Background and Objectives: Post-infarct ventricular septal rupture (PIVSR) continues to have significant morbidity and mortality, despite decreased prevalence. Impella and venoarterial extracorporeal membranous oxygenation (VA-ECMO) have been proposed as strategies to correct hemodynamic derangements and bridge patients to delayed operative repair when success rates are higher. This review places VA-ECMO and Impella support strategies in the context of bridging patients to successful PIVSR repair, with an additional case report of successful bridging with the Impella device. Materials and Methods: We report a case of PIVSR repair utilizing 14 days of Impella support. We additionally conducted a systematic review of contemporary literature to describe the application of VA-ECMO and Impella devices in the pre-operative period prior to surgical PIVSR correction. Expert commentary on the advantages and disadvantages of each of these techniques is provided. Results: We identified 19 studies with 72 patients undergoing VA-ECMO as a bridge to PIVSR repair and 6 studies with 11 patients utilizing an Impella device as a bridge to PIVSR repair. Overall, outcomes in both groups were better than expected from patients who were historically managed with medicine and balloon pump therapy, however there was a significant heterogeneity between studies. Impella provided for excellent left ventricular unloading, but did result in some concerns for reversal of shunting. VA-ECMO resulted in improved end-organ perfusion, but carried increased risks of device-related complications and requirement for additional ventricular unloading. Conclusions: Patients presenting with PIVSR in cardiogenic shock requiring a MCS bridge to definitive surgical repair continue to pose a challenge to the multidisciplinary cardiovascular team as the diverse presentation and management issues require individualized care plans. Both VA-ECMO and the Impella family of devices play a role in the contemporary management of PIVSR and offer distinct advantages and disadvantages depending on the clinical scenario. The limited case numbers reported demonstrate feasibility, safety, and recommendations for optimal management.
Symptoms attributable to a thoracic aortic aneurysm (TAA) are a separate indication for prophylactic repair, irrespective of aortic size. We present the case of a 56-year-old female with a history of a thoracic ascending aortic aneurysm (TAAA) and four other heart and arch vessel abnormalities who presented to us with chest pain radiating to her back. Computed Tomography and echocardiography showed no evidence of a dissection and revealed a maximal ascending aortic diameter of 4.2 cm. The patient subsequently underwent root-sparing ascending aortic and hemiarch replacement due to her threatening symptomatology. A focal dissection was discovered intraoperatively, resembling a similar case previously reported by our team.
Background The fate of the spared bicuspid aortic valve in patients undergoing ascending aortic aneurysm surgery is relatively unknown. Our institutional policy has been to replace all aortic valves with significant abnormalities, as evidenced by intraoperative transesophageal echocardiography or direct visual inspection. In this study, we elaborate our experience regarding the long‐term fate of preserved bicuspid aortic valves after ascending aortic aneurysm extirpation. Materials and Methods From 2000 to 2018, 407 consecutive ascending aortic aneurysm patients with concomitant bicuspid aortic valves underwent surgery by a single surgeon at our institution. Among these, 23 (5.65%) patients did not have their valve replaced, forming the study group. Postoperative and preoperative echocardiograms were compared to determine changes in valve function. Results Follow‐up was complete in 100% of patients. The average time between preoperative and postoperative echocardiograms was 4.50 ± 4.09 years (0.19‐15.63). Aortic stenosis or regurgitation changed from none to mild in 5 (21.7%) of patients, with an average echocardiographic interval follow‐up of 3.08 years, and from none to severe in 2 (8.7%), with an interval of 11.7 years. One patient required reoperation, including aortic valve replacement, during follow‐up. Conclusion Bicuspid aortic valves free of aortic stenosis or insufficiency before surgery and “healthy” appearing at surgery can safely be preserved.
Valvular heart disease is a common pathologic condition that affects 6 million people in the United States and more than 100 million worldwide. The most common valvular disorder is aortic stenosis. Current American and European guidelines recommend surgical management for symptomatic aortic stenosis with low risk of perioperative complications and endovascular intervention for high-risk patients with multiple comorbidities. Considering the increasing volume of aortic valve replacement (AVR) with biological valves, it is very important to select the appropriate anticoagulant after surgical AVR. In this article, we review the impact of anticoagulation on immediate and remote complications after AVR.
WRINKLED1 belongs to AP2/EREB family of transcription factors whose role has been well established in seed oil biosynthesis. The objective of the study was to trace the role of fiber related Gbwri1 in seed development and fatty acid biosynthesis. In this study, we isolated a transcript from elite fiber producing cotton (Gossypium barbadense), which is over-expressed in G. barbadense fibers as compared to G. hirsutum and G. arboreum. The putative protein encoded by this transcript exhibited homology in specific domains and protein structure with WRINKLED1 of Arabidopsis thaliana and was thus designated as Gbwri1. In this study, we investigated the functional homology of fiber elongation related Gbwri1 with fatty acid biosynthesis regulator Atwri1. Ectopic expression of Gbwri1 in wri1-3 mutant of A. thaliana was analyzed. In the transgenic lines of A. thaliana, Gbwri1 resumed the seed weight, seed area, and surface morphology to the wild type. Gbwri1 transformation rescued the wrinkled phenotype of wri1-3 mutants by resuming the expression of fatty acid biosynthesis genes biotin carboxyl carrier protein isoform 2 (bccp2) and keto-ACP synthase 1 (kas1). Moreover, the seedling development of transgenic lines on non-sucrose medium demonstrated that the Gbwri1 was able to regulate the supply of sucrose for normal seedling establishment. Our results showed that the transformation of Gbwri1 in A. thaliana wri1-3 mutant was able to complement wri1-3 impaired phenotype. Thus, Gbwri1 is involved in cotton fiber development and fatty acid biosynthesis in seeds. © 2021 Friends Science Publishers
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