Attempt at off-label balloon valvuloplasty post-dilation for intuity sutureless valve.

Alternatives to traditional aortic valve replacement now form part of the valve surgeon's armamentarium. Sutureless valves offer decreased bypass and crossclamp times, excellent maneuverability, and promising outcomes. We present a case of a sutureless aortic valve replacement for a late failed David procedure, complicated by postoperative development of severe paravalvular regurgitation. We attempted off-label balloon post-dilation to improve expansion of the valve, however paravalvular regurgitation persisted. The patient underwent subsequent aortic valve replacement using a mechanical valve and experienced no further paravalvular leak.

The Use of Branched Endografts for the Aortic Arch in the Endovascular Era.

The endovascular realm has steadily increased its footing in the treatment of the aorta and all of its territories since the foundational case in 1990 by Parodi. The aortic arch, however, continues to be one of the last bastions for treatment via open surgery, which remains the gold standard. Significant comorbidity and prior cardiac surgery prevent open surgery from being the only preferred option, allowing novel endovascular procedures to be considered. Since 1999, more advanced endovascular systems have been created by companies such as Cook Medical, Bolton Medical, Medtronic, Endospan, Gore Medical, and, recently, Kawasumi. The unique shape and angulation of the aortic arch often require the use of custom-made grafts, though arch reconstruction may also include in situ or back-table physician alterations to off-the-shelf devices. The goal of branched endografts is to exclude the aneurysm, while maintaining flow to supra-aortic trunk vessels. Technical success and device durability are limited by the physical constraints of the aortic arch, though greater experience may yield better patient outcomes. Typically, the initial stent-graft (SG) is introduced and deployed into the arch first. Bridging SG are then inserted via axillary or carotid access. Most often, the bridging SG extends from the innominate branch to the distal innominate, and from the left carotid branch to the left common carotid. The major concern is that manipulation of catheters and wires, both within the carotid arteries and aortic arch, create the potential for emboli leading to stroke and paraplegia. The development of endovascular-only techniques for aortic arch pathology will only increase with the aging population of the United States and associated accumulation of comorbidities, making open surgery too grave of a risk.

Hybrid Repair Techniques for Complex Aneurysms and Dissections Involving the Aortic Arch and Thoracic Aorta.

Aortic aneurysms involving the ascending aorta, aortic arch, and descending thoracic aorta have been a challenging entity to surgically treat for over 60 years. Despite the mortality of the disease, early open surgical procedures also had significant morbidity and mortality. The inherent risk in treating multiple anatomic segments simultaneously led to the innovation of the staged elephant trunk (ET) approach by Borst in 1983. To avoid the thoracotomy and associated complications related to the second stage of the procedure, an endovascular completion paradigm was begun by Volodos in 1991. This theoretical hybrid technique combinined shorter and less elaborate open supra-aortic trunk debranching with less invasive endovascular exclusion and has grown since then in terms of different approaches and case volume. The rise of thoracic endovascular aortic repair (TEVAR) combined with debranching bypass has allowed certain lesions to be treated without a large scale intrathoracic open surgical procedure. The complexity and extensiveness of certain lesions, however, has necessitated a hybrid approach such as the frozen elephant trunk (FET) and the standard ET with second stage TEVAR. The former has been used to treat multifocal degenerative aneurysms, chronic dissections with aneurysm, and acute extensive dissections. After conventional proximal aortic replacement, a stent-graft (SG) is delivered antegrade through the transected arch where it is sutured proximally and then "frozen" distally via endovascular means. The FET has the advantage of avoiding a second stage, but potentially introduces a greater rate of spinal cord ischemia compared to the standard elephant trunk. Improvements on the FET procedure have included the development of more advanced hybrid SG such as the Vascutek® Thoraflex™ Hybrid graft (Vascutek Ltd, Scotland, UK), which consists of a distal en,dograft sealed to a proximal four-branched Vascutek Gelweave™ Vascutek Ltd, Scotland, UK) and incorporated sewing collar. While open surgery continues to be a component of complex aortic arch aneurysms, the development of hybrid devices that can bridge the gap between open and endovascular surgery will continue to flourish.

Short-term outcomes in adult cardiac surgery in the use of del Nido cardioplegia solution.

