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Objective: Extensive arterial grafting with the radial artery in elderly patients is still debated, because of the reduced life expectancy and the supposedly higher periprocedural morbidity caused by an accelerated atherosclerosis of arterial grafts in elderly patients, which might hamper functional results., Methods: We reviewed our experience with patients undergoing radial artery myocardial revascularization (coronary artery bypass grafting) between January 2003 and December 2006, divided into 2 groups: elderly patients (> or =70 years, group A) and young patients (< or =60 years, group B). Hospital outcome and transit-time flowmetric maximum and mean flow, pulsatility index, and graft flow reserve were compared. Results were stratified by target vessel, surgical technique, and subgroups at risk., Results: Hospital outcome, troponin I levels, and echocardiographic segmental kinetics were comparable in the 2 groups. Stratifying patients for target vessels, no differences in radial artery transit-time flowmetric results were recorded between the 2 groups either on-pump or off-pump, as free grafts or Y grafts, or in diabetic patients and hypertensive patients. Although graft flow reserve was significantly improved in all patients (P < .05 in the young and elderly groups, regardless of the target vessel, the surgical technique, and the comorbidities), graft flow reserve of radial artery grafts was comparable between elderly and young patients., Conclusions: Radial artery coronary artery bypass grafting showed similar transit-time flowmetric functional results in elderly and young patients, regardless of the target vessel, the use or avoidance of cardiopulmonary bypass, the construction of proximal anastomoses, and the presence of comorbidities. These data explain the reported better results of arterial revascularization in the elderly and suggest an increase in extensive radial artery grafting in the last decades of life.

Objective: We sought to evaluate if patients with proximal critical circumflex (CX) lesions did better with single SV-CABG on the best obtuse marginal (OM), or with sequential SV-CABG on two OM branches., Design: Ninety patients were prospectively randomised to single SV-CABG on the best OM (sSV-CABG-45 patients; Group A) or to sequential SV-CABG on 2 OM (seqSV-CABG 45 patients; Group B). Transit-time flowmetry (TTF), and graft flow reserve were evaluated. Recurrent angina, acute myocardial infarction, readmission for coronary reintervention were defined "treatment failure" during follow-up., Results: SeqSV-CABG showed better intraoperative maximum (119.1+/-57.5 ml/min vs. sSV-CABG 62.4+/-29.6; p=0.001), mean (56.3+/-31.5 ml/min vs. 30.8+/-12.8; p=0.0001), minimum flow (22.8+/-9.2 ml/min vs. 11.8+/-8.9; p=0.001) and P.I. (0.71+/-0.4 vs.1.46+/-0.9; p=0.006). Graft flow reserve also proved to be higher (95.4+/-29.7 ml/min mean flow vs. sSV-CABG 42.3+/-15.2 ml/min mean flow; p=0.0001; flow reserve 1.72+/-0.99 vs 1.32+/-1.09; p=0.001) as well as freedom from treatment failure (97.5+/-0.5% vs 88.7+/-0.4%; p=0.05)., Conclusions: SeqSV-CABG showed higher TTF flows, with no incremental risk for perioperative morbidity. Higher flows and graft flow reserve may allow lower treatment failure at mid-term follow-up.

Background: Linear flow during cardiopulmonary bypass is considered a potential mechanism of lung damage in patients with chronic obstructive pulmonary disease (COPD). We evaluated differences in lung function of patients with COPD undergoing preoperative intraaortic balloon pumping (IABP), between linear flow during cardiopulmonary bypass (IABP-off) and maintenance of pulsatile flow (IABP-on at automatic 80 bpm) during cardioplegic arrest., Methods: Fifty patients with COPD undergoing preoperative IABP were randomized between January 2004 and July 2005 to receive nonpulsatile cardiopulmonary bypass with IABP discontinued during cardioplegic arrest (25 patients; group A), or IABP-induced pulsatile cardiopulmonary bypass (25 patients; group B). Hospital outcome, need for noninvasive ventilation, oxygenation (partial pressure of oxygen, arterial to fraction of inspired oxygen [Pao(2)/Fio(2])), respiratory system compliance, and scoring of chest radiographs were compared., Results: There were no hospital deaths, no IABP-related complications, and no differences in postoperative noninvasive ventilation (group A: 6 of 25, 24.0% vs group B: 5 of 25, 20%; p = not significant [NS]). One patient in both groups developed pneumonia (p = NS). Intensive care and hospital stay were comparable (p = NS). Group B showed lower intubation time (8.3 +/- 5.1 hours versus group A: 13.2 +/- 6.0; p = 0.001), better Pao(2)/Fio(2) at aortic declamping (369.5 +/- 93.7 mm Hg vs 225.7 +/- 99.3; p = 0.001) at admission in intensive care (321.3 +/- 96.9 vs 246.2 +/- 109.7; p = 0.003), and at 24 hours (349.8 +/- 100.4 vs 240.8 +/- 77.3; p = 0.003). The respiratory system compliance was better in group B at the end of surgery (56.4 +/- 8.2 mL/cm H(2)O vs 49.4 +/- 7.0; p = 0.004) and 8 hours postoperatively (76.4 +/- 8.2 vs 59.4 +/- 7.0; p = 0.0001), as well as scoring of chest radiograph at intensive care admission (0.20 +/- 0.41 vs 0.38 +/- 0.56; p = 0.05) and on the first day (0.26 +/- 0.45 vs 0.50 +/- 0.67; p = 0.025)., Conclusions: Automatic 80 bpm IABP during cardioplegic arrest preserves lung function in patients with COPD.

