Rick Esposito - Academia.edu (original) (raw)

Papers by Rick Esposito

Research paper thumbnail of Perioperative morbidity and mortality in combined vs. staged approaches to carotid and coronary revascularization

Annals of Vascular Surgery, 1996

Between 1986 and 1994 we identified 57 patients who underwent carotid endarterectomy (CEA) and co... more Between 1986 and 1994 we identified 57 patients who underwent carotid endarterectomy (CEA) and coronary artery bypass grafting (CABG) during the same hospitalization. Simultaneous CABG and CEA was performed in 28 patients (mean age 70.5 years, 58% male). Indications for CABG in these patients were myocardial infarction in two, crescendo angina in 19, congestive heart failure in two and left main or triple-vessel coronary artery disease noted during carotid preoperative evaluation in five. Indications for CEA were transient ischemic attack (TIA) in 12, crescendo TIA in six, cerebrovascular accident (CVA) in five, and asymptomatic stenosis in five. There were no postoperative myocardial infarctions or perioperative deaths. Two patients developed atrial fibrillation, and four patients had CVAs (two were ipsilateral to the side of CEA). Twenty-nine patients underwent staged procedures (i.e., not performed concomitantly but during the same hospitalization). Indications for CABG and CEA were comparable to those in the group undergoing simultaneous procedures. In 17 patients CEA was performed before CABG. There was a single CVA, the result of an intracerebral hemorrhage. Five of the 17 patients had a myocardial infarction and two died; one patient had first-degree heart block requiring a pacemaker. Four additional patients developed atrial fibrillation, one of whom required cardioversion. The remaining 12 patients had CABG followed by CEA. There were no CVAs, myocardial infarctions, arrhythmias, or deaths in this subgroup. These data demonstrate that the performance of simultaneous CABG and CEA procedures is associated with increased neurologic morbidity (14.3%), both ipsilateral and contralateral to the side of carotid surgery in contrast to staged CABG and CEA (3.4%). In addition, when staged carotid surgery preceded coronary revascularization in those with severe coronary artery disease, the combined cardiac complication and mortality rate was significantly higher than when coronary revascularization preceded CEA. This evidence suggests that when CABG and CEA must be performed during the same hospitalization, the procedures should be staged with CABG preceding CEA.

Research paper thumbnail of Early Results of Posterior Leaflet Folding Plasty for Mitral Valve Reconstruction

Annals of Thoracic Surgery, 1998

Background. Standard reconstruction for posterior mitral leaflet (PML) disease is quadrangular re... more Background. Standard reconstruction for posterior mitral leaflet (PML) disease is quadrangular resection and annular plication; when the PML is excessively high, a sliding plasty is used. We have developed an alternative technique, a posterior leaflet folding plasty. It is performed by folding down the cut vertical edges of the PML. The central height of the PML is reduced, leaflet coaptation is moved posteriorly, and annular plication is unnecessary.

Research paper thumbnail of Minimally invasive versus sternotomy approaches for mitral reconstruction: Comparison of intermediate-term results

Journal of Thoracic and Cardiovascular Surgery, 2001

Background. Over the past decade, minimally invasive (MI) mitral valve surgery has grown in popul... more Background. Over the past decade, minimally invasive (MI) mitral valve surgery has grown in popularity. The purpose of this study was to compare both short-and long-term outcomes of mitral valve repair and replacement performed through a MI versus traditional sternotomy (ST) incision using a propensity analysis approach to account for differences in baseline risk.

