Tommaso Regesta - Academia.edu (original) (raw)

Papers by Tommaso Regesta

Research paper thumbnail of “Edge-to-edge” repair for anterior mitral leaflet prolapse

Seminars in Thoracic and Cardiovascular Surgery, 2004

The aim of this study is to report our results in a series of 150 consecutive patients (mean age ... more The aim of this study is to report our results in a series of 150 consecutive patients (mean age 53 ؎ 15.4 years) in whom mitral regurgitation (MR) due to isolated anterior mitral leaflet (AML) prolapse was corrected using the edge-to-edge (E to E) technique over a period of more than 10 years. At admission, 49 (32.6%) patients were in NYHA class I, 46 (30.6%) in II, 51 (34%) in III and 4 (2.6%) in IV. In the great majority of the cases (111 patients, 74%), degenerative disease was the cause of MR. Hospital mortality was 0.6% (1/150). There were 7 late deaths. The actuarial overall survival and freedom from reoperation at 9 years were 91.6% ؎ 3.16% and 96.6% ؎ 1.74%, respectively. At follow-up (4.5 ؎ 3.21 years, range 2 months-12 years), the mean mitral valve area was 2.7 ؎ 0.5 cm 2 and mitral regurgitation was absent or mild in 132 patients (88%). The results of this study demonstrate the effectiveness and durability of the E to E repair in the setting of AML prolapse. In our institution, this technique, in conjunction with annuloplasty, remains the method of choice to correct segmental prolapse of the AML.

Research paper thumbnail of Edge-to-edge" repair for anterior mitral leaflet prolapse

Seminars in thoracic and cardiovascular surgery, 2004

The aim of this study is to report our results in a series of 150 consecutive patients (mean age ... more The aim of this study is to report our results in a series of 150 consecutive patients (mean age 53 +/- 15.4 years) in whom mitral regurgitation (MR) due to isolated anterior mitral leaflet (AML) prolapse was corrected using the edge-to-edge (E to E) technique over a period of more than 10 years. At admission, 49 (32.6%) patients were in NYHA class I, 46 (30.6%) in II, 51 (34%) in III and 4 (2.6%) in IV. In the great majority of the cases (111 patients, 74%), degenerative disease was the cause of MR. Hospital mortality was 0.6% (1/150). There were 7 late deaths. The actuarial overall survival and freedom from reoperation at 9 years were 91.6% +/- 3.16% and 96.6% +/- 1.74%, respectively. At follow-up (4.5 +/- 3.21 years, range 2 months-12 years), the mean mitral valve area was 2.7 +/- 0.5 cm(2) and mitral regurgitation was absent or mild in 132 patients (88%). The results of this study demonstrate the effectiveness and durability of the E to E repair in the setting of AML prolapse. I...

Research paper thumbnail of Expectation and quality of life after aortic valve replacement over 85 years of age match those of the contemporary general population

The International Journal of Artificial Organs, 2016

In the transcatheter aortic valve implantation (TAVI) years, very elderly patients with aortic st... more In the transcatheter aortic valve implantation (TAVI) years, very elderly patients with aortic stenosis (AS) are referred to surgery with reluctance despite excellent hospital outcomes. A poorly assessed outcome of discharged survivors might further overlook the actual efficacy of the surgical strategy in this cohort. We thus evaluated life-expectancy and functional results in discharged survivors over 85 years operated on for AS. Between January 2001 and December 2013, 57 consecutive patients aged ≥85 years underwent aortic valve replacement (AVR) with or without concomitant procedures at our institution. Late survival rate (SR), New York Heart Associaion (NYHA) functional class and quality of life (RAND SF-36) were assessed. SR and quality of life (QoL) were than compared to the contemporary general population matched for age and gender, as calculated by the Italian National Institute of Statistics. Overall in-hospital mortality was 8.8% (5 pts). In patients without concomitant coronary artery bypass grafting (CABG), in-hospital mortality was 2.9%. Survival at 5 and 9 years was 57.7 ± 8.4% and 17.9 ± 11.4%, respectively. No predictors of late mortality including concomitant CABG were identified at Cox analysis. The mean NYHA class for long-term survivors improved from 3.1 to 1.6 (p<0.001). Survivors reported better QoL-scores compared to the age- and gender-matched contemporary general population in 4 RAND SF-36 domains. Life-expectancy resulted comparable to that predicted for the age and gender-matched general population. Isolated AVR in patients aged ≥85 years can be performed with acceptable risk. Survivors improve in NYHA class and, when compared to age- and gender-matched individuals, show a similar life expectancy and a no lower QoL.

