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Objective(s): We conducted a meta-analysis of propensity score-matching (PSM) studies comparing long-term survival of patients receiving right internal thoracic artery (RITA) versus radial artery (RA) as a second arterial conduit for coronary artery bypass grafting., Methods: A literature search was conducted using MEDLINE, EMBASE, and Web of Science to identify relevant articles. Primary endpoint was long-term mortality. Secondary endpoints were operative mortality, incidence of sternal wound infection, and repeat revascularization. Binary events were pooled using the DerSimonian and Laird method. For time-to-event outcomes, estimates of log hazard ratio (HR) and standard errors obtained were combined using the generic inverse-variance method., Results: A total of 8 PSM studies were finally selected including 15,374 patients (RITA, 6739; RA, 8635) with 2992 matched pairs for final comparison. Mean follow-up time ranged from 45 to 168 months. When compared with RA, RITA was associated with a lower risk reduction of late death (HR, 0.75; 95% confidence interval [CI], 0.58-0.97; P = .028) and repeat revascularization (HR, 0.37; 95% CI, 0.16-0.85; P = .03). On the other hand, RITA did not increase operative mortality (odds ratio [OR], 1.53; 95% CI, 0.97-2.39; P = .07). RITA was associated with an increased risk of sternal wound complication when pedicled harvesting was used (OR, 3.18; 95% CI, 1.34-7.57), but not with skeletonized harvesting (OR, 1.07; 95% CI, 0.67-1.71)., Conclusions: The present PSM data meta-analysis suggests that the use of RITA compared with RA was associated with superior long-term survival and freedom from repeat revascularization, with similar operative mortality and incidence of sternal wound complication when the skeletonized harvesting technique was used., (Copyright © 2016 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: The purpose of this study was to assess the prognostic effect of coronary collaterals on early and midterm clinical outcomes in patients undergoing first time isolated off-pump coronary artery bypass (OPCAB) surgery., Methods: Preoperative angiograms from 861 patients were evaluated to assess the presence and extent of coronary collaterals (Rentrop classification). Coronary collaterals (CC) were present in 485 (56.3%) patients (CC group). Patients with coronary collaterals had a higher incidence of preoperative myocardial infarction, lower ejection fraction, and higher Parsonnet scores compared with patients without coronary collaterals (no-CC group)., Results: Coronary collaterals were associated with myocardial protection during OPCAB surgery, as evidenced by a significantly lower incidence of intraoperative ST-segment changes (propensity matched cohort, p = 0.008). No other statistically significant differences in in-hospital outcomes were detected between the two groups. Five years after surgery patient survival was 84.8% (95% confidence interval [CI] 79.4 to 88.8) in the CC group compared with 89.2% (95% CI 84.4 to 92.6) in the no-CC group (p = 0.48). Cardiac-related event-free survival after 5 years was 50.6% (95% CI 43.5 to 57.3) in the CC group and 54.5% (95% CI 47.1 to 61.4) in the no-CC group (p = 0.96), with no significant differences between both groups, before or after risk adjustment, or when comparing propensity-matched cohort., Conclusions: Although patients with coronary collaterals had more extensive coronary artery disease, poor left ventricular function, and more cardiac risk factors than patients without collaterals, the early and midterm clinical outcome after OPCAB surgery was comparable between the two groups.

Background: Surgery of the ascending aorta with or without arch is being performed in an increasingly elderly population with risks of coexisting coronary artery disease., Aim: To define specific groups requiring coronary artery bypass graft (CABG) and to analyse the influence of concomitant CABG on outcome., Design: Over a 10-year period in a single institution, 296 consecutive procedures on the ascending aorta with or without arch were carried out in 291 patients. CABG was required in 42 (14.2%) procedures. In 24 (57%) patients, CABG was planned preoperatively and in 18 (43%) patients, on a salvage basis., Results: In-hospital mortality for patients undergoing concomitant CABG was higher (21.4% v 11%, p<0.06). Adjusting for baseline and operative characteristics, this was attributable to operative priority, and was not a consequence of concomitant CABG (adjusted OR 0.30, 95% CI 1.1 to 8.31; p = 0.48). However, in-hospital mortality was significantly higher when CABG was performed as salvage rather than as a planned procedure (38.9% v 8.9%, p = 0.025), and this difference remained after adjusting for confounding variables (adjusted OR 16.2, 95% CI 1.03 to >200; p = 0.047). The 3-year survival was significantly lower with concomitant CABG (59% v 81.9%, p<0.001)., Conclusions: In association with surgery of the ascending aorta with or without arch planned concomitant CABG did not entail any added operative risk. However, salvage CABG, which occurred almost exclusively in association with emergency cases, was associated with a higher early mortality. Patients needing concomitant CABG had worse survival at 3 years compared with those requiring isolated surgery of the ascending aorta with or without arch.