OBJECTIVES: Del Nido cardioplegia in adult cardiac surgery has not been studied although it has been in common use as a "single" dose cardioplegia in pediatric heart surgery. We retrospectively assessed the short-term (in-hospital) clinical outcomes of patients undergoing aortic valve replacement (AVR) using del Nido cardioplegia solution, comparing it to conventional multi-dose whole blood cardioplegia. METHODS: We switched our cardioplegia protocol from conventional whole blood cardioplegia exclusively to del Nido solution in May 2011. In 2011, 240 consecutive patients underwent isolated AVR. One hundred and seventy-eight of them were operated on with the use of del Nido cardioplegia (del Nido group) and whole blood cardioplegia (conventional group) was used in the other 62 patients. Isolated AVR was chosen as a cohort because of its relative simplicity and the similarity of surgical techniques among surgeons. Propensity-score matching identified 54 matched pairs for analysis. RESULTS: The retrograde cardioplegia technique was used in 19 cases (35.2%) in the del Nido group and 52 cases (96.3%) in the conventional group (p<0.001). Mean cardiopulmonary bypass time and mean aortic cross-clamp time were significantly shorter in the del Nido group compared to the conventional group: 71 ± 16 min vs. 84 ± 28 min (p<0.01), 52 ± 14 min vs. 60 ± 16 min (p<0.01), respectively. Postoperative inotropic support was required in 11 patients (20.4 %) in the del Nido group and 13 patients (24.1 %) in the conventional group (p=0.82) with no statistical difference. No patient required a postoperative intra-aortic balloon pump and in-hospital mortality was 0% in both groups. There was no significant difference in postoperative complications between the two groups. CONCLUSIONS: Short-term outcomes in adult cardiac surgery using del Nido solution were acceptable and comparable to conventional multi-dose whole blood cardioplegia. The del Nido cardioplegia technique was associated with shortened cross-clamp times and less frequent utilization of the retrograde cardioplegia delivery technique.

Combinatorial binding of transcription factors in the pluripotency control regions of the genome.

The pluripotency control regions (PluCRs) are defined as genomic regions that are bound by POU5F1, SOX2, and NANOG in vivo. We utilized a high-throughput binding assay to record more than 270,000 different DNA/protein binding measurements along incrementally tiled windows of DNA within these PluCRs. This high-resolution binding map is then used to systematically define the context of POU factor binding, and reveals patterns of cooperativity and competition in the pluripotency network. The most prominent pattern is a pervasive binding competition between POU5F1 and the forkhead transcription factors. Like many transcription factors, POU5F1 is co-expressed with a paralog, POU2F1, that shares an apparently identical binding specificity. By analyzing thousands of binding measurements, we discover context effects that discriminate POU2F1 from POU5F1 binding. Proximal NANOG binding promotes POU5F1 binding, whereas nearby SOX2 binding favors POU2F1. We demonstrate by cross-species comparison and by chromatin immunoprecipitation (ChIP) that the contextual sequence determinants learned in vitro are sufficient to predict POU2F1 binding in vivo.

Circulating activated and effector memory T cells are associated with calcification and clonal expansions in bicuspid and tricuspid valves of calcific aortic stenosis.

We sought to delineate further the immunological significance of T lymphocytes infiltrating the valve leaflets in calcific aortic stenosis (CAS) and determine whether there were associated alterations in circulating T cells. Using clonotypic TCR ß-chain length and sequence analysis we confirmed that the repertoire of tricuspid CAS valves contains numerous expanded T cell clones with varying degrees of additional polyclonality, which was greatest in cases with severe calcification. We now report a similar proportion of clonal expansions in the much younger bicuspid valve CAS cases. Peripheral blood flow cytometry revealed elevations in HLA-DR(+) activated CD8 cells and in the CD8(+)CD28(null)CD57(+) memory-effector subset that were significantly greater in both bicuspid and tricuspid CAS cases with more severe valve calcification. Lesser increases of CD4(+)CD28(null) T cells were identified, principally in cases with concurrent atherosclerotic disease. Upon immunostaining the CD8 T cells in all valves were mainly CD28(null), and CD8 T cell percentages were greatest in valves with oligoclonal repertoires. T cell clones identified by their clonotypic sequence as expanded in the valve were also found expanded in the circulating blood CD28(null)CD8(+) T cells and to a lesser degree in the CD8(+)CD28(+) subset, directly supporting the relationship between immunologic events in the blood and the valve. The results suggest that an ongoing systemic adaptive immune response is occurring in cases with bicuspid and tricuspid CAS, involving circulating CD8 T cell activation, clonal expansion, and differentiation to a memory-effector phenotype, with trafficking of T cells in expanded clones between blood and the valve.

