Well, I finally met with Gabriel S. Aldea M.D and wow is all I can say! I have seen many doctors my days, but he was head and shoulders above any of them for just sure confidence, competency and knowledge. I came away from there knowing that when it comes time for my aortic root and valve and possibly replacing my old dacron tubing, that Dr. Gabe and his partner will do the best possible surgery for me.

I am so relieved. OMG…………..Look at the notes he wrote about me below. I am just going to stay on the 6 month ECHO testing and keep all my stuff with Dr. Gabe and Catherine Otto. Dr. Sherene Shalhub is my vascular doctor and it was her advice to finally reach out to Gabe, granted the Echo Team said I needed to start looking and had actually cancelled on Gabe one time. I am SURE glad I didn’t this time. He’s got to be the most skilled and confident surgeon I ever met. His attention to detail and showing me my CT results and Echo stuff and where things were and what needed to happen blew me away.

My results: This is the kind of expertise the U of W team offers!

Outpatient Consultation:  Mr. Tinsley is referred to us by Dr. Catherine Otto.  HISTORY OF PRESENT ILLNESS:Mr. Tinsley is a 56-year-old man status post type A aortic dissection treated by Dr. Brevig at Providence Everett in 2003 with an interposition graft. The patient is very involved with connective tissue disorders and ascending aortic aneurysms in the area and is very well known for his activism in this area on the entire west coast. He has been followed for a long time by Dr. Catherine Otto, most recently by Dr. Samir Gafoor at Swedish and has been seen at Stanford, Cleveland Clinic, Swedish, Overlake amongst others. He presents with increasing fatigue. Most recent echocardiogram demonstrates moderate aortic insufficiency. His ejection fraction is 56%. This is a bicuspid valve. Left ventricular and diastolic dimension is mildly increased to 5.9 cm. The maximal dimensions of the sinuses by my measurements are 48 mm. The graft is heavily calcified and terminates below the innominate artery. There is a chronic type A dissection that extends into the innominate, left carotid and left subclavian and descending thoracic aorta. The descending thoracic aorta is nonaneurysmal. PAST SURGICAL HISTORY:Significant for type A dissection by Dr. Brevig with an interposition graft in 2003 Providence Hospital and for varicose vein stripping. PAST MEDICAL HISTORY: 1. Moderate aortic insufficiency with a bicuspid valve.2. Root aneurysm with no dissection.3. History of type A dissection, status post ascending aortic replacement.4. Persistent dissection and descending and abdominal aorta. Most recent echocardiogram demonstrates mildly depressed ejection fraction. I believe by echocardiogram the sinuses are overly estimated to be 54 mm in diameter. By CT axial measurements they were only 48 mm. CT scan demonstrates normal right and left main coronary anatomy. Annular dimensions measured by TAVR protocol CT performed at Swedish demonstrate massively enlarged annulus to over 1000 sq mm. The patient had a stress echocardiogram performed by Dr. Gafoor. This demonstrates no evidence of aortic dissection. He has got reduced exercise capacity for age. He was asymptomatic. Again, ejection fraction was estimated to be 59%. The aortic valve is sclerotic and by echocardiogram is thought to be trileaflet rather than bicuspid. The vena contracta is 0.4 cm. The PISA radius is 0.8 cm. Regurgitant volume is 58 mm. Flow reversal is noted in the descending thoracic aorta. With exercise the vena contracta measures 0.86 sq cm. TAVR CTA was performed and was evaluated by me. Coronary artery heights are 26 mm on the right and 14 mm on the left. The LVOT diameter is massively enlarged to over 930 sq mm. At the annulus it is 1000 sq mm; 3 mm below the annulus it measures 930 sq mm. The graft appears to be very heavily calcified. There is chronic dissection in the innominate, left subclavian and left carotid arteries. The maximal dimensions of the sinuses are 48 mm with no evidence of dissection. CURRENT MEDICATIONS:Aspirin 81 mg a day, Lexapro 20 mg a day, metoprolol ER 100 mg a day, multivitamins and telmisartan/hydrochlorothiazide 80-25 mg p.o. daily. ALLERGIES:THE PATIENT IS ALLERGIC TO AMLODIPINE, MENTHOL AND LISINOPRIL. SOCIAL HISTORY:The patient is a lifelong nonsmoker. He has an occasional drink per week. FAMILY HISTORY:Negative for aneurysmal disease. Father has diabetes. There is no evidence of type A dissections. PHYSICAL EXAMINATION:VITAL SIGNS: Blood pressure is 140/60, pulse is 64. Patient is afebrile. His BMI is 27.9.HEENT: There are no transmitted carotid bruits or JVD or adenopathy.CHEST: Well-healed sternotomy incision. Clear to auscultation. No rales or wheezing.HEART: Regular rhythm with a 2/6 systolic murmur with a diastolic component.ABDOMEN: Soft, nontender with active bowel sounds. Pulses +2 and equal throughout. ASSESSMENT AND PLAN:I have had a very lengthy discussion with the patient. I have also offered to speak to his wife and parents who are very involved in his care. I believe the patient will come to a surgical intervention in the next year or so. He is scheduled to have another echocardiogram with Dr. Otto in 6 months. He is reaching absolute indication for surgical intervention at this point in time as he has moderate but symptomatic aortic insufficiency, reports increasing fatigue with exercise, currently can only play tennis as a doubles where he was playing singles before, but more importantly the left ventricle appears to be mildly dilated to 59 mm and in diastole and there is flow reversal in the descending thoracic aorta. The operative plan and goal for the surgery will be completion Bentall procedure. Of note is that the right coronary artery is very high and makes an acute bend. The left coronary arteries and the sinuses are both ample and I do not think are going to be an issue. The RVOT is close to the retrosternum and reentry I think it will be fine, but probably not going to be problematic, but either axillary or femoral artery and vein catheter-based access should be obtained. In addition, we have also discussed possibly replacing the entire calcified graft and considering debranching the innominate artery to facilitate future endovascular interventions if his arch or ascending aorta dilate over time. I do not think this is very likely given the fact that he is now nearly 16 years from his type A dissection and the arch and the descending thoracic aorta appear to be very stable. I have quoted the patient a 20% risk of morbidity including myocardial dysfunction, stroke, respiratory, renal, pulmonary, vascular, infectious, bleeding and arrhythmia complications. I believe he is fit and an excellent candidate for intervention when the timing is right and I believe we are nearing that point soon. The patient has finally decided to seek care at the University of Washington. I do not believe a Davidprocedure is an option for this patient given the fact that the valve is asymmetrical, the annulus is massively dilated and the patient is leaning toward a bioprosthetic rather than a mechanical valve, knowing that a future intervention is likely, most probably as a valve-in-valve TAVR. He has also had some discussions over the Inspiris Edwards valve versus the traditional Magna Ease valve if we proceed with Bio-Bentall. TIME-BASED EVALUATION: Duration of evaluation is 55 minutes. Thirty minutes were used in counseling. I told the patient if we proceed with surgery, will do it with my faculty colleague, Dr. Christopher Burke as we manage redo roots and completion Bentalls together to maximize outcomes and minimize risk.    

Gabriel S Aldea, MD at 7/30/2019  2:30 PM

Dictation #1MRN:U2347635 CSN:1838920829