Background: The purpose of this study was to investigate the effect of preexisting atrial fibrillation on early and midterm clinical outcome in patients undergoing coronary surgery., Methods: All elective patients undergoing coronary artery bypass grafting surgery between April 1996 and September 2002 were investigated. Patients were grouped according to their preoperative cardiac rhythm: sinus rhythm (SR) or preexisting atrial fibrillation (AF). In-hospital clinical outcomes and 5-year patient survival and cardiac-related event-free survival were compared using regression methods to adjust for differences between the groups. In all, 5,092 patients were identified, 175 (3.4%) with a history of preexisting AF. These patients were older (median, 64 versus 68 years) and had higher Parsonnet scores (median, 4 versus 8) than the SR group. Previous myocardial infarction, cerebrovascular accident, hypertension, diabetes mellitus, renal impairment, peripheral vascular disease, ejection fraction less than 50%, previous surgery, congestive heart failure, and use of angiotensin-converting enzyme inhibitors were also more common in the AF group., Results: There were 60 in-hospital deaths (1.2%), with no difference between the two groups (odds ratio 1.02, 95% CI: 0.35 to 2.94). Atrial fibrillation patients were more likely to need intraoperative inotropes (p = 0.044), postoperative intra-aortic balloon pump (p = 0.038), and were less likely to be discharged within 6 days (p = 0.017). The risk of death in the 5 years after surgery was higher in the AF group (relative risk 1.49, 95% CI: 1.06 to 2.08, p = 0.020). In the AF group, 109 (62.2%) patients were cardioverted spontaneously by surgery, but only 69 (39.4%) remained in SR until discharge. Longer-term rhythm follow-up data were available for 48 of these 69 patients, and only 36 remained in SR at a median follow-up of 1,483 days (interquartile range, 1,120 to 2,209). Spontaneous conversion to SR after surgery did not confer a midterm survival benefit (p = 0.91)., Conclusions: Preexisting AF in patients undergoing coronary artery bypass graft surgery is not associated with increased in-hospital mortality and major morbidity; however, it is a risk factor for reduced 5-year survival. Spontaneous cardioversion to SR during surgery is transient in the majority of patients and is not associated with midterm survival benefit.

Aim: A variety of chest radiograph abnormalities are recognized after coronary artery bypass grafting (CABG). This study analyzes the appearance of preoperative and postoperative chest radiographs in two groups of patients undergoing myocardial revascularization with or without the use of cardiopulmonary bypass (CPB)., Methods: Chest radiographs (preoperative and at 1 day, 6 days and 6 to 8 weeks post operatively) were analyzed according to a detailed protocol in cases of conventional CABG on CPB (n=60) or off-pump coronary artery bypass (OPCAB) (n=60) surgery. On each film 17 different major potential postoperative abnormalities were analyzed., Results: Clinical findings were similar in the two groups. Patients undergoing OPCAB surgery had decreased blood loss, decreased red cell and platelet transfusion, significantly lower intubation time and required less postoperative inotropic support compared with patients undergoing CPB. The CPB group had a significantly higher incidence of left band atelectasis than the OPCAB group (37.6% vs 17.5%, p=0.01) at 6 days postoperatively. There was no other statistically significant difference in any of the 16 remaining major chest radiograph findings between the two groups., Conclusion: Although OPCAB surgery is associated with improved clinical outcome compared with conventional CABG surgery, the analysis of postoperative chest radiographs demonstrated only a minor benefit as shown by a reduced degree of left band atelectasis in the OPCAB group.