Modified bentall procedure with composite biologic grafts.

OBJECTIVES: The search continues for the ideal composite biologic graft (CBG). We have performed aortic root replacements with CBGs, initially with a stented pericardial valve in a Valsalva graft (Gen1) and subsequently with the stentless 3f valve (Gen2). The valve is sewn at the base of the graft sinuses, leaving residual proximal graft to sew separately to the left ventricular outflow tract. This allows for CBG size standardization and permits fabrication prior to bypass. We share our institutional experience and aim to show noninferiority of this technique, as well as discuss potential advantages. METHODS: The first 75 patients to receive each generation of CBG were identified and assessed retrospectively. Overall survival was assessed as our primary outcome. Various secondary outcomes were also analyzed, including operative times and short-term outcomes. RESULTS: Operative times were shorter for Gen2, with cardiopulmonary bypass times that were significantly reduced (126.3 ± 5.2 minutes vs. 157.6 ± 5.8 minutes for Gen1, p = 0.001) and aortic cross-clamp times that trended lower (98.2 ± 4.2 minutes vs. 107.7 ± 3.8 minutes for Gen1, p = 0.095). There were no postoperative myocardial infarctions (MIs) or aortic insufficiency graded 2+ or greater in either group. There was only one stroke in a Gen1 patient who recovered fully. Kaplan-Meier survival analysis showed a strong trend toward improved survival among Gen2 patients (p = 0.0566). CONCLUSIONS: Our experience with Gen2 CBG showed decreased operative times and a trend toward improved survival, though further patient follow-up and larger sample sizes in prospective studies are necessary. Further research with this CBG and additional improvements are warranted.

Total aortic arch replacement using a frozen elephant trunk device: Results of a 1-year US multicenter trial.

OBJECTIVE: In this prospective US investigational device exemption trial, we assessed the safety and 1-year clinical outcomes of the Thoraflex Hybrid device (Terumo Aortic) for the frozen elephant trunk technique to repair the ascending aorta, aortic arch, and descending thoracic aorta. METHODS: For the trial, which involved 12 US sites, 65 patients without rupture were recruited into the primary study group, and 9 patients were recruited into the rupture group. All patients underwent open surgical repair of the ascending aorta, aortic arch, and descending thoracic aorta in cases of aneurysm and/or dissection. The primary end point was freedom from major adverse events (MAE), defined as permanent stroke, permanent paraplegia/paraparesis, unanticipated aortic-related reoperation (excluding reoperation for bleeding), or all-cause mortality. RESULTS: In the primary study group, 2 patients were lost to follow-up at 1 year. Freedom from MAE at 1 year was 81% (51/63). Seven patients (11%) died (including 2 before 30 days or discharge), 3 patients (5%) suffered permanent stroke, and 3 (5%) developed permanent paraplegia/paraparesis. Twenty-six patients (41%) underwent planned extension procedures, including 22 endovascular procedures within a median of 122 (interquartile range, 64-156) days. In the aortic rupture group, 2 patients were lost to follow-up at 1 year. Freedom from MAE at 1 year was 71% (5/7). One patient (14%) died, 2 patients (29%) had permanent stroke, and none had permanent paraplegia/paraparesis. No extension procedures were performed in the rupture group. CONCLUSIONS: One-year results with the Thoraflex Hybrid device are acceptable. Long-term data are necessary to assess the durability of these repairs.

Designing a stentless valve conduit for use in a biological Bentall procedure.

Various modifications of the Bentall procedure have been described using mechanical valve conduits. A further modification, using a bioprosthetic valve, has grown in popularity as this prevents the need for lifelong anticoagulation. Additional innovation using a stentless bioprosthetic valve has the theoretical advantages of allowing for a larger bioprosthesis and an improved durability. The technical aspects involved in designing a stentless valve conduit for use in a biological Bentall procedure are described.

Total body irradiation in Australia and New Zealand: results of a practice survey.