Research paper thumbnail of Valve Repair Versus Replacement For Mitral Insufficiency: When Is A Mechanical Valve Still Indicated

Journal of Thoracic and Cardiovascular Surgery, 1998

Objectives: Although many advantages of mitral valve reconstruction have been demonstrated, wheth... more Objectives: Although many advantages of mitral valve reconstruction have been demonstrated, whether specific subgroups of patients exist in whom mechanical valve replacement offers advantages over mitral reconstruction remains undetermined. Methods: This study examined the late results of mitral valve surgery in patients with mitral insufficiency who received either a St. Jude Medical valve (n ‫؍‬ 514) or a mitral valve reconstruction with ring annuloplasty (n ‫؍‬ 725) between 1980 and 1996. Results: Overall operative mortality was 7.2% in the patients receiving a St. Jude Medical mitral valve and 5.4% in those undergoing mitral valve reconstruction (no significant difference); isolated mortality was 2.5% in the St. Jude Medical group and 2.2% in the valve reconstruction group (no significant difference). The follow-up interval was more than 5 years for 340 patients with a mean of 39.8 months (98.5% complete). Overall 8-year freedom from late cardiac death, reoperation, and all valve-related complications was 72.8% for the St. Jude Medical group and 64.8% for valve reconstruction group (no significant difference). For patients with isolated, nonrheumatic mitral valve disease, 8-year freedom from late cardiac death and reoperation was better in the mitral valve reconstruction group (88.3%) than in the St. Jude Medical valve group (86.0%; p ‫؍‬ 0.05). Furthermore, Cox proportional hazards regression revealed that mitral valve reconstruction was independently associated with a lesser incidence of late cardiac death (p ‫؍‬ 0.04), irrespective of preoperative New York Heart Association class. However, the St. Jude Medical valve offered better 8-year freedom from late cardiac death, reoperation, and all valve-related complications than did mitral valve reconstruction in patients with multiple valve disease (77.0% vs 45.3%; p < 0.01). Conclusions: Therefore, mitral valve reconstruction appears to be the procedure of choice for isolated, nonrheumatic disease, whereas insertion of a St. Jude Medical valve should be preferred for patients with multiple valve disease. (J Thorac Cardiovasc Surg 1998;115:389-96) Pure mitral insufficiency (%) 941 (75.9) 344 (91.2) 81 (44.5) 202 (59.9) Mixed insufficiency and stenosis (%) 298 (24.0) 33 (8.8) 101 (55.5) 135 (40.1)

Research paper thumbnail of Perioperative morbidity and mortality in combined vs. staged approaches to carotid and coronary revascularization

Annals of Vascular Surgery, 1996

Between 1986 and 1994 we identified 57 patients who underwent carotid endarterectomy (CEA) and co... more Between 1986 and 1994 we identified 57 patients who underwent carotid endarterectomy (CEA) and coronary artery bypass grafting (CABG) during the same hospitalization. Simultaneous CABG and CEA was performed in 28 patients (mean age 70.5 years, 58% male). Indications for CABG in these patients were myocardial infarction in two, crescendo angina in 19, congestive heart failure in two and left main or triple-vessel coronary artery disease noted during carotid preoperative evaluation in five. Indications for CEA were transient ischemic attack (TIA) in 12, crescendo TIA in six, cerebrovascular accident (CVA) in five, and asymptomatic stenosis in five. There were no postoperative myocardial infarctions or perioperative deaths. Two patients developed atrial fibrillation, and four patients had CVAs (two were ipsilateral to the side of CEA). Twenty-nine patients underwent staged procedures (i.e., not performed concomitantly but during the same hospitalization). Indications for CABG and CEA were comparable to those in the group undergoing simultaneous procedures. In 17 patients CEA was performed before CABG. There was a single CVA, the result of an intracerebral hemorrhage. Five of the 17 patients had a myocardial infarction and two died; one patient had first-degree heart block requiring a pacemaker. Four additional patients developed atrial fibrillation, one of whom required cardioversion. The remaining 12 patients had CABG followed by CEA. There were no CVAs, myocardial infarctions, arrhythmias, or deaths in this subgroup. These data demonstrate that the performance of simultaneous CABG and CEA procedures is associated with increased neurologic morbidity (14.3%), both ipsilateral and contralateral to the side of carotid surgery in contrast to staged CABG and CEA (3.4%). In addition, when staged carotid surgery preceded coronary revascularization in those with severe coronary artery disease, the combined cardiac complication and mortality rate was significantly higher than when coronary revascularization preceded CEA. This evidence suggests that when CABG and CEA must be performed during the same hospitalization, the procedures should be staged with CABG preceding CEA.