This review considers whether coronary artery bypass grafting (CABG) performed on the beating heart (off-pump or OPCAB) will supersede conventional CABG utilizing cardiopulmonary bypass (CPB) and cardioplegic arrest as the accepted gold standard. Randomized controlled trials, case-matched reports and observational studies have demonstrated lower morbidity in off-pump compared to conventional on-pump CABG with equivalent mid-term outcome at a significantly lower cost. Patients referred for surgical revascularization are increasingly elderly with more co-morbid medical conditions and elimination of CPB-related morbidity in these groups is associated with the most pronounced improvements in outcome, at least in observational studies. Long-term outcome, and in particular, long-term graft patency following OPCAB has not yet been reported. A barrier to the more widespread acceptance of OPCAB is the poor provision for training in off-pump techniques although structured cardiothoracic training that includes OPCAB surgery has been shown to be both possible and safe for patients. The evidence available to date therefore strongly supports the assertion that OPCAB may become the new gold standard in surgical revascularization. Whether it will ultimately replace conventional CABG, however, is dependent on the results of long-term patency studies and the wider development of adequate training programmes.

High thoracic epidural anaesthesia has recently been proposed to perform surgical revascularisation with arterial grafts in awake patients. However, in high-risk patients with associated co-morbidity it is not always possible to perform complete arterial revascularisation. A technique which combines thoracic epidural and selective lumbar subarachnoid block is described, allowing harvesting of saphenous vein and complete surgical revascularisation in awake patients.

Background: Patients presenting with severe left ventricular (LV) dysfunction undergoing coronary artery surgery are at increased risk of perioperative morbidity and mortality. The present study investigated early and midterm outcomes in a consecutive series of patients with severe LV dysfunction undergoing coronary surgery at our institution., Methods: Data on 5,195 consecutive patients undergoing coronary artery bypass grafting (CABG) alone (in-hospital mortality 1.35%) from April 1996 to August 2002 were prospectively recorded in the Patient Analysis and Tracking System. Two hundred and fifty patients (median age 65 years [interquartile range, 57 to 70]) with preoperative left ventricular ejection fraction less than 30% (74 off pump; 29.6%) were identified and early and midterm clinical outcomes analyzed. Propensity scores were used to take account of the imbalance in the distribution of prognostic factors between the on-pump and off-pump groups., Results: Patients undergoing on-pump surgery were less likely to have current congestive heart failure, insulin-dependent diabetes, a history of hypertension, have had gastrointestinal tract surgery or an ulcer, or unstable angina. They had on average lower Parsonnet scores and New York Heart Association and Canadian Cardiovascular Score ratings. However they were more likely to have more extensive coronary artery heart disease and to require more grafts than those undergoing off-pump surgery. After adjustment for consultant team and propensity scores no differences between groups with regard to in-hospital mortality and morbidity were found. The only in-hospital outcome to show a significant difference after adjustment was the need for intraoperative inotropic support, which was higher in the on-pump group (odds ratio 5.1; 95% confidence interval 2.55 to 10.2; p < 0.001)). The median follow-up times for the on- and off-pump groups were 3.4 years and 1.4 years respectively. Three-year survival was higher with on-pump surgery (87% on-pump versus 73% off-pump) but this difference did not reach statistical significance after adjustment for prognostic variables (hazard ratio 0.54, 95% confidence interval 0.22 to 1.26, p = 0.16)., Conclusions: In-hospital mortality and morbidity in patients presenting with severe LV dysfunction is low with comparable results with both on- and off-pump coronary artery surgery. Midterm clinical outcome is encouraging and seems to justify surgical revascularization for this high-risk group of patients.