Total body irradiation (TBI) is an important treatment modality for the preparation of patients for bone marrow transplants. It is technically challenging and the actual delivery may vary from clinic to clinic. Knowledge of the pattern of practice may be helpful for clinics to determine future practice. We carried out an email survey from April to September 2019 sending 48 TBI related questions to all radiotherapy clinics in Australia and New Zealand via the Australasian College of Physical Scientists in Medicine email distribution list. Centres not performing TBI were not expected to complete the survey and centres that had participated in a previous survey, or that were known to perform the treatment, were followed up if no response was received. Of a total of approximately 70 centres, 14 clinics responded to the survey. The vast majority of clinics use conventional lateral and/or anterior-posterior beams at extended SSD for TBI treatment delivery. However, treatment planning, ancillary equipment (used for immobilisation/modulation), beam energy and prescribed lung doses vary considerably-with some clinics delivering the prescription dose to the lungs and some aiming to deliver a lung dose which is lower than the prescription dose. Only one clinic reported using an advanced delivery technique with modulated arcs at extended SSD. Centres either said they had no access to outcome data or did not answer this question. Compared with an earlier survey from 2005, 3 clinics have lowered their linac dose rate and 7 are the same or similar. The TBI practice in Australia and New Zealand remains varied, with considerable differences in treatment planning, beam energy, accepted lung doses and delivered dose rates.

Matching extended-SSD electron beams to multileaf collimated photon beams in the treatment of head and neck cancer.

PURPOSE: Matching the penumbra of a 6 MeV electron beam to the penumbra of a 6 MV photon beam is a dose optimization challenge, especially when the electron beam is applied from an extended source-to-surface distance (SSD), as in the case of some head and neck treatments. Traditionally low melting point alloy blocks have been used to define the photon beam shielding over the spinal cord region. However, these are inherently time consuming to construct and employ in the clinical situation. Multileaf collimators (MLCs) provide a fast and reproducible shielding option but generate geometrically nonconformal approximations to the desired beam edge definition. The effects of substituting Cerrobend for the MLC shielding mode in the context of beam matching with extended-SSD electron beams are the subject of this investigation. METHODS: Relative dose beam data from a Varian EX 2100 linear accelerator were acquired in a water tank under the 6 MeV electron beam at both standard and extended-SSD and under the 6 MV photon beam defined by Cerrobend and a number of MLC stepping regimes. The effect of increasing the electron beam SSD on the beam penumbra was assessed. MLC stepping was also assessed in terms of the effects on both the mean photon beam penumbra and the intraleaf dose-profile nonuniformity relative to the MLC midleaf. Computational techniques were used to combine the beam data so as to simulate composite relative dosimetry in the water tank, allowing fine control of beam abutment gap variation. Idealized volumetric dosimetry was generated based on the percentage depth-dose data for the beam modes and the abutment geometries involved. Comparison was made between each composite dosimetry dataset and the relevant ideal dosimetry dataset by way of subtraction. RESULTS: Weighted dose-difference volume histograms (DDVHs) were produced, and these, in turn, summed to provide an overall dosimetry score for each abutment and shielding type/angle combination. Increasing the electron beam SSD increased the penumbra width (defined as the lateral distance of the 80% and 20% isodose contours) by 8-10 mm at the depths of 10-20 mm. Mean photon beam penumbra width increased with increased MLC stepping, and the mean MLC penumbra was approximately 1.5 times greater than that across the corresponding Cerrobend shielding. Intraleaf dose discrepancy in the direction orthogonal to the beam edge also increased with MLC stepping. CONCLUSIONS: The weighted DDVH comparison techniques allowed the composite dosimetry resulting from the interplay of the abovementioned variables to be ranked. The MLC dosimetry ranked as good or better than that resulting from beam matching with Cerrobend for all except large field overlaps (-2.5 mm gap). The results for the linear-weighted DDVH comparison suggest that optimal MLC abutment dosimetry results from an optical surface gap of around 1 +/- 0.5 mm. Furthermore, this appears reasonably lenient to abutment gap variation, such as that arising from uncertainty in beam markup or other setup errors.

Mitral Regurgitation Exacerbation Due to Sutureless Aortic Valve Replacement.

Sutureless aortic valves are increasingly used for aortic valve replacement (AVR) with excellent outcomes. Implantation requires device expansion in a subannular position within the native aortic root. We report a patient with severe aortic stenosis who received a Perceval sutureless AVR (LivaNova, London, United Kingdom), resulting in a competent prosthesis with an absence of paravalvular leak and aortic regurgitation. However, this implantation resulted in the exacerbation of mitral regurgitation. The sutureless valve required explantation, and a traditional sutured valve was subsequently implanted, which returned the mitral regurgitation to baseline. We discuss a potential etiology of this sutureless AVR-specific complication.

CD90 Identifies Adventitial Mesenchymal Progenitor Cells in Adult Human Medium- and Large-Sized Arteries.