Research paper thumbnail of Biological and clinical outcomes in the elderly with left ventricular dysfunction: Are there differences between on-pump and off-pump coronary artery bypass grafting?

Annali italiani di chirurgia

To compair biological and clinical outcomes after off-pump coronary artery bypass grafting (OPCAB... more To compair biological and clinical outcomes after off-pump coronary artery bypass grafting (OPCABG) and conventional on-pump coronary artery bypass grafting (CCABG) in the elderly with left ventricular (LV) dysfunction. We retrospectively reviewed 90 consecutive patients aged more than 75 years with preoperative left ventricular ejection fraction (LVEF) < 50% who underwent isolated coronary artery bypass grafting at our Institution between January 2000 and July 2009. According to operative technique, patients were categorized in to the OPCABG group (39 patients) or in to the CCABG group (51 patients). We compared postoperative CK, CK-MB, troponin T serum levels and major adverse cardiac and cerebrovascular events (MACCE). The overall in-hospital mortality was 2% (2/90) and was similar in both groups (p=0.8336). Mean troponin T levels at 6,24,48 hours after operation were significantly lower in the OPCABG group (p=0.0001; p=0.0021; p=0.0070, respectively). Overall survival was 77....

Research paper thumbnail of Does patient–prosthesis mismatch after aortic valve replacement affect survival and quality of life in elderly patients?

Journal of Cardiovascular Medicine, 2015

Research paper thumbnail of Neuroprotective strategies in acute ischemic stroke

Italian journal of neurological sciences, 1998

Focal ischemic injury in the brain is related to both the intensity and the duration of the decre... more Focal ischemic injury in the brain is related to both the intensity and the duration of the decrement of cerebral blood flow. The ischemic penumbra is an area characterized by levels of blood flow slightly greater than that in the ischemic core itself. In this area, metabolic rate is preserved or is even higher, probably because of a recurrent ischemic

Research paper thumbnail of Fate of the aortic valve after root reconstruction in type A aortic dissection: a 20-year follow up

The Journal of heart valve disease, 2009

The study aim was to evaluate the fate of the aortic valve after root reconstruction in acute typ... more The study aim was to evaluate the fate of the aortic valve after root reconstruction in acute type A aortic dissection. Between 1982 and 2006, a total of 373 consecutive patients underwent emergency surgery for acute type A aortic dissection at the authors' institution. Of these patients, 298 (mean age 63 +/- 11 years; range: 22-85 years) underwent replacement of the supracoronary aorta with root reconstruction. The mean follow up period was 6.9 +/- 5.2 years (range: 2 months to 23 years), and was 98% complete. Aortic valve function was assessed by the incidence of aortic valve reoperation and transthoracic echocardiography. The 30-day mortality was 27% (82/298). Survival was 80%, 57% and 49% at five, 10 and 15 years, respectively. For survivors at the latest follow up, freedom from moderate or severe aortic regurgitation (AR) was 93%, 84% and 72% at five, 10 and 15 years, respectively. Four patients had severe AR but were not reoperated on. Among 200 patients discharged, 13 (6....

Research paper thumbnail of Surgical treatment of active infective endocarditis: A continued challenge

The Journal of Thoracic and Cardiovascular Surgery, 2007

Objective: This study was undertaken to examine the outcomes of surgery for active infective endo... more Objective: This study was undertaken to examine the outcomes of surgery for active infective endocarditis in a large cohort of patients.

Research paper thumbnail of Fate of the preserved aortic root after treatment of acute type A aortic dissection: 23-year follow-up