Background: Homocysteine (Hcy) is an independent risk factor for coronary artery disease, but there are no reports on Hcy levels in patients undergoing coronary artery bypass graft (CABG) surgery. Interactions between Hcy and copper may mediate the vasculopathic impact of Hcy, and this may play a role in vein graft failure. The aim of this study was to assess the perioperative levels of Hcy, copper, ceruloplasmin (CP), folate, and vitamin B12 in patients undergoing myocardial revascularization surgery., Methods: Blood samples were taken from 55 consecutive patients undergoing elective conventional CABG (43 male; mean age, 63.2 +/- 5.2 years) 1 day preoperatively and postoperatively at 1 day, 6 days, and 6 weeks. Hcy, copper, CP, red cell folate, vitamin B12, creatinine, and C-reactive protein (CRP) were then measured using standard clinical chemistry methods. The same protocol was applied to 10 patients (7 male; mean age, 63.3 +/- 5.2 years) undergoing off-pump coronary artery bypass (OPCAB) surgery., Results: In the conventional CABG group, there were significant increases in the plasma concentrations at 6 days and 6 weeks postoperatively of Hcy (from 10.1 to 11.6 and 13.5 micromol/L, respectively), plasma copper (from 13.5 to 20.3 and 18.5 micromol/L), and serum ceruloplasmin (from 0.3 to 0.41 and 0.44 g/L). CRP and vitamin B12 were elevated at 6 days but not 6 weeks after the operation. In contrast, red cell folate and creatinine were not significantly changed. The subgroup analysis for the OPCAB patients showed the same trend as for the conventional group., Conclusions: Coronary surgery precipitates a significant and sustained increase in the blood concentrations of Hcy and copper, which is not due to a decrease in folate and vitamin B12, altered renal function, or inflammation. Further studies are required to establish whether the concomitant increase in Hcy and copper plays an etiological role in vein graft disease.

Background: Off-pump coronary artery bypass surgery has been demonstrated to reduce morbidity in elective patients. However, high-risk patients might benefit the most from this surgical procedure. Our goal was to investigate the effectiveness of on-pump and off-pump coronary artery bypass surgery on early clinical outcome in a consecutive series of overweight patients., Methods and Results: From April 1996 to April 2001, data on 4321 patients undergoing coronary surgery (mortality 1.4%) were prospectively entered into the Patient Analysis and Tracking System. Data were extracted for all patients with a body mass index > or =25 kg/m(2). A risk-adjusted analysis was performed to assess the effect of surgical technique in the whole overweight cohort. 2844 patients were identified (2261 male, median age 63, interquartile range 56 to 68). Patients undergoing on-pump surgery (2170, 76.3%) were less likely than those undergoing off-pump surgery to have hypercholesterolemia or left main stem disease and were, on average, less obese. However, they were more likely to have unstable angina and to have had a previous myocardial infarction, and they had more extensive coronary disease and received more grafts (all P<0.05). Unadjusted analyses, taking account only of consultant team, showed significant benefits of off-pump surgery in terms of hospital deaths, arrhythmias, inotropic use, use of intra-aortic balloon pump, blood loss, transfusion requirement, postoperative hemoglobin, chest infections, neurological complications, intensive care unit and hospital stay (all P<0.05). After adjustment for confounding prognostic factors, the benefits of off-pump surgery were still significant for death in hospital, transfusion requirement, postoperative hemoglobin, neurological complications, intensive care unit and hospital stay (ORs 0.35 to 0.79, P<0.05)., Conclusions: These results suggest that off-pump surgery is safe and effective and is associated with a reduced in-hospital mortality and morbidity in overweight patients when compared with conventional coronary surgery with cardiopulmonary bypass and cardioplegic arrest.

Background: Although no randomised controlled trial has assessed the midterm effects of coronary-artery bypass surgery on the beating heart, this technique is being used in more and more patients. We did two randomised trials to compare the short-term morbidity associated with off-pump and on-pump myocardial revascularisation. Our aim was to pool the results to assess midterm outcomes., Methods: From March, 1997, to November, 1999, we randomly allocated 200 patients to off-pump and 201 to on-pump coronary surgery. In Beating Heart Against Cardioplegic Arrest Study (BHACAS) 1, we excluded patients who had had myocardial infarction in the past month or who required grafting of the circumflex artery distal to the first obtuse marginal branch. In BHACAS 2, we included such patients. Primary outcomes were all-cause mortality and cardiac-related events at midterm follow-up (1-3 years). Analysis was by intention to treat., Findings: Analyses of combined data from both trials showed the following risk differences with off-pump compared with on-pump surgery: atrial fibrillation -25% (95% CI -33% to -16%); chest infection -12% (-19% to -5%); inotropic requirement -18% (-25% to -10%); transfusion of red blood cells -31% (-41 to -21); and hospital stay longer than 7 days -13% (-21 to -5). Mean follow-up was 25 0 months (SD 9.1) for BHACAS 1 and 13.7 months (5 5) for BHACAS 2. Four (2%) of 200 patients in the off-pump groups died from any cause, compared with seven (3%) of 201 in the on-pump group (hazard ratio 0.57, 95% CI 0.17-1.96). 33 (17%) of 200 patients in the off-pump group died or had a cardiac-related event, compared with 42 (21%) of 201 in the on-pump group (0.78, 0 49-1.22)., Interpretation: Off-pump coronary surgery significantly lowers in-hospital morbidity without compromising outcome in the first 1-3 years after surgery compared with conventional on-pump coronary surgery.