Background: Myocardial infarction remains a devastating complication after coronary revascularization. Although electrocardiography (ECG) and echocardiography suggest transmural infarction, myocardial damage and the quality of myocardial protection are not recognized unless troponin I (TnI) is assessed. Determinants and prognosis of TnI elevation after coronary artery bypass grafting (CABG) were evaluated., Methods: Data of 776 consecutive patients undergoing CABG between January 2002 and January 2004 were prospectively exposed to univariate and multivariate analysis. We evaluated the prognosis of patients with all the ECG, echocardiographic, and biochemical criteria for acute myocardial infarction and that of patients with only TnI elevation. Twelve-month follow-up survival and freedom from cardiac events (FCE) were accomplished., Results: Troponin I greater than 3.1 mug/L at 12 hours was detected in 6.9% of the population, and correlated with lower in-hospital (p < 0.001) and follow-up survival (p = 0.00001), and lower FCE (p = 0.0009). Twenty-one (38.8%) of these fulfilled ECG-echocardiographic criteria (p = 0.05), demonstrating higher TnI values at 12 (p = 0.001), 24 (p = 0.01), 48 (p = 0.01), and 72 (p = 0.04) hours, prolonged ventilation time (p = 0.001), higher in hospital mortality (p = 0.003), lower follow-up survival (p = 0.023), and lower FCE (p = 0.0084). A EuroSCORE greater than 6, ongoing unstable angina, aortic cross-clamp time greater than 90 minutes, cardiopulmonary bypass time greater than 180 minutes, incomplete revascularization, and intraoperative intraaortic balloon pump were independent predictors of myocardial damage (MD) at multivariate analysis. Combined antegrade and retrograde cardioplegia and postoperative enoximone infusion were associated with a lower TnI elevation., Conclusions: Troponin I greater than 3.1 mug/L at 12 hours defines perioperative MD. Associated ECG-echocardiographic criteria indicate acute myocardial infarction and anticipate a worse outcome. Identification of predictors for MD is important to develop preventative strategies, as antegrade plus retrograde cardioplegia and enoximone infusion.

Background: Although accepted worldwide as the first-choice conduit for myocardial revascularization (coronary artery bypass graft surgery), it is still questionable if left internal mammary arteries (LIMAs) do better as pedicled or skeletonized grafts. Recent reports have suggested that the skeletonized technique improves the outcomes. Methods: In all, 516 consecutive isolated coronary artery bypass graft surgery patients admitted between January 2003 and February 2007 were grouped according to the harvesting technique of LIMAs (387 pedicled versus 129 skeletonized). Intraoperative transit time flow results, hospital outcome, perioperative troponin I leakage, and echocardiographic results were analyzed. Maximum, mean, and minimum flows, pulsatility index, and graft flow reserve were stratified according to the type of surgery (on pump and off pump) and subgroups at risk (severe left ventricular hypertrophy). Results: The transit time flow results were unsatisfactory in 4 patients (0.8%), all 4 of whom underwent redo anastomosis. Maximum, mean, and minimum flows and pulsatility index values were comparable between skeletonized and pedicled LIMAs (p = not significant), for both on-pump and off-pump surgeries (p = not significant). Graft flow reserve was comparable between the two groups (p = not significant), as well as transit time flow results in severe ventricular hypertrophy. Troponin leakage, postoperative echocardiographic recovery, and hospital outcome were comparable between the two groups (p = not significant at all time points). Only superficial wound complications proved higher in the pedicled group (2.6% versus skeletonized group: 0%; p = 0.05). Conclusions: Pedicled LIMA carries a higher risk for minor wound complications. Neverthless, the two techniques showed similar in-vivo functional behavior and hospital outcome. Therefore, there is no reason to prefer one technique over the other. [Copyright &y& Elsevier]