Mesenchymal stem cells (MSCs) reportedly exist in a vascular niche occupying the outer adventitial layer. However, these cells have not been well characterized in vivo in medium- and large-sized arteries in humans, and their potential pathological role is unknown. To address this, healthy and diseased arterial tissues were obtained as surplus surgical specimens and freshly processed. We identified that CD90 marks a rare adventitial population that co-expresses MSC markers including PDGFRα, CD44, CD73, and CD105. However, unlike CD90, these additional markers were widely expressed by other cells. Human adventitial CD90+ cells fulfilled standard MSC criteria, including plastic adherence, spindle morphology, passage ability, colony formation, and differentiation into adipocytes, osteoblasts, and chondrocytes. Phenotypic and transcriptomic profiling, as well as adoptive transfer experiments, revealed a potential role in vascular disease pathogenesis, with the transcriptomic disease signature of these cells being represented in an aortic regulatory gene network that is operative in atherosclerosis.

Survival after heart transplantation is not diminished among recipients with uncomplicated diabetes mellitus: an analysis of the United Network of Organ Sharing database.

BACKGROUND: This study compares posttransplantation outcomes of survival and morbidity among recipients with and without diabetes mellitus (DM). METHODS AND RESULTS: The United Network of Organ Sharing (UNOS) provided deidentified patient-level data. Primary analysis focused on 20,412 first-time heart transplant recipients aged > or = 18 years who underwent transplantation between January 1, 1995, and December 31, 2005. To determine severity of DM, DM recipients were stratified by their aggregate number of diabetes-related complications (DRCs), including pretransplantation history of renal failure (serum creatinine = 2.5 mg/dL), peripheral vascular disease, cerebrovascular accident, and severe obesity (body mass index > or = 35 kg/m2). Kaplan-Meier analysis was performed to compare time to event. Although posttransplantation survival was significantly better (P<0.001) among patients without DM (median survival 10.1 years) than among those with DM (9.0 years), survival did not differ (P=0.08) between those without DM (10.1 years) and those with uncomplicated DM (0 DRCs; 9.3 years). Among those with DM, survival was worse with each additional DRC: 0 DRC, 9.3 years; 1 DRC, 6.7 years; and > or = 2 DRCs, 3.6 years. Although acute rejection and transplant coronary artery disease-free survival did not differ between groups, renal failure and severe infection-free survival were worse in those with DM and were inversely related to the number of DRCs. CONCLUSIONS: Posttransplantation survival among patients with uncomplicated DM was not significantly different than that among nondiabetics. However, when stratified by disease severity, recipients with more severe diabetes had significantly worse survival than nondiabetics. Therefore, although DM alone should not be a contraindication to heart transplantation, given the critical shortage of transplantable organs, maximal benefit may be achieved by exploring alternative treatment options in patients with severe DM. These include use of high-risk transplant lists and destination therapy.

Transcatheter aortic valve replacement in patients with critical aortic stenosis: rationale, device descriptions, early clinical experiences, and perspectives.

The development of lesser invasive transcatheter techniques for aortic valve replacement (AVR) to treat high surgical risk patients with severe aortic stenosis (AS) has engendered controversy among traditional cardiovascular therapists. Presently, there are two catheter-based treatment systems (the Cribier-Edwards Aortic Bioprosthesis and the CoreValve Revalving System) utilizing either a balloon-expandable or a self-expanding stent (or cage) platform which unfolds a pericardial tissue valve within the displaced diseased aortic valve. After ex vivo durability testing and animal studies, several clinical registries with these transcatheter AVR systems in almost 300 patients worldwide have demonstrated the following: (1) good acute hemodynamic performance with reduction in mean aortic valve gradients to <10 mm Hg; (2) frequent para-valvular regurgitation, which has improved with self-expanding devices and the use of larger (26 mm) valve sizes; (3) acceptable periprocedural (30-day) mortality (<10%) with the newest generation devices and improved operator techniques. Enlightened interdisciplinary treatment teams incorporating surgeons, interventionalists, and medical therapists as well as rigorously conducted randomized clinical trials will be required to determine if these innovative transcatheter AVR approaches will represent a viable therapy for high-risk patients with severe AS in the future.

Viral gene transfer of the antiapoptotic factor Bcl-2 protects against chronic postischemic heart failure.

