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Biomedical subjects

T E David

Publications and source records attributed to T E David.

At least 19 recordsLinked to original sources
PubMed1998

Fifteen-year trends in risk severity and operative mortality in elderly patients undergoing coronary artery bypass graft surgery.

BACKGROUND: Trends in risk-severity and operative mortality (OM) were examined in 3330 consecutive patients aged 70 years and older who underwent isolated coronary artery bypass graft surgery (CABG) between 1982 and 1996. METHODS AND RESULTS: The proportion of elderly patients rose significantly over time (P<.001). Crude OM among the elderly was 7.2% in 1982 to 1986, fell to 4.4% in 1987 to 1991, but did not improve thereafter. Logistic regression analysis of OM was used to construct relative risk groups (low, medium, or high). The prevalence of high-risk elderly patients rose significantly over time (P=.001) from 16.2% in 1982 to 1986 to 19.5% in 1987 to 1991 and 26.9% in 1992 to 1996. OM in high-risk patients fell significantly (P=.044) from 17.2% in 1982 to 1986 to 9.1% in 1987 to 1991 and was 8.9% in 1992 to 1996. Contemporary independent predictors of OM among elderly patients were poor ventricular function (LV grade 2 to 3, odds ratio [OR], 2.6; 95% confidence interval [CI], 1.3 to 5.2; and LV grade 4, OR, 10.7; 95% CI, 4.4 to 26); previous CABG (OR, 3.7; 95% CI, 2.0 to 7.0), female sex (OR, 1.8; 95% CI, 1.1 to 2.8), peripheral vascular disease (OR, 1.8; 95% CI, 1.1 to 2.8), and diabetes (OR, 1.7; 95% CI, 1.1 to 2.7). Previous angioplasty was protective (OR, 0.3; 95% CI, 0.1 to 0.9). CONCLUSIONS: OM in elderly patients has declined significantly in recent years despite an increase in the prevalence and severity of their risk factors. A careful weighing of risk, rather than advanced age alone, should determine who is offered surgical revascularization. In this regard, poor ventricular function and repeat CABG continue to have the greatest impact on OM in elderly patients.

Age Distribution↗
PubMed1998

Stentless aortic bioprostheses: compelling data from the Second International Symposium.

BACKGROUND: Stentless aortic xenografts are an important addition to the range of prosthetic valves. So far their use has been restricted to a limited number of study centers. This report summarizes the principal findings from the Second International Symposium on Stentless Bioprostheses. Attention is focused on the Toronto SPV and Freestyle valves recently approved by the United States Food and Drug Administration. METHODS: Stentless xenografts are used predominantly in elderly patients with aortic stenosis. Implant techniques are more complex than for stented valves, as reflected by longer ischemic and cardiopulmonary bypass times. The valves have been subjected to detailed serial echocardiographic assessment and clinical follow-up. RESULTS: The hemodynamic characteristics resemble those of the aortic homograft. There is a progressive increase in effective orifice area and decrease in transvalvular pressure gradients with time. Left ventricular mass index and wall thickness normalize between 6 and 12 months postoperatively. Left ventricular remodeling is accompanied by improved symptomatic status and a low incidence of valve-related complications. Limited comparative studies suggest important benefits over stented xenografts. Improved hemodynamics may translate into better bioprosthetic durability. CONCLUSIONS: Reproducible and reliable implant methods should be taught carefully, but the hemodynamic advantages are substantial. Stentless xenografts are ideal for the elderly patient with aortic stenosis.

Aorta↗
PubMed1998

Deep sternal wound infection: risk factors and outcomes.