We report the successful management of a gigantic circumflex coronary artery aneurysm with fistulisation into the coronary sinus. Transoesophageal echocardiography allowed continuous visualisation of ventricular wall motion during dissection and closure of the aneurysm whilst operating on cardiopulmonary bypass on the beating heart.

Background: Preoperative renal insufficiency is a predictor of acute renal failure in patients undergoing conventional coronary artery bypass grafting. Off-pump coronary artery bypass operations have been shown to reduce renal dysfunction in patients with normal renal function, but the effect of this technique in patients with preoperative nondialysis-dependent renal insufficiency is unknown., Methods: From June 1996 to December 1999, data of 3,250 consecutive patients undergoing coronary artery bypass grafting were prospectively entered into the Patient Analysis & Tracking Systems (PATS, Dendrite Clinical Systems, London, UK). Two hundred and fifty-three patients with preoperative serum creatinine more than 150 micromol/L were identified (202 patients on-pump, 51 patients off-pump), and clinical outcomes were analyzed. Serum creatinine and urea, in-hospital mortality, and morbidity were compared between groups. The association of perioperative factors with acute renal failure was investigated by multiple logistic regression analysis., Results: Preoperative characteristics were similar between the groups. Mean number of grafts was 2.9 +/- 0.8 and 2.3 +/- 0.8 in the on-pump and off-pump groups, respectively (p < 0.0001). Comparison between groups showed a significantly higher incidence of stroke, inotropic requirement, blood loss, and transfusion of red packed cell and platelets in the on-pump group (all p < 0.05). Postoperative serum creatinine and urea were higher in the on-pump group with a significant difference at 12 hours postoperatively (p < 0.05). Logistic regression analysis identified cardiopulmonary bypass, serum creatinine level 60 hours postoperatively, inotropic requirement, need for intraaortic balloon pump, transfusion of red packed cell, and hours of ventilation as predictors of postoperative acute renal failure., Conclusions: This study suggests that off-pump coronary artery bypass operations reduce in-hospital morbidity and the likelihood of acute renal failure in patients with preoperative nondialysis-dependent renal insufficiency undergoing myocardial revascularization.

Background: Off-pump coronary artery bypass (OPCAB) operations are evolving rapidly and becoming established in many cardiothoracic centers. For the technique to be widely applicable, teaching methods must be developed for surgical trainees. Early and midterm clinical outcomes of OPCAB performed at our institution by trainees as first operators under supervision were compared to those obtained in patients operated on by consultants., Methods: Analysis was undertaken on data prospectively inserted in the Patient Analysis & Tracking System. Of the 559 OPCAB operations performed between January 1997 and May 2000, 124 (22%) were carried out by a supervised trainee and 435 (78%) by a consultant., Results: There was no difference in age, sex, angina class, New York Heart Association functional class, or operative priority and extent of coronary artery disease in the two groups. More patients operated on by consultants had a history of congestive heart failure requiring medical therapy, significantly lower ejection fraction, and higher Parsonnet score compared with patients operated on by trainees. Early and midterm clinical results, in terms of morbidity and mortality, were similar in patients operated on by trainees or by consultants., Conclusions: Our data show no differences in early and midterm clinical outcome for patients undergoing OPCAB operations performed either by consultants or by trainees under supervision. The improvements in exposure and stabilization techniques, as well as the use of intracoronary shunts, have made it possible and safe to teach trainees off-pump multivessel coronary artery revascularization.

