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Tirone E David

Publications and source records attributed to Tirone E David.

At least 37 records · Page 2Linked to original sources
PubMed2005

Intraoperative fracture of the right coronary artery: recognition and management.

We describe the recognition and management of two patients who developed intraoperative fracture of the right coronary artery (RCA). Both patients had a calcified RCA without a hemodynamically significant stenosis. Compression of the right atrioventricular groove during the surgical procedure resulted in fracture of the RCA, leading to ventricular arrhythmias and hemodynamic instability. Coronary bypass grafting without cardioplegic arrest was used for definitive diagnosis and treatment. Both patients made a rapid and uneventful recovery.

Aorta↗
PubMed2005

Mitral repair versus replacement for ischemic mitral regurgitation.

BACKGROUND: We compared mitral repair to replacement in patients with chronic ischemic mitral regurgitation (IMR), due to left ventricular dysfunction (LV-IMR) or papillary muscle infarction (PM-IMR). METHODS: Patients with IMR undergoing repair (n = 65) or replacement (n = 137) from 1990 to 2001 were evaluated. There were 87 patients with LV-IMR, and 115 patients with PM-IMR. Patients presenting in cardiogenic shock were excluded. Outcomes were evaluated by Cox survival analysis with propensity score adjustment and bootstrap validation. RESULTS: Survival at 3, 5, and 9 years was, respectively, 0.94, 0.79, and 0.63 in the repair group, and 0.73, 0.67, and 0.59 in the replacement group. The hazard ratio (HR) of death for mitral repair versus replacement was not constant over the period of follow-up. Repair was associated with better early survival in the PM-IMR group, with an adjusted HR of 0.25 (95% confidence interval: 0.09 to 0.71) at 1 year. In the LV-IMR group and in patients with PM-IMR with high acuity and comorbidity, there was no significant survival advantage associated with repair. The beneficial effect of repair was not evident at late follow-up in either group. These findings were independent of the surgeon. Need for reoperation was more common after repair than after replacement (14% versus 3%, p = 0.003). CONCLUSIONS: Patients with PM-IMR benefit from mitral repair with a significantly better early survival. However, the benefit of repair is not evident at longer follow-up. There was a nonsignificant trend toward greater early survival among patients with LV-IMR who underwent repair.

Aged↗
PubMed2005

Stentless aortic valves are hemodynamically superior to stented valves during mid-term follow-up: a large retrospective study.

BACKGROUND: Several studies have compared left venticular mass (LVM) regression and hemodynamic data for stentless versus stented aortic bioprostheses with conflicting results. The major limitations of these studies are their small sample size and short-term follow-up. We therefore compared midterm LVM regression, hemodynamic data, and survival in a large population of tissue aortic valve replacement (AVR) patients. METHODS: All patients undergoing tissue AVR at our institution between 1998 and 2001 were included (n = 737). Patients were divided into two groups according to type of bioprosthetic implanted: stentless patients (total n = 310) (Toronto SPV [St Jude Medical, St Paul, MN], n = 146 and Freestyle [Medtronic, Minneapolis, MN], n = 164) and stented patients (total n = 427) (Perimount [Edwards Life Sciences Inc, Irvine, CA], n = 291 and Mosaic [Medtronic], n = 136). RESULTS: The two groups of patients had similar preoperative transvalvular gradients and LVM index (130 +/- 47 vs 130 +/- 42 g/m2 for stentless versus stented valves, respectively). Predischarge echos revealed that stentless patients had significantly lower mean transvalvular gradients (11 +/- 5 vs 15 +/- 6 mm Hg, p < 0.001) and larger effective orifice areas (1.32 +/- 0.52 vs 1.22 +/- 0.48 cm2, p = 0.01). Follow-up echocardiograms were obtained in 99% of surviving patients 28 +/- 22 (range, 0-79) months postoperatively. Stentless patients had significantly lower LVM index during follow-up (100 +/- 32 vs 107 +/- 32 g/m2, p = 0.005) and stentless valves were an independent predictor of LVM regression. Furthermore, a higher proportion of stented patients had residual LV hypertrophy during follow-up (28% vs 18%, p = 0.001). Stentless valves were associated with improved midterm survival by univariate analysis, but not by multivariable analysis. CONCLUSIONS: Midterm follow-up in a large number of patients reveals that stentless bioprostheses are hemodynamically superior to stented valves.

Aged↗
PubMed2005

Mitral annular disjunction in advanced myxomatous mitral valve disease: echocardiographic detection and surgical correction.