BACKGROUND: Deep sternal wound infection (DSWI) is a serious complication of cardiac operations performed by median sternotomy. We attempted to define the predictors of DSWI and to describe the outcomes of two treatment strategies used at our institution. METHODS: Retrospective review was performed using prospectively gathered data on 12,267 consecutive cardiac surgical patients from 1990 to 1995. Chart review was performed on all patients in whom DSWI developed, and follow-up was obtained on 100% of these patients. RESULTS: Deep sternal wound infections developed in 92 patients (incidence 0.75%). Multivariable predictors for development of DSWI in all patients were (odds ratios and 95% confidence intervals in parentheses) (1) diabetes mellitus (2.6; 1.7 to 4.0) and (2) male sex (2.2; 1.3 to 3.9). In patients receiving coronary artery bypass grafting alone, independent predictors were (1) bilateral internal thoracic artery grafts (3.2; 1.1 to 8.9), (2) diabetes (2.7; 1.6 to 4.3), and (3) male sex (1.8; 0.9 to 3.7). For all other patients, predictors were (1) age more than 74 years (3.3; 1.1 to 10.1), (2) male sex (3.0; 1.1 to 8.1), and (3) diabetes (2.3; 0.9 to 5.8). Bilateral internal thoracic artery grafts increased the risk of DSWI in all subgroups of coronary artery bypass graft patients, particularly in diabetics who had a 14.3% incidence of DSWI after bilateral internal thoracic artery grafting. Patients with DSWIs received either sternal debridement with primary closure (n=45) or sternectomy with flap reconstruction (n=46). The 6-month freedom from adverse event rate (ie, readmission, reoperation, or death) was 76% for both groups of patients. CONCLUSIONS: Male sex and diabetes are predictors of DSWI in all cardiac surgical patients. Bilateral internal thoracic artery grafting may be contraindicated in diabetic patients.

Age Factors↗
PubMed1998

Aortic valve replacement with stentless and stented porcine valves: a case-match study.

OBJECTIVES: To assess the potential benefits of the hemodynamic superiority of stentless valves, we conducted a case-match study among patients who underwent aortic valve replacement with two types of porcine bioprostheses: the Toronto SPV and the stented Hancock II bioprosthesis. METHODS: Preoperative clinical variables predictive of death after aortic valve replacement were determined by a stepwise logistic regression analysis in a series of 908 consecutive patients who received porcine aortic bioprostheses during a 14-year interval. Advanced age, New York Heart Association functional class IV, left ventricular ejection fraction of less than 30%, and coronary artery disease were independent predictors of death. On the basis of these four variables, 198 pairs of patients who survived aortic valve replacement with stentless and stented porcine valves were matched. The follow-up, truncated to the shortest interval for each matched pair, was 43 +/- 24 months for both groups. RESULTS: At 8 years the actuarial survival was 91% +/- 4% for the Toronto SPV group and 69% +/- 8% for the Hancock II group (p = 0.006); the freedom from cardiac-related death was 95% +/- 4% for the Toronto SPV and 81% +/- 8% for the Hancock II (p = 0.01); the freedom from any valve-related complication was 81% +/- 5% for the Toronto SPV and 50% +/- 10% for the Hancock II (p = 0.008). A Cox proportional hazard model demonstrated a significant reduction in cardiac mortality rates and valve-related morbidity in patients who received the Toronto SPV bioprosthesis. CONCLUSIONS: Although it is possible that confounding factors may have played a role in the clinical outcomes of this case-control study, the study suggests that aortic valve replacement with a stentless porcine valve enhances survival. This is believed to be due to the hemodynamic superiority of these valves.

Adult↗
PubMed1998

Long-term results of mitral valve repair for myxomatous disease with and without chordal replacement with expanded polytetrafluoroethylene sutures.