The Journal of Thoracic and Cardiovascular Surgery, 2013

The objective of this study was to examine the fate of the native aortic root after replacement o... more The objective of this study was to examine the fate of the native aortic root after replacement of the ascending aorta to treat acute type A aortic dissection. Between June 1985 and January 2010, 319 consecutive patients (mean age, 63 ± 11 years) with acute type A aortic dissection underwent replacement of the ascending aorta with preservation of the aortic root. The aortic valve was also replaced in 21 of these patients (7%). The intervention was extended to the aortic arch in 210 patients (66%), of whom 173 (54%) underwent hemiarch replacement, and 37 (12%), total arch replacement. There were 109 (34%) in-hospital deaths. Of the 210 discharged patients, survival was 95%, 58%, and 27% at 1, 10, and 23 years, respectively. Freedom from reoperation on the proximal aorta was reported by 97%, 92%, and 82% patients at 5, 10, and 23 years, respectively. Twelve patients were reoperated for aortic root dilatation and 2 died during reoperation. Univariate and multivariate Cox regression analyses revealed that significant risk factors for proximal reoperation were age &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;60 years (P = .005; relative risk, 1.94) and Marfan syndrome (P = .011; relative risk, 2.76). At follow-up, 15 patients (11%) had an aortic root diameter of &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;45 mm, but they were not reoperated. For acute type A aortic dissection, replacement of the ascending aorta with root preservation shows long-term effectiveness with low reoperation and aortic root dilatation rates.

Research paper thumbnail of Aortic Valve Replacement with Smaller Prostheses in Elderly Patients: Does Patient Prosthetic Mismatch Affect Outcomes?

Journal of Cardiac Surgery, 2013

To evaluate the influence of patient-prosthesis mismatch (PPM) on survival, and quality of life (... more To evaluate the influence of patient-prosthesis mismatch (PPM) on survival, and quality of life (QOL) after aortic valve replacement (AVR) in elderly patients with small prosthesis size. Between 2005 and 2010, 142 patients older than 65 years were discharged from the hospital after AVR with 19 or 21 mm prosthesis for aortic stenosis. Their median age was 79 years (range 66 to 91). Prosthesis effective orifice area (EOA) was derived from the continuity equation and PPM was defined as an indexed EOA (IEOA) &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.85 cm(2)/m(2). Patients having IEOA &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.75 cm(2)/m(2) and IEOA &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.60 cm(2)/m(2) were also investigated. Mean follow-up was 23 months (range 1 to 58) and was 98% complete. PPM was found in 86 patients, 63 had an IEOA ≤ 0.75 cm(2) /m(2), and 23 had an IEOA ≤ 0.60 cm(2) /m(2). The groups were similar except for older age (p = 0.0364), larger body surface area (p = 0.0068), more male gender (p = 0.0186), and more EF &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 40% in patients with PPM. Survival at 58 months was 81 ± 6.4% and was not influenced by PPM (p = 0.9845). At Cox analysis only preoperative NYHA class (p = 0.0064) was identified as an independent risk factor for late death. The SF12 test was used to analyze the QOL of patients and it did not reveal differences between groups. PPM does not affect survival in this series of elderly patients. We believe that more aggressive surgical procedures are not justified in these patients.

Research paper thumbnail of Outcomes After Surgical Treatment for Type A Acute Aortic Dissection in Octogenarians: A Multicenter Study

The Annals of Thoracic Surgery, 2009

Methods. Beginning January 2000, we established a registry including all octogenarian patients op... more Methods. Beginning January 2000, we established a registry including all octogenarian patients operated on for type A acute aortic dissection. We evaluated 57 consecutive patients enrolled up to December 2006. Their median age was 82 (range, 80 to 89 years). Compassionate indication operations were attempted in 2 moribund patients and in 5 presenting with shock associated with neurologic symptoms or renal failure, or both. Operations followed the standard procedure recommended in younger patients. Follow-up was 100% complete (mean, 3.9 ؎ 2 years; range, 5 months to 8 years).

Research paper thumbnail of Octogenarians With Uncomplicated Acute Type A Aortic Dissection Benefit From Emergency Operation

The Annals of Thoracic Surgery, 2013

The management of acute type A aortic dissection (aTAAD) in octogenarian patients is controversia... more The management of acute type A aortic dissection (aTAAD) in octogenarian patients is controversial. This study analyzed the surgical outcomes to identify patients who should undergo operations. Beginning in January 2000, we established a registry including all octogenarian patients operated on for type A acute aortic dissection. We evaluated 79 consecutive patients enrolled up to December 2010. Their median age was 81.6 years (range, 80 to 89 years). Sixteen patients (20%) presented a complicated type because of a neurologic deficit, mesenteric ischemia, a requirement for cardiopulmonary resuscitation, or some combination of those features. Operations followed the standard procedure recommended for younger patients. Follow-up was 95% complete (mean, 4.6±2.8 years). The overall in-hospital mortality was 44.3%. The in-hospital mortality among patients with uncomplicated aTAAD was 33.3%. Multivariate analysis identified complicated aTAAD as the only risk factors for in-hospital mortality (p&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.0001). Postoperative complications occurred in 50 patients (68.5%) and were associated with a higher mortality (p&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.0001). The overall survival was 53% at 1 year and 32% at 5 years. In uncomplicated aTAAD, the overall survival was 63% at 1 year and 38% at 5 years. Octogenarians with uncomplicated aTAAD benefit from emergency surgical repair. In those patients, early and midterm outcomes are good and are similar to those in published series of younger patients. Complicated aTAAD should be medically managed.