Mitral annular disjunction is a structural abnormality of the mitral annulus fibrosus described by pathologists in association with mitral leaflet prolapse and defined as a separation between the atrial wall-mitral valve (MV) junction and the left ventricular attachment allowing for hypermobility of the MV apparatus. The transesophageal echocardiographic characteristics of this abnormality have not been previously described. In patients undergoing MV repair for myxomatous MV degeneration and evaluated using a standardized transesophageal echocardiographic protocol, annular disjunction (mean value 10 +/- 3 mm) was seen at the base of the posterior leaflet in 98% of patients with advanced, and in 9% of patients with mild/moderate MV degeneration. There was a significant correlation between the magnitude of disjunction and the number of segments with prolapse/flail (r = 0.397, P = .001). We found annular disjunction to be a common component of MV apparatus in advanced MV degeneration. Its recognition on transesophageal echocardiography is important to facilitate optimal MV repair. The modification of the repair technique allows surgical correction of the annular disjunction, which seems to optimize long-term results in these challenging cases.

Cardiac Surgical Procedures↗
PubMed2005

Aortic and mitral valve replacement with reconstruction of the intervalvular fibrous body: an analysis of clinical outcomes.

OBJECTIVE: This study was undertaken to evaluate the late outcomes of reconstruction of the intervalvular fibrous body during aortic and mitral valve replacement. METHODS: Seventy-six consecutive patients underwent reconstruction of the intervalvular fibrous body with replacement of the mitral and aortic valves. There were 35 men and 41 women whose mean age was 58 +/- 12 years. Additional procedures were circumferential reconstruction of the mitral annulus in 27 patients, tricuspid valve repair in 21, coronary artery bypass in 15, and aortic root replacement in 4. Indications for the operation were active infective endocarditis with abscess in 15 patients, extensive calcification of the mitral annulus and interventricular fibrous body in 24, lack of fibrous tissue to secure a prosthetic valve in 17, and treatment or prevention of patient-prosthesis mismatch in 20. Fifty-five patients had undergone one or more previous valve operations, and 52 (68%) were in functional class IV. The mean follow-up was 47 +/- 47 months, and it was complete. RESULTS: There were 8 (10%) operative and 18 (24%) late deaths. The 10-year survival was 50% +/- 9%. There were 15 reoperations in 12 patients: 7 for prosthetic valve endocarditis (5 early, 2 late), 7 for patch or valve dehiscence (3 early, 4 late), and 1 for structural valve deterioration. All but 2 reoperations were re-reconstruction of the intervalvular fibrous body and double valve replacement. The 10-year freedom from reoperation was 73% +/- 7%. CONCLUSION: Reconstruction of the intervalvular fibrous body during double valve replacement is a technically challenging operation, but it is useful in patients with complex valve pathology for whom no alternative procedure is available.

Adult↗
PubMed2005

Management of the valve and ascending aorta in adults with bicuspid aortic valve disease.

Bicuspid aortic valve (BAV) disease is the most common congenital cardiac malformation, being present in 1% to 2% of the population. It is heritable and is three to four times more likely to occur in men. The pathogenesis of BAV disease is unknown. Bicuspid valves progress to aortic stenosis or insufficiency in the majority of patients. BAV disease is associated with several anomalies of the aorta including coarctation, aneurysm formation, and dissection. Several lines of evidence suggest that aortic complications are caused by the same underlying factor that causes BAV disease, rather than being a consequence of turbulent blood flow through a stenotic valve. Several different surgical options exist for patients with BAV disease depending on the age of presentation and the size and appearance of the aorta. We herein describe our surgical management of the aortic valve and ascending aorta in patients with BAV disease.

Adult↗
PubMed2005

Bicuspid aortic valve disease: recent insights in pathophysiology and treatment.

Bicuspid aortic valve is a common congenital cardiac malformation with a broad spectrum of clinical outcomes. Bicuspid aortic valve may go undetected throughout an individual's lifetime or, alternatively, they may have devastating clinical consequences, resulting in death. Both clinicians and medical scientists have taken a renewed interest in the development, pathophysiology and treatment options for this subtle but often substantial clinical entity. Evidence is mounting to suggest that an underlying disease of the aorta is inherited with bicuspid aortic valve, although considerable controversy surrounds this theory. Novel molecular mechanisms underlying the valve and vascular pathologies, as well as new surgical therapies for these patients have been proposed in the past 10 years.