OBJECTIVE: This study was carried out to evaluate the long-term results of mitral valve repair for mitral regurgitation caused by myxomatous disease of the mitral valve and the late effects of chordal replacement with expanded polytetrafluoroethylene sutures in this operation. METHODS: A total of 324 patients with mitral regurgitation caused by myxomatous disease underwent mitral valve repair from 1981 to 1995; the group comprised 241 men and 83 women whose mean age was 58 +/- 14 years. Chordal replacement with expanded polytetrafluoroethylene sutures has been performed in 165 patients since 1985. Most of the patients who had chordal replacement with expanded polytetrafluoroethylene sutures had prolapse of the anterior leaflet or prolapse of both leaflets, whereas most patients who had mitral valve repair without chordal replacement had prolapse of the posterior leaflet. Patients were followed up at annual intervals and had a Doppler echocardiographic study. The follow-up was complete and extended from 6 to 156 months (mean 36 +/- 30 months). RESULTS: Two operative and 21 late deaths occurred (14 cardiac and 7 noncardiac). At 10 years the actuarial survival was 75% +/- 5%, the freedom from stroke was 94% +/- 2%, the freedom from transient ischemic attacks was 92% +/- 4%, the freedom from endocarditis was 99% +/- 1%, the freedom from mitral valve reoperation was 96% +/- 1%, and the freedom from severe mitral regurgitation was 93% +/- 3%. Chordal replacement with expanded polytetrafluoroethylene sutures had no effect on any of these end points. CONCLUSIONS: Mitral valve repair was feasible in most patients with mitral regurgitation caused by myxomatous disease and it was associated with low rates of valve-related complications. Chordal replacement with expanded polytetrafluoroethylene had no adverse effect on the late outcome and was believed to have increased the probability of mitral valve repair.

Adolescent↗
PubMed1998

Surgical repair of postinfarction ventricular septal defect by infarct exclusion.

Repair of postinfarction ventricular septal defect (VSD) by infarct exclusion has been used for a decade in our unit. It involves securing a glutaraldehyde-preserved bovine pericardial patch to the endocardium of the left ventricle all around the necrotic myocardium to exclude the VSD and the infarct from the left ventricular cavity. Fifty-two patients with postinfarction VSD underwent this type of repair from 1987 to 1996. Thirty-four patients were in shock when undergoing operation; 26 had anterior VSD and 26 had posterior. Ten patients died perioperatively, for surgical mortality of 19%. Three patients developed recurrent VSD; one died and two survived. Preoperative cardiogenic shock and age older than 70 years were associated with an increased operative mortality. Operative survivors were followed up from 6 to 135 months, mean of 65 months. The actuarial survival at 8 years was 59% +/- 6%. Repair of postinfarction VSD by infarct exclusion is a relatively simple operative procedure and seems to have improved the results of surgery in patients with posterior VSD.

Actuarial Analysis↗
PubMed1998

The use of pericardium in acquired heart disease: a review article.

Pericardium is an excellent material for reconstruction of the heart during the surgical management of certain acquired heart defects. This review details our experience with pericardium as a patch material for various parts of the left ventricle. MITRAL ANNULUS: Extensive calcification of the mitral annulus, abscess, multiple previous mitral valve replacements and rupture of the posterior wall of the left ventricle are challenging surgical problems that can be satisfactorily managed by reconstructing the mitral annulus with either fresh autologous or glutaraldehyde-fixed bovine pericardium. The mitral valve prosthesis is secured to the newly reconstructed mitral annulus. This procedure has proven to be durable and has provided very good long-term results. LEFT VENTRICULAR OUTFLOW TRACT: We have used bovine pericardium to enlarge the aortic annulus in patients with small aortic annulus undergoing aortic valve replacement with bioprosthetic valves. Patch enlargement of the aortic annulus probably increases the operative mortality of aortic valve replacement but it may favorably effect the clinical outcome and late survival. Another problem in the aortic root that frequently requires reconstruction with pericardium is aortic root abscess. We believe that radical resection of the abscess is the single most important component to eradicate infection in these patients. Pericardium is an excellent material to reconstruct all parts of the left ventricular outflow tract and the results have been excellent. RECONSTRUCTION OF THE LEFT VENTRICULAR WALL: We have also used pericardium to repair the left ventricle in patients with postinfarction ventricular septal defect. We have used a technique of infarct exclusion by suturing a properly tailored bovine pericardium to the endocardium of the left ventricle all around the infarct, excluding the left ventricular cavity from the infarcted wall. This technique has improved the outcome of surgery for this mechanical complication of myocardial infarction, particularly in patients with posterior interventricular septal rupture.