Research paper thumbnail of Coronary artery bypass grafting in octogenarians: long-term results

Objective Coronary artery bypass grafting (CABG) is gradually increasing in the elderly populatio... more Objective Coronary artery bypass grafting (CABG) is gradually increasing in the elderly population. We aimed to investigate the risk factors and the results of CABG along with the long term survival in patients at an age of 80 and older. Methods Between January 2002 and December 2011, a total of 101 consecutive patients at an age of 80 and older who underwent CABG in our hospital were included in the study. The patients were followed and the long-term survival was estimated. Results The mean age of the patients was 82.98 ± 2.27 years. Sixty-four (63.4%) were males and 37 (36.6%) were females. Emergency surgery, duration of cardiopulmonary bypass, the intensive care unit (ICU) stay, inotropic support, intra aortic balloon pulsation application, amount of erythrocyte transfusion and fresh frozen plasma transfusion and ventilation period were significantly higher in the patients who died in the hospital. The duration of cardiopulmonary bypass (CPB) was found to be an independent predictor of mortality (OR: 1.18, 95% CI 1.01−1.38, P = 0.034). The in-hospital mortality was 16.8%. Kaplan-Meier analyses revealed a survival ratio of 91.3% at one year, 82.9% at three years and 69.0% at five years. Conclusions Patients at the age of 80 and older can be candidates for the CABG procedure bearing in mind that they may have a longer ventilation period and intensive care unit stay. The morbidity and mortality of this age group is considered within an acceptable range. Approaches to minimize CPB, or the choice of off-pump surgery, may be a preventive method to lower the incidence of mortality. Hence, CABG may be performed in this age group with a satisfactory survival ratio.

Research paper thumbnail of A 20-year experience with mitral valve repair with artificial chordae in 608 patients

The Journal of Thoracic and Cardiovascular Surgery, 2008

Mitral valve repair with artificial chordae for degenerative mitral regurgitation is widely adopt... more Mitral valve repair with artificial chordae for degenerative mitral regurgitation is widely adopted. We evaluated long-term results of mitral repair with expanded polytetrafluoroethylene sutures (GORE-TEX CV-5; W. L. Gore &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp; Associates, Inc, Flagstaff, Ariz). Between November 1986 and November 2006, 608 consecutive patients underwent mitral repair with artificial neochordae. Mean age was 55 +/- 11 years (15-85 years); 433 (71.2%) were male. Valve disease was purely degenerative in 555 patients (91.3%). Prolapse of anterior, posterior, or both leaflets was present in 47 (7.7%), 308 (50.7%), and 253 (41.6%), respectively. Atrial fibrillation was associated in 117 (19.2%). In 125 cases (20.5%), additional surgical procedures were performed. Follow-up was complete at a median of 5.7 years (interquartile range 2.2-9.8 years, range 0-19.4 years). In-hospital mortality was less than 1% (6 deaths). Overall and cardiac late mortalities were 6.6% and 3.9% (34 and 24 deaths). Kaplan-Meier survival at 15 years was 84% (95% confidence interval 75%-90%). Freedoms from endocarditis, thromboembolic events, reoperation, and recurrent mitral regurgitation at 15 years were 97% (95% confidence interval 93%-99%), 92% (87%-95%), 92% (88%-95%), and 85% (78%-91%), respectively. Sinus rhythm was restored in 75% (33 patients) after surgical atrial fibrillation correction. Calcification of GORE-TEX neochordae was never reported. Mitral valve repair with GORE-TEX artificial chordae is effective, safe, and associated with low operative mortality and low rates of valve-related complications at long-term follow-up. Artificial chordae showed excellent biologic adaptation, retaining flexibility and tension with time.