Research paper thumbnail of Early Results of Posterior Leaflet Folding Plasty for Mitral Valve Reconstruction

Annals of Thoracic Surgery, 1998

Background. Standard reconstruction for posterior mitral leaflet (PML) disease is quadrangular re... more Background. Standard reconstruction for posterior mitral leaflet (PML) disease is quadrangular resection and annular plication; when the PML is excessively high, a sliding plasty is used. We have developed an alternative technique, a posterior leaflet folding plasty. It is performed by folding down the cut vertical edges of the PML. The central height of the PML is reduced, leaflet coaptation is moved posteriorly, and annular plication is unnecessary.

Research paper thumbnail of Minimally invasive versus sternotomy approaches for mitral reconstruction: Comparison of intermediate-term results

Journal of Thoracic and Cardiovascular Surgery, 2001

Background. Over the past decade, minimally invasive (MI) mitral valve surgery has grown in popul... more Background. Over the past decade, minimally invasive (MI) mitral valve surgery has grown in popularity. The purpose of this study was to compare both short-and long-term outcomes of mitral valve repair and replacement performed through a MI versus traditional sternotomy (ST) incision using a propensity analysis approach to account for differences in baseline risk.

Research paper thumbnail of Valve Repair Versus Replacement For Mitral Insufficiency: When Is A Mechanical Valve Still Indicated

Journal of Thoracic and Cardiovascular Surgery, 1998

Objectives: Although many advantages of mitral valve reconstruction have been demonstrated, wheth... more Objectives: Although many advantages of mitral valve reconstruction have been demonstrated, whether specific subgroups of patients exist in whom mechanical valve replacement offers advantages over mitral reconstruction remains undetermined. Methods: This study examined the late results of mitral valve surgery in patients with mitral insufficiency who received either a St. Jude Medical valve (n ‫؍‬ 514) or a mitral valve reconstruction with ring annuloplasty (n ‫؍‬ 725) between 1980 and 1996. Results: Overall operative mortality was 7.2% in the patients receiving a St. Jude Medical mitral valve and 5.4% in those undergoing mitral valve reconstruction (no significant difference); isolated mortality was 2.5% in the St. Jude Medical group and 2.2% in the valve reconstruction group (no significant difference). The follow-up interval was more than 5 years for 340 patients with a mean of 39.8 months (98.5% complete). Overall 8-year freedom from late cardiac death, reoperation, and all valve-related complications was 72.8% for the St. Jude Medical group and 64.8% for valve reconstruction group (no significant difference). For patients with isolated, nonrheumatic mitral valve disease, 8-year freedom from late cardiac death and reoperation was better in the mitral valve reconstruction group (88.3%) than in the St. Jude Medical valve group (86.0%; p ‫؍‬ 0.05). Furthermore, Cox proportional hazards regression revealed that mitral valve reconstruction was independently associated with a lesser incidence of late cardiac death (p ‫؍‬ 0.04), irrespective of preoperative New York Heart Association class. However, the St. Jude Medical valve offered better 8-year freedom from late cardiac death, reoperation, and all valve-related complications than did mitral valve reconstruction in patients with multiple valve disease (77.0% vs 45.3%; p < 0.01). Conclusions: Therefore, mitral valve reconstruction appears to be the procedure of choice for isolated, nonrheumatic disease, whereas insertion of a St. Jude Medical valve should be preferred for patients with multiple valve disease. (J Thorac Cardiovasc Surg 1998;115:389-96) Pure mitral insufficiency (%) 941 (75.9) 344 (91.2) 81 (44.5) 202 (59.9) Mixed insufficiency and stenosis (%) 298 (24.0) 33 (8.8) 101 (55.5) 135 (40.1)