Objective: Coronary artery bypass grafting on the beating heart through median sternotomy is a relatively new treatment, which allows multiple revascularization without the use of cardiopulmonary bypass. A prospective randomized study was designed to investigate the effect of coronary bypass with or without cardiopulmonary bypass on postoperative blood loss and transfusion requirement., Methods: Two hundred patients with coronary artery disease were prospectively randomized to (1) on-pump treatment with conventional cardiopulmonary bypass and cardioplegic arrest and (2) off-pump treatment on the beating heart. Postoperative blood loss identified as total chest tube drainage, transfusion requirement, and related costs together with hematologic indices and clotting profiles were analyzed., Results: There was no difference between the groups with respect to preoperative and intraoperative patient variables. The mean ratio of postoperative blood loss and 95% confidence interval between groups was 1.64 and 1.39 to 1.94, respectively, suggesting on average a postoperative blood loss 1.6 times higher in the on-pump group compared with the off-pump group. Seventy-seven patients in the off-pump group required no blood transfusion compared with only 48 in the on-pump group (P <.01). Furthermore, less than 5% of patients in the on-pump group required fresh frozen plasma and platelet transfusion compared with 30% and 25%, respectively, in the on-pump group (both P <.05). Mean transfusion cost per patient was higher in the on-pump compared with that in the off-pump group ($184.8 +/- $35.2 vs $21.47 +/- $6.9, P <.01)., Conclusions: Coronary artery bypass grafting on the beating heart is associated with a significant reduction in postoperative blood loss, transfusion requirement, and transfusion-related cost when compared with conventional revascularization with cardiopulmonary bypass and cardioplegic arrest.

Objectives: To determine whether patients with critical left main stem (LMS) coronary artery disease can undergo off-pump coronary artery bypass (OPCAB) surgery safely and successfully., Methods: From May 1996 to March 2000 data for patients with critical (> or =50%) LMS stenosis who underwent conventional coronary artery bypass surgery with cardiopulmonary bypass (CCAB) or without (OPCAB) were collected prospectively using the Patient Analysis & Tracking System. A reusable pressure stabilizer, intra-coronary shunts and a single posterior pericardial stitch exposure technique were used in all OPCAB cases. Non-randomized, retrospective data analysis included demographic and preoperative risk factors, operative details, clinical outcome and early follow-up., Results: During the study period 387 patients with LMS stenosis underwent surgery (OPCAB n=75, CCAB n=312). Groups were similar in terms of preoperative and intraoperative variables although CCAB patients received significantly more grafts per patient (3.1+/-0.73 vs. 2.6+/-0.76, P< or =0.001). Mortality was similar in both groups (OPCAB 1.3% vs. CCAB 2.6%). OPCAB patients when compared to CCAB patients had a lower requirement for postoperative inotropes (12.0% vs. 38.1%, P=0.0001), temporary postoperative pacing (2.7% vs. 10.1%, P=0.02), and blood product transfusion (6.7% vs. 31.4%, P<0.0001), a lower incidence of postoperative chest infection (0% vs. 6.7%, P=0.02) and a slightly reduced postoperative length of stay (7.9+/-5.46 vs. 8.3+/-5.11 days, P=0.01). At 24 months follow-up, CCAB and OPCAB actuarial survival was 94.1+/-1.7% and 97.7+/-2.3%, respectively., Conclusions: OPCAB surgery is safe and effective in patients with critical LMS disease.

The study is retrospective review of the demographic, clinical, angiographic, and operative data of the first 205 consecutive CABG operations performed by Caribbean Heart Care at the Eric Williams Medical Sciences Complex (EWMSC), Trinidad and Tobago, between November 1993 and December 1997. The aim of the study was to determine the in-hospital and intermediate-term follow-up results. The mean age of patients was 59 +/- 10 years and 78% were male. Sixty-four per cent were of East Indian descent, whereas 16% were of African descent. Forty-eight per cent of the patients were hypertensive, 46% were diabetic, 33% had hyperlipidaemia, 20% had a recent history of cigarette smoking and 16% were obese. Sixty-five per cent had a positive family history of ischaemic heart disease. The average time interval between angiography and surgery was 2.3 months. At the time of angiography, 63.5% of patients had Canadian Cardiac Society (CCS) class 3 or 4 angina. The mean ejection fraction was 61 +/- 15%. Wall motion abnormalities were seen in 67% of patients. Significant stenoses of the left anterior descending artery, right circumflex artery, circumflex and ramus coronary arteries were present in 91%, 78%, 54% and 5%, respectively. Many patients (67%) had severe diffuse disease on angiography. The mean intensive care stay was 2.2 +/- 0.8 days. In-hospital mortality was 3.9% (8/205). The most frequent post-operative complication was haemorrhage (2.6%). Acute renal failure occurred in 2.1%; pulmonary collapse, 1.6%; stroke, 1% and cardiac arrest, 1%. Both sternal wound infections and systemic sepsis occurred in 0.5%. Intermediate-term follow-up data were obtained for 92% (189/205). The duration of follow-up ranged from 1 to 5 years (mean 3.7 years). During the follow-up period, 7 patients (3.4%) died. Angina severity was reduced from a mean CCS score of 2.61 +/- 0.95 before CABG to 1.22 +/- 0.55 at the time of follow-up (p < 0.0001). Overall 4-year mortality compared favourably with data from international studies. Among survivors, quality of life improved as evidenced by the reduction in the mean angina score.