BACKGROUND: Apoptosis secondary to acute ischemia and chronic remodeling is implicated as a mediator of heart failure. This study was designed to assess the effect of in vivo viral gene transfer of the anti-apoptotic factor Bcl-2 to block apoptosis and preserve ventricular geometry and function. METHODS AND RESULTS: In a rabbit model of regional ischemia followed by reperfusion, an experimental group treated with adeno-Bcl-2 was compared with a control group receiving empty vector adeno-null. Function was assessed by echocardiography, and sonomicrometry of the border zone was compared with the normal left ventricle (LV). Animals were killed at 6 weeks, and an additional group was killed after 3 days to see whether virus administration conferred an immediate effect. Animals that were administered Bcl-2 maintained higher ejection fractions at 2, 4, and 6 weeks compared with controls. Sonomicrocrystals demonstrated greater protection of border zone fractional shortening at 6 weeks. The Bcl-2 group had superior preservation of LV geometry with less ventricular dilatation and wall thinning. There was also reduced apoptosis compared with the controls. Finally, in the animals killed at 3 days, no functional difference was observed between the Bcl-2 and control groups. CONCLUSIONS: Gene transfer of Bcl-2 preserves LV function after ischemia despite the absence of an observed acute protective effect. The benefit at 6 weeks is postulated to result from a Bcl-2-mediated reduction in apoptosis and ventricular remodeling. Adeno-Bcl-2 administration offers a potential strategy to protect the heart from late postischemic heart failure.

Simplified placement of multiple artificial mitral valve chords.

BACKGROUND: The use of artificial chords for the replacement of diseased mitral valve chordae and the correction of anterior and posterior leaflet prolapse is well described, although it is infrequently applied because of technical challenges. METHODS: A simplified approach to attaching the new chords to a single papillary muscle base within the left ventricle has been reported, and we present a series of 13 patients with moderate-severe mitral regurgitation (MR) who underwent chordal replacement using this improved technique. RESULTS: The MR grade by echocardiogram improved from 3.7 +/- 0.4 preoperatively to 1.0 +/- 0.8 postoperatively. All patients were doing well at a mean follow-up interval of 285 +/- 62 days. CONCLUSION: Chordal replacement for both anterior and posterior leaflet prolapse is an effective treatment for MR when combined with standard mitral valve repair techniques. The authors' technique of determining proper chordal height and placing multiple chordae is also discussed.

Blocking the development of postischemic cardiomyopathy with viral gene transfer of the apoptosis repressor with caspase recruitment domain.

OBJECTIVES: Apoptosis caused by acute ischemia and subsequent ventricular remodeling is implicated as a mediator of heart failure. This study was designed to assess the efficacy of in vivo viral gene transfer of the antiapoptotic factor apoptosis repressor with caspase recruitment domain to block apoptosis and preserve ventricular geometry and function. METHODS: In a rabbit model of regional ischemia followed by reperfusion, an experimental group treated with adenovirus-apoptosis repressor with caspase recruitment domain was compared with empty vector adenovirus-null controls. Cardiac function was assessed by echocardiography and sonomicrometry of the border zone compared with the normal left ventricle. Animals were killed at 6 weeks with measurements of ventricular geometry and apoptosis. RESULTS: Animals with the apoptosis repressor with caspase recruitment domain (ARC group) maintained higher ejection fractions at 4 and 6 weeks, and sonomicrometry demonstrated greater protection of border zone fractional shortening at 6 weeks compared with the control group. The ARC group maintained superior preservation of left ventricular geometry with less ventricular dilation and wall thinning. Finally, there was reduced apoptosis in the rabbits treated with apoptosis repressor with caspase recruitment domain compared with the controls. CONCLUSIONS: Gene transfer of apoptosis repressor with caspase recruitment domain preserves left ventricular function after ischemia. The benefit at 6 weeks is postulated to result from an apoptosis repressor with caspase recruitment domain-mediated reduction in apoptosis and ventricular remodeling. Adenovirus-apoptosis repressor with caspase recruitment domain administration offers a potential strategy after myocardial ischemia to protect the heart from late postischemic cardiomyopathy.

Left ventricular assist device for right side assistance in patients with transposition.

Right (systemic) ventricular dysfunction is well described after Senning operations for transposition of the great arteries, and patients with congenitally corrected transposition of the great arteries. Transplantation remains the only definitive therapy for refractory heart failure, however patients may deteriorate clinically prior to the availability of a donor heart. This report details the implantation of a TCI Heartmate (Thoratec Corp., Pleaston, CA) as a morphologic right ventricular assist device to bridge these patients to transplantation.