Aortic Valve↗
PubMed1998

Histological and morphometric analyses of early and late aortocoronary vein grafts and distal anastomoses.

BACKGROUND: Aortocoronary vein grafts develop fibromuscular intimal hyperplasia within the first year of implantation. Tissue remodeling may promote development of graft atherosclerosis and thrombosis. Angiographic studies show that human aortocoronary vein grafts in situ for one or more years become stenosed, preferentially at the distal anastomosis versus the body or trunk of the graft or at the proximal anastomosis. Previous studies have not reported morphological data on the nature and distribution of intimal lesions around the distal graft/artery anastomoses. OBJECTIVE: To examine and quantify histological and morphometric changes within the intima of 27 aortocoronary vein grafts and their distal anastomoses. METHODS: Seventy-two hearts obtained at autopsy and one at heart transplantation were examined, photographed and fixed in 10% buffered formaldehyde solution. Three to seven 3 mm long segments of grafts and their distal anastomoses were sectioned, stained and examined by light microscopy. RESULTS: Eleven early grafts were implanted for six weeks or less, and they showed significant cellular hyperplasia mainly at the suture line. In 16 late grafts in situ 1.5 to 15 years, the degree of fibromuscular intimal thickening was greatest on the hood and at the suture line, whereas on the floor of the native artery and in the graft body the degree of thickening was approximately one-third and two-thirds, respectively, that seen on the hood. CONCLUSIONS: Stenosis of aortocoronary vein grafts at their distal anastomosis is likely related to the preferential development of intimal thickening on the hood of the graft and at the suture line. Because fibromuscular intimal hyperplasia has been reported to play a role in the development of atherosclerosis and thrombosis in the body of vein grafts, this focal hyperplasia at the distal anastomosis may also play a role in vein graft failure.

Aged↗
PubMed1998

Aortic valve replacement with stentless porcine aortic valves: a ten-year experience.

BACKGROUND AND AIMS OF THE STUDY: It has been shown that although stentless porcine aortic valves have better hemodynamic features than stented porcine valves, their long-term durability remains unknown. This study was undertaken to examine the long-term clinical outcome of aortic valve replacement (AVR) with stentless porcine aortic valves. METHODS: Between 1987 and 1989, custom-made stentless valves were implanted in 29 patients (mean age 58 years), and between 1991 and 1997, the Toronto SPV was implanted in 213 patients (mean age 63 years). In addition to AVR, one-third of the patients had coronary artery bypass. All patients were followed up at annual intervals and underwent Doppler echocardiography. RESULTS: There were two operative and 11 late deaths (four cardiac, seven non-cardiac). The actuarial survival rate was 89 +/- 4% at nine years. There were two strokes and seven transient ischemic attacks; freedom from thromboembolic complications was 92 +/- 4% at nine years. Two patients developed infective endocarditis, one early and one late; freedom from prosthetic valve endocarditis was 98 +/- 1% at nine years. Freedom from primary tissue failure was 85 +/- 8% at nine years. Seven patients required repeat AVR, because of endocarditis (two) and aortic insufficiency (five); freedom from repeat AVR was 82 +/- 8% at nine years. Periodic hemodynamic assessment by echocardiography indicated that the mean systolic gradients across the valve decreased during the first year of implantation, the valve effective orifice increased, and valve competence remained stable. CONCLUSIONS: Stentless porcine aortic valves have provided excellent clinical results. These valves may suffer degenerative changes and fail at the same rate as stented porcine aortic valves but, because of their superior hemodynamic performance, they may enhance patients' survival by allowing complete regression of left ventricular hypertrophy and restoration of normal ventricular function.

Animals↗
PubMed1998

Twelve-year experience with Carpentier-Edwards PERIMOUNT pericardial valve in the mitral position: a multicenter study.