Objectives: The inflammatory response to cardiopulmonary bypass is believed to play an important role in end organ dysfunction after open heart surgery and may be more profound after normothermic systemic perfusion. The aim of the present study was to investigate the effects of cardiopulmonary bypass temperature on the production of markers of inflammatory activity after coronary artery surgery., Methods: Forty-five low risk patients undergoing elective coronary artery surgery were prospectively randomized into three groups: hypothermia (28 degrees C, n = 15), moderate hypothermia (32 degrees C, n = 15), and normothermia (37 degrees C, n = 15). All patients received cold antegrade crystalloid cardioplegia and topical myocardial cooling with saline at 4 degrees C. Serum samples were collected for the estimation of neutrophil elastase, interleukin 8, C3d, and IgG under ice preoperatively, 5 min after heparinisation, 30 min following start of CPB, at the end of CPB, 5 min after protamine administration, and 4, 12 and 24 h postoperatively., Results: Patients were similar with regard to preoperative and intraoperative characteristics (age, sex, severity of symptoms, number of grafts performed, aortic cross clamp time, cardiopulmonary bypass time). Neutrophil elastase concentration increased markedly as early as 30 min after the onset of cardiopulmonary bypass and peaked 5 min after protamine administration. Levels were not significantly different between the three groups. A similar finding was apparent for C3d release. Interleukin 8 concentrations also demonstrated a considerable increase related to cardiopulmonary bypass in all groups, but there was a significantly more rapid decline in interleukin 8 concentrations in the normothermic group in the postoperative period. Eluted IgG fraction showed a much earlier peak concentration than the other markers, occurring within 30 min of the start of cardiopulmonary bypass. Levels reached a plateau, before declining soon after the end of bypass and remained higher than preoperative values at 24 h. There was no difference between the three groups. The cumulative release of all markers was calculated from the concentration-time curves, and was not statistically different between groups., Conclusion: Normothermic systemic perfusion was not shown to produce a more profound inflammatory response compared to hypothermic and moderately hypothermic cardiopulmonary bypass.

Coronary artery bypass surgery on the beating heart either via a left anterior small thoracotomy (LAST) or a median sternotomy is becoming increasing popular world-wide. Concern still remains about the potential for a temporary regional myocardial ischaemia associated with the stabilisation and occlusion of the coronary during construction of the anastomosis. This review summarises the results of a series of studies intended to evaluate the effect of beating heart coronary revascularization on myocardial function, myocardial tissue injury and clinical outcome.

Objective: Conventional coronary artery bypass grafting (CABG) is both safe and effective. Nevertheless, the use of cardiopulmonary bypass (CPB) and cardioplegic arrest are associated with several adverse effects. Over the last 2 years there has been a revival of interest in performing CABG on the beating heart. In this prospective randomized study we evaluated the efficacy and safety of on and off pump coronary revascularization on myocardial function., Methods: Eighty patients (65 males, mean age 61+/-9.7 years) undergoing first time CABG were prospectively randomized to: (i) conventional revascularization with CPB at normothermia and cardioplegic arrest with intermittent warm blood cardioplegia (on pump) or (ii) beating heart revascularization (off pump). Troponin I (Tn I) release was serially measured as a specific marker of myocardial damage. Haemodynamic measurements as well as inotropic requirement, incidence of arrhythmia and postoperative myocardial infarction were also recorded., Results: There were no significant differences between the two groups in terms of age, sex, extent of disease, left ventricular function and number of grafts. There were no deaths or intraoperative myocardial infarctions in either group. Tn I release was constantly lower in the off pump group and this was significant at 1, 4, 12 and 24 h postoperatively. Furthermore, in this group there was a significantly reduced incidence of arrhythmias. Inotropic requirements were less in the off pump group but this did not reach statistical significance., Conclusion: These results suggest that off pump coronary revascularization is a safe and effective strategy for myocardial revascularization. Myocardial injury as assessed by Tn I release is also reduced when compared with conventional coronary revascularization with CPB and cardioplegic arrest.