Research paper thumbnail of “Edge-to-edge” repair for anterior mitral leaflet prolapse

Seminars in Thoracic and Cardiovascular Surgery, 2004

The aim of this study is to report our results in a series of 150 consecutive patients (mean age ... more The aim of this study is to report our results in a series of 150 consecutive patients (mean age 53 ؎ 15.4 years) in whom mitral regurgitation (MR) due to isolated anterior mitral leaflet (AML) prolapse was corrected using the edge-to-edge (E to E) technique over a period of more than 10 years. At admission, 49 (32.6%) patients were in NYHA class I, 46 (30.6%) in II, 51 (34%) in III and 4 (2.6%) in IV. In the great majority of the cases (111 patients, 74%), degenerative disease was the cause of MR. Hospital mortality was 0.6% (1/150). There were 7 late deaths. The actuarial overall survival and freedom from reoperation at 9 years were 91.6% ؎ 3.16% and 96.6% ؎ 1.74%, respectively. At follow-up (4.5 ؎ 3.21 years, range 2 months-12 years), the mean mitral valve area was 2.7 ؎ 0.5 cm 2 and mitral regurgitation was absent or mild in 132 patients (88%). The results of this study demonstrate the effectiveness and durability of the E to E repair in the setting of AML prolapse. In our institution, this technique, in conjunction with annuloplasty, remains the method of choice to correct segmental prolapse of the AML.

Research paper thumbnail of Edge-to-edge" repair for anterior mitral leaflet prolapse

Seminars in thoracic and cardiovascular surgery, 2004

The aim of this study is to report our results in a series of 150 consecutive patients (mean age ... more The aim of this study is to report our results in a series of 150 consecutive patients (mean age 53 +/- 15.4 years) in whom mitral regurgitation (MR) due to isolated anterior mitral leaflet (AML) prolapse was corrected using the edge-to-edge (E to E) technique over a period of more than 10 years. At admission, 49 (32.6%) patients were in NYHA class I, 46 (30.6%) in II, 51 (34%) in III and 4 (2.6%) in IV. In the great majority of the cases (111 patients, 74%), degenerative disease was the cause of MR. Hospital mortality was 0.6% (1/150). There were 7 late deaths. The actuarial overall survival and freedom from reoperation at 9 years were 91.6% +/- 3.16% and 96.6% +/- 1.74%, respectively. At follow-up (4.5 +/- 3.21 years, range 2 months-12 years), the mean mitral valve area was 2.7 +/- 0.5 cm(2) and mitral regurgitation was absent or mild in 132 patients (88%). The results of this study demonstrate the effectiveness and durability of the E to E repair in the setting of AML prolapse. I...

Research paper thumbnail of Expectation and quality of life after aortic valve replacement over 85 years of age match those of the contemporary general population

The International Journal of Artificial Organs, 2016

In the transcatheter aortic valve implantation (TAVI) years, very elderly patients with aortic st... more In the transcatheter aortic valve implantation (TAVI) years, very elderly patients with aortic stenosis (AS) are referred to surgery with reluctance despite excellent hospital outcomes. A poorly assessed outcome of discharged survivors might further overlook the actual efficacy of the surgical strategy in this cohort. We thus evaluated life-expectancy and functional results in discharged survivors over 85 years operated on for AS. Between January 2001 and December 2013, 57 consecutive patients aged ≥85 years underwent aortic valve replacement (AVR) with or without concomitant procedures at our institution. Late survival rate (SR), New York Heart Associaion (NYHA) functional class and quality of life (RAND SF-36) were assessed. SR and quality of life (QoL) were than compared to the contemporary general population matched for age and gender, as calculated by the Italian National Institute of Statistics. Overall in-hospital mortality was 8.8% (5 pts). In patients without concomitant coronary artery bypass grafting (CABG), in-hospital mortality was 2.9%. Survival at 5 and 9 years was 57.7 ± 8.4% and 17.9 ± 11.4%, respectively. No predictors of late mortality including concomitant CABG were identified at Cox analysis. The mean NYHA class for long-term survivors improved from 3.1 to 1.6 (p&amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.001). Survivors reported better QoL-scores compared to the age- and gender-matched contemporary general population in 4 RAND SF-36 domains. Life-expectancy resulted comparable to that predicted for the age and gender-matched general population. Isolated AVR in patients aged ≥85 years can be performed with acceptable risk. Survivors improve in NYHA class and, when compared to age- and gender-matched individuals, show a similar life expectancy and a no lower QoL.