BACKGROUND AND AIMS OF THE STUDY: The study aim was to assess the durability of the Carpentier-Edwards PERIMOUNT pericardial bioprosthesis in the mitral position. METHODS: This seven-center retrospective clinical study involved the follow up of 333 patients who underwent isolated mitral valve replacement and 102 patients who underwent double (mitral and aortic) valve replacement with the PERIMOUNT pericardial valve between 1984 and 1989. Mean patient age at implant was 60.7 +/- 11.6 years; 41.1% were males. The most common etiology was rheumatic heart disease (53.9%) and the most common mechanism mitral insufficiency. All patients but six were followed for an average of 7.2 +/- 3.6 years after surgery; total follow up was 3071.7 patient-years (pt-yr). RESULTS: The total operative mortality rate was 7.6%; this included a valve-related mortality rate of 0.2%. The late mortality rate was 5.2% per pt-yr, of which 1.4% per pt-yr was considered valve-related. At 11 years, the overall actuarial survival rate was 53.3 +/- 2.8%, and actuarial freedom from valve-related death 83.9 +/- 2.6%. At follow up, 80% of patients were in NYHA class I or II, and 74% showed improvement. Twenty-eight incidences of deterioration requiring explant were observed. At 11 years the actuarial freedom from explant due to structural failure was 84.9 +/- 3.1%. Rates of structural failure decreased with age: the actuarial freedom from explant due to structural failure was 78.1 +/- 4.8% for patients aged < or = 60 years, 89.4 +/- 4.4% for those aged 61-70 years, and 100% for those aged over 71 years. CONCLUSION: The Carpentier-Edwards PERIMOUNT pericardial bioprosthesis is a reliable choice when a tissue valve is required, especially in patients over 60 years of age.

Bioprosthesis↗
PubMed1997

Aortic valve replacement with patch enlargement of the aortic annulus.

BACKGROUND: Aortic annulus enlargement has long been advocated for the placement of valve prostheses larger than otherwise would have been possible. Little information exists, however, on the short- and long-term outcome of this surgical procedure. METHODS: We performed a retrospective review of 530 patients enrolled in a registry for patients who underwent aortic valve replacement using the Hancock II bioprosthesis and were followed up prospectively over the course of 11 years at a single institution. In an effort to avoid prosthetic valve-patient mismatch, the aortic annulus was enlarged in 98 patients (18%). Short- and long-term outcome was analyzed. RESULTS: Enlargement of the aortic annulus during aortic valve replacement increased the operative mortality rate from 3.5% to 7.1%, but this difference did not reach statistical significance (p = 0.10). The long-term survival of patients who had annulus enlargement was similar to that of patients who did not. Because there were differences in the clinical profile of patients who had annulus enlargement and those who did not, a case-control study was carried out. This study showed similar long-term survival, freedom from valve-related and cardiac death, and combined end points in the two groups of patients. CONCLUSION: Aortic annulus enlargement increased the operative mortality of aortic valve replacement. However, patients who underwent enlargement of a small aortic annulus had long-term survival and freedom from cardiac and valve-related death comparable to those of patients who received larger aortic prostheses.

Aged↗
PubMed1997

Aortic root aneurysms: remodeling or composite replacement?

BACKGROUND: Patients with ascending aortic aneurysms often have aortic insufficiency due to dilatation of the aortic root. Although composite replacement of the aortic valve and ascending aorta has been the standard treatment, an aortic valve-sparing operation is feasible in patients with normal aortic valve leaflets. METHODS: From 1988 to 1996, 208 patients with ascending aortic aneurysms and aortic insufficiency were operated on. Aortic valve-sparing operations were performed in 101 patients: 70 men and 31 women with a mean age of 53 years (range, 14 to 82 years). Twenty-eight patients had the stigmata of Marfan's syndrome. Fifteen patients had acute and 8 had chronic type A aortic dissection. Coronary artery disease was detected in 19 patients and mitral regurgitation in 5. Two types of aortic valve-sparing operations were performed: remodeling of the aortic root with preservation of the aortic valve in 73 patients and reimplantation of the aortic valve in a tubular Dacron graft in 28. Patients were followed up from 3 to 108 months (mean, 31 months). Doppler echocardiographic studies were performed annually. RESULTS: There were two operative deaths. One patient had to have aortic valve replacement because of persistent aortic insufficiency. There were five late deaths; the actuarial survival rate at 6 years was 87% +/- 5%. One patient required aortic valve replacement 2 years after the initial operation; the freedom from aortic valve replacement at 6 years was 97% +/- 2%. There have been no thromboembolic or infective complications. Only 3 patients have moderate aortic insufficiency; the remaining patients have mild or no aortic insufficiency. CONCLUSIONS: The midterm results of aortic valve-sparing operations have been excellent and justify their continued use in patients with aortic root aneurysms and normal or near-normal aortic valve leaflets.

