer Inst 1959;22:719-748.
7. Anthunes M.J. Clinical performance of St. Jude and Medtronic Hall prostheses: a randomized comparative study. Ann Thorac Surg 1990;50:743-747.[Abstract]
8. Fiore A.C., Naunheim K.S., D’Orazio S., et al. Mitral valve replacement: randomized trial of St. Jude and Medtronic Hall prostheses. Ann Thorac Surg 1992;54:68-73.[Abstract]
9. Keenan R.J., Armitage J.M., Trento A., et al. Clinical experience with the Medtronic Hall valve prosthesis. Ann Thorac Surg 1990;50:748-753.[Abstract]
10. Arom K.V., Nicoloff D.M., Kersten T.E., et al. Ten years’ experience with the St. Jude Medical valve prosthesis. Ann Thorac Surg 1989;47:831-837.[Abstract]
11. Vallejo J.L., Gonzales-Santos J.M., Albertos J., et al. Eight years’ experience with the Medtronic Hall valve prosthesis. Ann Thorac Surg 1990;50:429-436.[Abstract]
12. Ibrahim M., Cleland J., O’Kane H., Gladstone D., Mulholland C., Craig B. The St. Jude Medical prosthesis: a thirteen-year experience. J Thorac Cardiovasc Surg 1994;108:221-230.[Abstract/Free Full Text]
13. Anthunes M.J., Wessels A., Sadowski R.G., et al. Medtronic Hall replacement in a third-world population group. J Thorac Cardiovasc Surg 1988;95:980-993.[Abstract]
14. Baudet E.M., Oca C.C., Roques X.F., et al. A 5 year experience with the St. Jude Medical cardiac valve prosthesis. J Thorac Cardiovasc Surg 1985;90:137-144.[Abstract]
15. Nitter-Hauge S., Abdelnoor M. Ten-year experience with the Medtronic Hall valvular prosthesis. Circulation 1989;80(Suppl 1):43-48.[Abstract/Free Full Text]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Andrew C. Fiore Hendrick B. Barner Marc T. Swartz Lawrence R. McBride Gary L. Grunkemeier George C. Kaiser Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Fiore, A. C. Articles by Kaiser, G. C. Search for Related Content PubMed PubMed Citation Articles by Fiore, A. C. Articles by Kaiser, G. C.