Research paper thumbnail of Biological and clinical outcomes in the elderly with left ventricular dysfunction: Are there differences between on-pump and off-pump coronary artery bypass grafting?

Annali italiani di chirurgia

To compair biological and clinical outcomes after off-pump coronary artery bypass grafting (OPCAB... more To compair biological and clinical outcomes after off-pump coronary artery bypass grafting (OPCABG) and conventional on-pump coronary artery bypass grafting (CCABG) in the elderly with left ventricular (LV) dysfunction. We retrospectively reviewed 90 consecutive patients aged more than 75 years with preoperative left ventricular ejection fraction (LVEF) < 50% who underwent isolated coronary artery bypass grafting at our Institution between January 2000 and July 2009. According to operative technique, patients were categorized in to the OPCABG group (39 patients) or in to the CCABG group (51 patients). We compared postoperative CK, CK-MB, troponin T serum levels and major adverse cardiac and cerebrovascular events (MACCE). The overall in-hospital mortality was 2% (2/90) and was similar in both groups (p=0.8336). Mean troponin T levels at 6,24,48 hours after operation were significantly lower in the OPCABG group (p=0.0001; p=0.0021; p=0.0070, respectively). Overall survival was 77....

Research paper thumbnail of Does patient–prosthesis mismatch after aortic valve replacement affect survival and quality of life in elderly patients?

Journal of Cardiovascular Medicine, 2015

Research paper thumbnail of Neuroprotective strategies in acute ischemic stroke

Italian journal of neurological sciences, 1998

Focal ischemic injury in the brain is related to both the intensity and the duration of the decre... more Focal ischemic injury in the brain is related to both the intensity and the duration of the decrement of cerebral blood flow. The ischemic penumbra is an area characterized by levels of blood flow slightly greater than that in the ischemic core itself. In this area, metabolic rate is preserved or is even higher, probably because of a recurrent ischemic

Research paper thumbnail of Fate of the aortic valve after root reconstruction in type A aortic dissection: a 20-year follow up

The Journal of heart valve disease, 2009

The study aim was to evaluate the fate of the aortic valve after root reconstruction in acute typ... more The study aim was to evaluate the fate of the aortic valve after root reconstruction in acute type A aortic dissection. Between 1982 and 2006, a total of 373 consecutive patients underwent emergency surgery for acute type A aortic dissection at the authors' institution. Of these patients, 298 (mean age 63 +/- 11 years; range: 22-85 years) underwent replacement of the supracoronary aorta with root reconstruction. The mean follow up period was 6.9 +/- 5.2 years (range: 2 months to 23 years), and was 98% complete. Aortic valve function was assessed by the incidence of aortic valve reoperation and transthoracic echocardiography. The 30-day mortality was 27% (82/298). Survival was 80%, 57% and 49% at five, 10 and 15 years, respectively. For survivors at the latest follow up, freedom from moderate or severe aortic regurgitation (AR) was 93%, 84% and 72% at five, 10 and 15 years, respectively. Four patients had severe AR but were not reoperated on. Among 200 patients discharged, 13 (6....

Research paper thumbnail of Surgical treatment of active infective endocarditis: A continued challenge

The Journal of Thoracic and Cardiovascular Surgery, 2007

Objective: This study was undertaken to examine the outcomes of surgery for active infective endo... more Objective: This study was undertaken to examine the outcomes of surgery for active infective endocarditis in a large cohort of patients.

Research paper thumbnail of Fate of the preserved aortic root after treatment of acute type A aortic dissection: 23-year follow-up