Adolescent↗
PubMed1997

Aortic and mitral valve replacement with reconstruction of the intervalvular fibrous body.

OBJECTIVE: The intervalvular fibrous body between the aortic and mitral valves can be damaged by infective endocarditis, degenerative calcification, or multiple previous heart valve operations, making double valve replacement difficult. We have managed this problem by approaching the aortic and mitral valves through the aortic root and the dome of the left atrium. After excising the aortic valve, the diseased fibrous body, and the mitral valve, we suture a properly tailored patch of Dacron fabric or bovine pericardium to the lateral and medial fibrous trigones and to the aortic root, reestablishing the aortic and mitral anuli. A prosthetic mitral valve is implanted and a separate patch is used to close the left atriotomy before implantation of a prosthetic aortic valve. This study was undertaken to determine the efficacy of this operation. METHODS: Forty-three patients underwent reconstruction of the intervalvular fibrous body during aortic and mitral valve replacement because of infective endocarditis with abscess in 14 patients, extensive calcification in 9, lack of fibrous tissue because of multiple previous operations in 10, and to enlarge the aortic and mitral anuli in 10. The group comprised 18 men and 25 women with a mean age of 58 +/- 12 years. Thirty-two patients had had one or more previous heart valve replacements. All patients were in New York Heart Association functional classes III and IV, and 9 patients were in shock before the operation. RESULTS: Seven operative deaths occurred (16%). Early prosthetic valve endocarditis developed in two patients and necessitated reoperation. Follow-up extended from 4 to 108 months, with a mean of 38 months. No patient was lost to follow-up. Six late deaths occurred. The actuarial survival at 6 years was 56% +/- 6%. A Doppler echocardiographic study revealed normal prosthetic valve function and anatomically intact anuli in all 30 long-term survivors. CONCLUSIONS: Reconstruction of the intervalvular fibrous body during aortic and mitral valve replacement is a satisfactory operative approach in patients with complex valve annular pathology.

Animals↗
PubMed1997

Long-term results of surgery for active infective endocarditis.

OBJECTIVE: This paper was undertaken to determine the long-term outcome of active infective endocarditis treated with antibiotic and radical excision of infected tissues by surgery. METHODS: From October 1978 to August 1994, 122 consecutive patients were operated on during the acute phase of infective endocarditis. There were 85 men and 37 women whose mean age was 50 years, ranging from 20 to 79. Surgery was needed because of one or more of the following complications: cardiogenic/septic shock in 19 patients, congestive heart failure in 68, persistent sepsis in 64, peripheral embolization in 20, and cerebral embolization in 10. The offending microorganism was identified in 110 patients, staphylococci were the most common ones. Seventy-six patients had native valve endocarditis and 46 had prosthetic valve endocarditis. Simple valve replacement or repair was performed in 60 patients and radical resection of the valve and surrounding tissues with reconstruction of the heart with either fresh autologous pericardium or glutaraldehyde-fixed bovine pericardium was performed in 62 with paravalvular abscess. Pulmonary autograft and aortic homograft were used in only three patients, the remaining patients had either bioprostheses or mechanical heart valves if valve repair was not feasible. RESULTS: There were nine deaths, for an operative mortality of 7.4%. Logistic regression analysis identified preoperative shock and renal failure as predictors of operative mortality. Operative survivors were followed up from 4 to 173 months, mean of 56.4. The actuarial survival at 10 years was 61 +/- 6%. Logistic regression analysis identified preoperative New York Heart Association functional class IV and perioperative renal failure as predictors of late mortality. Eight patients developed recurrent endocarditis 10-102 months postoperatively. The freedom from recurrent endocarditis at 10 years was 79 +/- 9%. All patients who developed this late complication had paravalvular abscess at the time of original operation. CONCLUSIONS: These data suggest that surgery for active infective endocarditis yield a high probability of eradicating the infection with relatively low operative mortality and good long-term results.