Aortic Valve↗
PubMed2005

Results of valve preservation and repair for bicuspid aortic valve insufficiency.

BACKGROUND AND AIM OF THE STUDY: There is increasing interest in aortic valve-sparing and repair techniques for the treatment of aortic insufficiency (AI) and/or root aneurysm. The results of bicuspid aortic valve (BAV) repair at the authors' institution were evaluated. An attempt was made to assess the mode of failure and to identify surgical methods that provide durable repair results. METHODS: Aortic valve repair for BAV was performed in 71 patients (62 men, nine women; mean age 41.5 +/- 13.2 years) between 1993 and 2005. Repair techniques included cusp free margin plication (n = 47), subcommissural annuloplasty (n = 27), free margin reinforcement (n = 10), and cusp triangular resection (n = 7). Thirteen patients had remodeling of one or both aortic sinuses, and 16 had reimplantation of the aortic valve. The ascending aorta and arch were replaced in 29 and five patients, respectively. Concomitant mitral and coronary bypass surgeries were performed in 10 and three patients, respectively. RESULTS: There were no operative deaths. Early postoperative echocardiography revealed no or trace AI in 54 patients and mild AI in 17. There was only one late death which was non-cardiac-related. Eight-year freedom from endocarditis, thromboembolism and anticoagulation-related hemorrhage was 90%, 100% and 100%, respectively. Eight-year freedom from AI grade > or =3+ (moderate) and aortic valve replacement were 44% and 82%, respectively. At the latest follow up, 89% of patients were in NYHA functional class I. Patients who underwent aortic valve-sparing procedures had more stable valve function than those who had cusp repair and subcommissural plication. CONCLUSION: BAV repair is a safe procedure with good early functional results. However, recurrent AI remains a problem at five to eight years of follow up. Since dilation of the aortic root is a common cause of AI and a common feature of patients with BAV, aortic valve-sparing reimplantation operations should provide better long-term outcomes.

Adult↗
PubMed2004

St. Jude Medical Toronto biologic aortic root prosthesis: early FDA phase II IDE study results.

BACKGROUND: Several biological aortic root replacement techniques have distinct advantages over mechanical composite root replacement including better valvular hemodynamic characteristics and the lack of need for anticoagulation. Current biological root replacement options lack proven long-term durability or are limited by technical or practical concerns. We report the early results from a phase II multicenter clinical trial of the porcine St. Jude Toronto Bioprosthesis with BiLinx (Toronto root). METHODS: 176 Toronto roots were implanted as total aortic root replacement from August 2001 through August 2003. Concomitant cardiac procedures including coronary artery bypass grafting (31%) and ascending aortic replacement (55%) were performed in 74%. Patients were followed clinically and were examined with an echocardiogram at discharge, 6 months, 12 months, and yearly thereafter. Root sizes implanted included 29 mm in 38%, 27 mm in 30%, 25 mm in 20%, 23 mm in 10%, and 21 mm in 2.2%. RESULTS: There are 205 patient years of follow-up through October 2003. Operative mortality was 3.9% (none were valve related) and late mortality was 4%. Operative stroke rate was 1.1% and late stroke rate was 0.6%. Endocarditis developed in 1 patient. Freedom from aortic regurgitation is to date 100% at discharge, 6 months, and 1 year postimplant. Reoperation of the aortic valve/root was not required in any patient. Six-month mean transvalvular gradients for 21-29 mm valves were 12.8, 8.8, 5.3, 4.9, and 4.7 mm Hg, respectively. CONCLUSIONS: Aortic root replacement with the Toronto root is safe and provides superb transvalvular hemodynamics with freedom from anticoagulation. The Toronto root seems widely applicable for all types of aortic root pathology and these early data offer very encouraging results. Long-term follow-up is required.

Adult↗
PubMed2004

Aortic valve sparing operations: basic concepts.

Aortic valve sparing surgery offers a unique opportunity to save the normal aortic valve in patients who require surgery for aortic root disease such as aneurysms, annuloaortic ectasia or aortic dissection. The surgical anatomy of the aortic root and the basic concepts of aortic valve sparing surgery are reviewed to provide surgeons and cardiologists a better understanding of when such operations might be suitable.

Aortic Aneurysm↗
PubMed2004

Clinical outcomes after separate and composite replacement of the aortic valve and ascending aorta.