The Journal of Thoracic and Cardiovascular Surgery, 2013

The objective of this study was to examine the fate of the native aortic root after replacement o... more The objective of this study was to examine the fate of the native aortic root after replacement of the ascending aorta to treat acute type A aortic dissection. Between June 1985 and January 2010, 319 consecutive patients (mean age, 63 ± 11 years) with acute type A aortic dissection underwent replacement of the ascending aorta with preservation of the aortic root. The aortic valve was also replaced in 21 of these patients (7%). The intervention was extended to the aortic arch in 210 patients (66%), of whom 173 (54%) underwent hemiarch replacement, and 37 (12%), total arch replacement. There were 109 (34%) in-hospital deaths. Of the 210 discharged patients, survival was 95%, 58%, and 27% at 1, 10, and 23 years, respectively. Freedom from reoperation on the proximal aorta was reported by 97%, 92%, and 82% patients at 5, 10, and 23 years, respectively. Twelve patients were reoperated for aortic root dilatation and 2 died during reoperation. Univariate and multivariate Cox regression analyses revealed that significant risk factors for proximal reoperation were age &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;60 years (P = .005; relative risk, 1.94) and Marfan syndrome (P = .011; relative risk, 2.76). At follow-up, 15 patients (11%) had an aortic root diameter of &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;45 mm, but they were not reoperated. For acute type A aortic dissection, replacement of the ascending aorta with root preservation shows long-term effectiveness with low reoperation and aortic root dilatation rates.

Research paper thumbnail of Aortic Valve Replacement with Smaller Prostheses in Elderly Patients: Does Patient Prosthetic Mismatch Affect Outcomes?

Journal of Cardiac Surgery, 2013

To evaluate the influence of patient-prosthesis mismatch (PPM) on survival, and quality of life (... more To evaluate the influence of patient-prosthesis mismatch (PPM) on survival, and quality of life (QOL) after aortic valve replacement (AVR) in elderly patients with small prosthesis size. Between 2005 and 2010, 142 patients older than 65 years were discharged from the hospital after AVR with 19 or 21 mm prosthesis for aortic stenosis. Their median age was 79 years (range 66 to 91). Prosthesis effective orifice area (EOA) was derived from the continuity equation and PPM was defined as an indexed EOA (IEOA) &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.85 cm(2)/m(2). Patients having IEOA &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.75 cm(2)/m(2) and IEOA &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.60 cm(2)/m(2) were also investigated. Mean follow-up was 23 months (range 1 to 58) and was 98% complete. PPM was found in 86 patients, 63 had an IEOA ≤ 0.75 cm(2) /m(2), and 23 had an IEOA ≤ 0.60 cm(2) /m(2). The groups were similar except for older age (p = 0.0364), larger body surface area (p = 0.0068), more male gender (p = 0.0186), and more EF &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 40% in patients with PPM. Survival at 58 months was 81 ± 6.4% and was not influenced by PPM (p = 0.9845). At Cox analysis only preoperative NYHA class (p = 0.0064) was identified as an independent risk factor for late death. The SF12 test was used to analyze the QOL of patients and it did not reveal differences between groups. PPM does not affect survival in this series of elderly patients. We believe that more aggressive surgical procedures are not justified in these patients.

Research paper thumbnail of Outcomes After Surgical Treatment for Type A Acute Aortic Dissection in Octogenarians: A Multicenter Study

The Annals of Thoracic Surgery, 2009

Methods. Beginning January 2000, we established a registry including all octogenarian patients op... more Methods. Beginning January 2000, we established a registry including all octogenarian patients operated on for type A acute aortic dissection. We evaluated 57 consecutive patients enrolled up to December 2006. Their median age was 82 (range, 80 to 89 years). Compassionate indication operations were attempted in 2 moribund patients and in 5 presenting with shock associated with neurologic symptoms or renal failure, or both. Operations followed the standard procedure recommended in younger patients. Follow-up was 100% complete (mean, 3.9 ؎ 2 years; range, 5 months to 8 years).

Research paper thumbnail of Octogenarians With Uncomplicated Acute Type A Aortic Dissection Benefit From Emergency Operation

The Annals of Thoracic Surgery, 2013

The management of acute type A aortic dissection (aTAAD) in octogenarian patients is controversia... more The management of acute type A aortic dissection (aTAAD) in octogenarian patients is controversial. This study analyzed the surgical outcomes to identify patients who should undergo operations. Beginning in January 2000, we established a registry including all octogenarian patients operated on for type A acute aortic dissection. We evaluated 79 consecutive patients enrolled up to December 2010. Their median age was 81.6 years (range, 80 to 89 years). Sixteen patients (20%) presented a complicated type because of a neurologic deficit, mesenteric ischemia, a requirement for cardiopulmonary resuscitation, or some combination of those features. Operations followed the standard procedure recommended for younger patients. Follow-up was 95% complete (mean, 4.6±2.8 years). The overall in-hospital mortality was 44.3%. The in-hospital mortality among patients with uncomplicated aTAAD was 33.3%. Multivariate analysis identified complicated aTAAD as the only risk factors for in-hospital mortality (p&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.0001). Postoperative complications occurred in 50 patients (68.5%) and were associated with a higher mortality (p&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.0001). The overall survival was 53% at 1 year and 32% at 5 years. In uncomplicated aTAAD, the overall survival was 63% at 1 year and 38% at 5 years. Octogenarians with uncomplicated aTAAD benefit from emergency surgical repair. In those patients, early and midterm outcomes are good and are similar to those in published series of younger patients. Complicated aTAAD should be medically managed.