Improved outcome after coronary bypass surgery over the last decade has been attributed largely to the increasing use of arterial conduits and their superior patency rates over that of saphenous vein grafts. In spite of this trend, autologous saphenous vein has remained an important and convenient conduit for a variety of operative scenarios, and is still used for more than 70% of grafts. As a result, vein graft failure continues to represent a significant clinical and economic burden upon the health care service. Between 15 to 30% of saphenous vein grafts occlude within the first year of surgery, increasing to over 50% after 10 years. By this time, more than 10% of patients will require further intervention to alleviate symptoms arising from occluded grafts and progression of native disease. Graft occlusion arises either from early thrombosis or the later onset of 'vein graft disease' and subsequent atherosclerotic changes.

Objective: Minimally invasive direct coronary artery bypass (MIDCAB) using the left internal mammary artery (IMA) to the left anterior descending (LAD) coronary artery can be performed with low operative risk. MIDCAB can be combined with percutaneous transluminal coronary angioplasty (PTCA) to treat patients with multivessel disease. We report here our experience with staged MIDCAB and PTCA in the management of a selected group of patients., Methods and Results: 11 patients (9 males, mean age 64.6+/-8.7 years) with multivessel coronary artery disease received left IMA grafts to the LAD using the MIDCAB approach. There were no postoperative morbidity or mortality. All patients were extubated within 4 h of leaving the operating room with a mean ITU stay of 12.8 h. All patients but two underwent coronary angioplasty during the same hospital admission, 3.8+/-1.3 days after the MIDCAB procedure. Angiography confirmed IMA grafts patency in all patients, and complete revascularisation by PTCA of other coronary arteries was possible in all patients but one. Mean hospital stay was 5.9 days, and all patients remain free of angina at a mean follow-up period of 11.4 months., Conclusions: Staged MIDCAB and angioplasty is an experimental approach for the management of selected patients with multi-vessel coronary artery disease. Further experience is needed to clarify patient selection and the long-term outcome of this approach.

A prospective study of 100 patients undergoing coronary artery bypass surgery was performed to demonstrate the effectiveness of a posterior pericardiotomy in reducing the incidence of pericardial effusions and, consequently, reducing the incidence of supraventricular arrhythmias in the post-operative period. Pericardial effusion occurred in 4 of 50 patients following a posterior pericardiotomy, whereas effusion occurred in 20 of 50 patients in whom a pericardiotomy was not created (P < 0.0005). Supra-ventricular arrhythmias occurred in 4 patients in the pericardiotomy group and 18 in the group treated without pericardiotomy (P < 0.005). No complications resulted from this procedure. We conclude that pericardiotomy is a simple, safe and effective method for reducing the incidence or pericardial effusion and thereby post-operative supra-ventricular arrhythmias.

Coronary artery disease is a common finding, responsible for substantial morbidity and mortality in the elderly. Despite this, there is a general reluctance to refer elderly patients for further investigation as the perceived risks are thought to outweight any potential benefit. This is not however borne out by the available evidence, which suggests that revascularisation procedures carry little additional risk in appropriately selected elderly patients. Chronological age per se should, therefore, no longer be a bar to myocardial revascularisation.

The role of heparin in the treatment of coronary artery disease remains unclear. Although of benefit in unstable angina and the prevention of acute occlusion following angioplasty, its value as adjunctive therapy in myocardial infarction is limited. Further studies are needed to assess the effect of heparin on angioplasty restenosis and late venous graft occlusion.

Three cases are presented of supra-ventricular tachyarrhythmias following open heart surgery refractory to direct current cardioversion and pharmacological treatment. Echocardiography demonstrated a moderate to large posterior pericardial effusion in each case. Surgical evacuation of the effusion was followed by reversion to sinus rhythm.