OBJECTIVES: We sought to compare the clinical profile and outcomes of operations for aortic valve disease and ascending aortic aneurysm in patients treated with aortic valve replacement and supracoronary replacement of the ascending aorta or composite replacement of the aortic valve and ascending aorta (Bentall operation). METHODS: From 1990 through 2001, 133 patients had aortic valve replacement and supracoronary replacement of the ascending aorta, and 452 patients had Bentall operations. Aortic valve replacement and supracoronary replacement of the ascending aorta was performed in patients who had aortic valve disease and dilation of the ascending aorta, whereas the Bentall operation was performed in patients with aortic root abnormality and ascending aortic aneurysm. Mean follow-up was 4.6 +/- 3.1 years and was 100% complete. RESULTS: Patients who had aortic valve replacement and supracoronary replacement of the ascending aorta were older (61 +/- 13 vs 52 +/- 16 years, P <.001) and more likely to have aortic stenosis, coronary artery disease, and mitral valve disease than those who had Bentall operations. The use of mechanical valves was equal in both groups (42% for aortic valve replacement and supracoronary replacement of the ascending aorta and 43% for the Bentall operation). Operative mortality was 5% for patients undergoing aortic valve replacement and supracoronary replacement of the ascending aorta and 4% for patients undergoing the Bentall operation (P =.45). Survival at 10 years was 57% +/- 8% for patients undergoing aortic valve replacement and supracoronary replacement of the ascending aorta and 74% +/- 4% for patients undergoing the Bentall operation (P =.04), but the type of operation had no effect on survival. Older age, moderate or severe left ventricular dysfunction, active endocarditis, previous cardiac surgery, and coronary artery disease were independent predictors of death. The freedom from reoperation at 10 years was 95% +/- 5% for patients undergoing aortic valve replacement and supracoronary replacement of the ascending aorta and 94% +/- 3% for patients undergoing the Bentall operation (P =.18). Reoperations were mostly because of tissue valve failure or endocarditis. The risk of valve-related complications was the same in both groups. No patient required reoperation for aortic root aneurysm after having aortic valve replacement and supracoronary replacement of the ascending aorta. CONCLUSIONS: Aortic valve replacement and supracoronary replacement of the ascending aorta and the Bentall operation provide comparable long-term results. The Bentall operation is more appropriate for patients with aortic root abnormality and a dilated ascending aorta, whereas aortic valve replacement and supracoronary replacement of the ascending aorta is a perfectly acceptable operation for patients with aortic valve disease, normal or mildly dilated aortic sinuses, and a dilated ascending aorta.

Aortic Aneurysm, Thoracic↗
PubMed2004

Should the ascending aorta be replaced more frequently in patients with bicuspid aortic valve disease?

OBJECTIVE: The optimal diameter at which replacement of the ascending aorta should be performed in patients with bicuspid aortic valve disease is not known. METHODS: We reviewed all patients with bicuspid aortic valves undergoing aortic valve replacement at our institution from 1979 through 1993 (n = 201). Patients undergoing concomitant replacement of the ascending aorta were excluded. RESULTS: Follow-up was obtained on 98% of patients and was 10.3 +/- 3.8 (mean +/- SD) years. The average patient age was 56 +/- 15 years, and 76% were male. The ascending aorta was normal (<4.0 cm) in 115 (57%) patients, mildly dilated (4.0-4.4 cm) in 64 (32%) patients, and moderately dilated (4.5-4.9 cm) in 22 (11%) patients. All patients with bicuspid aortic valves with marked dilation (>5.0 cm) underwent replacement of the ascending aorta and were therefore excluded. Fifteen-year survival was 67%. During follow-up, 44 patients required reoperation, predominantly for aortic valve prosthesis failure. Twenty-two patients had long-term complications related to the ascending aorta: 18 required an operative procedure to replace the ascending aorta (for aortic aneurysm), 1 had aortic dissection, and 3 experienced sudden cardiac death. Fifteen-year freedom from ascending aorta-related complications was 86%, 81%, and 43% in patients with an aortic diameter of less than 4.0 cm, 4.0 to 4.4 cm, and 4.5 to 4.9 cm, respectively ( P < .001). CONCLUSIONS: Patients undergoing operations for bicuspid aortic valve disease should be considered for concomitant replacement of the ascending aorta if the diameter is 4.5 cm or greater.

Aged↗
PubMed2004

A large lipoma of the ascending aorta.

Ascending aortic tumors are extremely rare. We describe a patient with a large lipoma of the ascending aorta, which was discovered after opening the pericardium for a surgical procedure for mitral regurgitation due to prolapse.

Adult↗