Research paper thumbnail of Coronary artery bypass grafting in octogenarians: long-term results

Objective Coronary artery bypass grafting (CABG) is gradually increasing in the elderly populatio... more Objective Coronary artery bypass grafting (CABG) is gradually increasing in the elderly population. We aimed to investigate the risk factors and the results of CABG along with the long term survival in patients at an age of 80 and older. Methods Between January 2002 and December 2011, a total of 101 consecutive patients at an age of 80 and older who underwent CABG in our hospital were included in the study. The patients were followed and the long-term survival was estimated. Results The mean age of the patients was 82.98 ± 2.27 years. Sixty-four (63.4%) were males and 37 (36.6%) were females. Emergency surgery, duration of cardiopulmonary bypass, the intensive care unit (ICU) stay, inotropic support, intra aortic balloon pulsation application, amount of erythrocyte transfusion and fresh frozen plasma transfusion and ventilation period were significantly higher in the patients who died in the hospital. The duration of cardiopulmonary bypass (CPB) was found to be an independent predictor of mortality (OR: 1.18, 95% CI 1.01−1.38, P = 0.034). The in-hospital mortality was 16.8%. Kaplan-Meier analyses revealed a survival ratio of 91.3% at one year, 82.9% at three years and 69.0% at five years. Conclusions Patients at the age of 80 and older can be candidates for the CABG procedure bearing in mind that they may have a longer ventilation period and intensive care unit stay. The morbidity and mortality of this age group is considered within an acceptable range. Approaches to minimize CPB, or the choice of off-pump surgery, may be a preventive method to lower the incidence of mortality. Hence, CABG may be performed in this age group with a satisfactory survival ratio.

Research paper thumbnail of A 20-year experience with mitral valve repair with artificial chordae in 608 patients

The Journal of Thoracic and Cardiovascular Surgery, 2008

Mitral valve repair with artificial chordae for degenerative mitral regurgitation is widely adopt... more Mitral valve repair with artificial chordae for degenerative mitral regurgitation is widely adopted. We evaluated long-term results of mitral repair with expanded polytetrafluoroethylene sutures (GORE-TEX CV-5; W. L. Gore &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp; Associates, Inc, Flagstaff, Ariz). Between November 1986 and November 2006, 608 consecutive patients underwent mitral repair with artificial neochordae. Mean age was 55 +/- 11 years (15-85 years); 433 (71.2%) were male. Valve disease was purely degenerative in 555 patients (91.3%). Prolapse of anterior, posterior, or both leaflets was present in 47 (7.7%), 308 (50.7%), and 253 (41.6%), respectively. Atrial fibrillation was associated in 117 (19.2%). In 125 cases (20.5%), additional surgical procedures were performed. Follow-up was complete at a median of 5.7 years (interquartile range 2.2-9.8 years, range 0-19.4 years). In-hospital mortality was less than 1% (6 deaths). Overall and cardiac late mortalities were 6.6% and 3.9% (34 and 24 deaths). Kaplan-Meier survival at 15 years was 84% (95% confidence interval 75%-90%). Freedoms from endocarditis, thromboembolic events, reoperation, and recurrent mitral regurgitation at 15 years were 97% (95% confidence interval 93%-99%), 92% (87%-95%), 92% (88%-95%), and 85% (78%-91%), respectively. Sinus rhythm was restored in 75% (33 patients) after surgical atrial fibrillation correction. Calcification of GORE-TEX neochordae was never reported. Mitral valve repair with GORE-TEX artificial chordae is effective, safe, and associated with low operative mortality and low rates of valve-related complications at long-term follow-up. Artificial chordae showed excellent biologic adaptation, retaining flexibility and tension with time.