Abscess↗
PubMed1997

Aortic valve-sparing operations in patients with ascending aortic aneurysms.

Composite replacement of the aortic valve and ascending aorta was the standard treatment for patients with aortic insufficiency and aortic root aneurysm. However, it has been pointed out that the aortic valve leaflets are normal or near normal in almost one half of the patients who undergo surgery for aortic root aneurysms. It is now possible to accurately determine the quality of the aortic valve leaflets using transesophageal multiplane echocardiography, and with current knowledge of the functional anatomy of the aortic root, it is feasible to reconstruct the aortic root and preserve the aortic valve leaflets in these patients. There are various aortic valve-sparing procedures depending on the mechanism of aortic insufficiency and the pathology of the aortic root. Although these operations are now performed in many cardiac centers, long-term results are not yet available. Aortic valve-sparing operations have been performed in 97 patients in our institution since 1988; the clinical results have been excellent and the valve repair remains stable for up to 8 years of follow-up. These results justify the continued use of these operative procedures.

Aorta↗
PubMed1997

Incidental detection of an aortic valve papillary fibroelastoma by echocardiography in an asymptomatic patient presenting with hypertension.

Papillary fibroelastomas are rare, frond-like tumours of uncertain etiology seen on cardiac valves, uncommonly found antemortem. They carry a significant risk of embolization, making their detection and excision during life an important issue. A case of an aortic valve papillary fibroelastoma is described, which was found at echocardiography in a patient being assessed for previously unrecognized, severe hypertension.

Aortic Valve↗
PubMed1996

Changing pattern of valve surgery.

BACKGROUND: Advances in surgical technique and perioperative myocardial protection have reduced the risk of aortic and mitral valve surgery. Improved methods of valve repair have reduced the proportion of patients who require valve replacement. However, patients who require valve replacement often have advanced disease and/or extensive calcification and may therefore be at increased risk for perioperative morbidity and mortality. METHODS AND RESULTS: We reviewed the results of 2898 patients who underwent aortic (AVR) or mitral (MVR) valve replacement at the Toronto Hospital. We compared patients who underwent surgery between January 1982 and December 1986 (early group) with those who were operated on between January 1989 and December 1993 (late group). The univariable and multivariable predictors of postoperative low-output syndrome (LOS) and operative mortality (OM) were determined for each time period. A total of 1779 patients underwent AVR (late, n = 997; early, n = 782). Multivariable analyses revealed that the late group had significantly more patients with independent pre-epidemiology operative risk factors for both OM and LOS. Despite the greater proportion of high risk patients, the incidence of postoperative LOS was lower in the late group (10% versus early, 14%; P = .012). There was no difference in OM between the two groups (late, 3.4% versus early, 3.7%; P = .732). A Total of 1119 patients underwent MVR (late, n = 493; early, n = 626). Compared with the early group, the late group had significantly more patients with preoperative multivariable risk factors for OM and LOS. There was no difference in postoperative LOS (late, 19% versus early, 21%; P = .361) or OM between the two groups (late, 5.8% versus early, 6.9%; P = .432). CONCLUSIONS: Despite an increase in high-risk patients, there was no significant increase in mortality or morbidity associated with aortic or mitral valve surgery.

Adult↗