Surgery Insight: the dilated ascending aorta—indications for surgical intervention

Repair of an ascending aortic aneurysm associated with an anomalous right coronary artery origin

BACKGROUND

Anomalous right coronary artery (RCA) origin off the ascending aorta, above the level of the sinus of Valsalva, is rare and can be associated with altered hemodynamics, decreased coronary perfusion, and presents unique considerations during intraoperative management in the surgical treatment of concomitant ascending aneurysmal disease.

CASE PRESENTATION

A 58-year-old female with prior symptomatic visceral aneurysmal rupture and cerebrovascular disease presented with a 5 cm ascending aortic aneurysm, elevated aortic index, and increased rupture risk factors. She was preoperatively diagnosed with an anomalous, high RCA origin off the ascending aorta 15 mm above the sinotubular junction. She underwent successful ascending aortic repair using a 28 mm Dacron hemiarch graft with reimplantation of an RCA button.

CONCLUSION

Our successful reconstructive surgical repair using an RCA button is effective management for high anomalous RCA take-offs from the ascending aorta and presents the first documented case of this rare coronary anomaly in the context of ascending aortic aneurysmal disease.

Vascularisation for cardiac tissue engineering: the extracellular matrix

Cardiovascular diseases present a major socio-economic burden. One major problem underlying most cardiovascular and congenital heart diseases is the irreversible loss of contractile heart muscle cells, the cardiomyocytes. To reverse damage incurred by myocardial infarction or by surgical correction of cardiac malformations, the loss of cardiac tissue with a thickness of a few millimetres needs to be compensated. A promising approach to this issue is cardiac tissue engineering. In this review we focus on the problem of in vitro vascularisation as implantation of cardiac patches consisting of more than three layers of cardiomyocytes (> 100 μm thick) already results in necrosis. We explain the need for vascularisation and elaborate on the importance to include non-myocytes in order to generate functional vascularised cardiac tissue. We discuss the potential of extracellular matrix molecules in promoting vascularisation and introduce nephronectin as an example of a new promising candidate. Finally, we discuss current biomaterial- based approaches including micropatterning, electrospinning, 3D micro-manufacturing technology and porogens. Collectively, the current literature supports the notion that cardiac tissue engineering is a realistic option for future treatment of paediatric and adult patients with cardiac disease.

Marfan syndrome

PURPOSE

To provide an overview of Marfan syndrome (MFS), including diagnostic criteria, genetic factors involved, emerging theories for treatment, a case study, and an overview of genetic counseling for individuals and families of those with MFS.

DATA SOURCES

Selected research, review, and clinical articles.

CONCLUSIONS

MFS is a connective tissue disorder with distinct physical characteristics. Recent advances in the field of genetics have traced this disease process to certain gene mutations. Affecting the optical, skeletal and cardiovascular systems, MFS can cause significant morbidity and mortality if left untreated. Close surveillance and early treatment are necessary to ensure a normal life span.

IMPLICATIONS FOR PRACTICE

It is important for the advanced practice nurse (APN) to be aware of the complications in those with MFS. Attentive surveillance can decrease mortality and morbidity associated with this syndrome. A multidisciplinary approach, utilizing the expertize of the APN, is necessary for comprehensive care.