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Introduction: Sepsis and its sequelae are the leading causes of morbidity and mortality in critically ill patients. The burden to healthcare economies is also considerable. As the pathophysiology of sepsis is better defined, interventions aiming to treat sepsis are emerging. Eritoran (E5564), a toll-like receptor 4 (TLR4)-directed endotoxin antagonist, is one such emerging therapeutic option for treatment of sepsis., Aims: This review assesses evidence for the potential therapeutic value of eritoran in the management of sepsis., Evidence Review: Evidence from a single phase II trial of eritoran usage in sepsis suggests that it is a safe and effective therapeutic option for patients with sepsis, and is especially beneficial for patients at high risk of mortality. However, the cost effectiveness of eritoran and its place in therapy compared with other available treatment options and those currently in development remains to be determined., Clinical Potential: Eritoran is a potential therapeutic option for management of sepsis and other TLR4- and lipopolysaccharide-mediated disorders with a reasonable safety and tolerability profile that must be validated by several rigorous, blinded, placebo-controlled, adequately powered, multicenter, randomized clinical trials.

Pulmonary arterial hypertension (PAH) is a debilitating disease associated with significant morbidity and a high mortality if left untreated. Over the past 5 years, there have been significant advances with regard to the understanding of the pathogenesis, diagnosis and classification of PAH. The availability of newer drugs has resulted in a radical change in the management of this disease with significant improvement in both the quality of life and mortality. One of the recent drugs is an orally active dual endothelin receptor antagonist, bosentan; this drug has shown to improve the exercise capacity and survival in patients with PAH. This review article discusses the pharmacology of bosentan and summarises the current available evidence for the safety and efficacy of bosentan for the treatment of PAH.

A best evidence topic in cardiothoracic surgery was written according to a structured protocol. The question addressed was whether neoadjuvant chemotherapy improves survival in patients with resectable oesophageal cancer. Altogether 685 papers were identified using the below mentioned search. Nine represented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group, relevant outcomes and weaknesses were tabulated. We conclude that combining neoadjuvant chemotherapy with surgery for resectable thoracic oesophageal cancer has theoretical appeal and may offer a modest survival advantage compared to surgery alone. The most recent meta-analysis and the largest randomised trial of 804 patients demonstrated an absolute survival advantage of around 7-9% at two years which just reached statistical significance. Benefit was less clear for squamous cell carcinoma than adenocarcinoma and the second largest randomised trial did not demonstrate a significant benefit.

The systemic inflammatory response after coronary artery bypass grafting using cardiopulmonary bypass (CPB) contributes substantially to postoperative organ dysfunction and coagulation disorders. Important features of this inflammatory reaction include the activation of complement and leukocytes, the release of proinflammatory cytokines, alterations in the metabolism of nitric oxide, and an increase in the production of oxygen-free radicals, which in some cases may lead to oxidant stress injury. Several strategies including the use of steroids, use of aprotinin, heparin-coated CPB circuits, and hemofiltration have been reported to reduce the inflammatory reaction induced by CPB and its consequences. A more radical and effective way of counteracting the effects of the inflammatory reaction and oxidative stress may be the omission of CPB itself. The development and application of off-pump coronary artery bypass (OPCAB) technology has largely been driven by this theme of avoiding systemic inflammatory reaction to decrease the incidence and/or severity of adverse outcomes. This review article discusses the influence of cardiopulmonary bypass on systemic inflammation and attempts to evaluate the current best available evidence on the impact of OPCAB on systemic inflammation.

Coronary artery stenting is currently the most frequently performed percutaneous coronary intervention for the treatment of coronary artery disease. Recently, drug- eluting stents, loaded with anti-inflammatory, anti-migratory, anti-proliferative or pro-healing drugs, have revolutionized the management of coronary artery disease by markedly reducing in-stent restenosis. Despite the excellent short- and mid-term results of randomized controlled trials observed with drug-eluting stents, there remain a number of unresolved issues and valid concerns about long-term safety and efficacy of this revolutionary technology. Important safety issues such as thrombosis, late stent malapposition, aneurysm formation, edge effect, late inflammation due to choice of polymer used to bind the drug, the release of toxins, and potential interactions with brachytherapy and drugs have not been completely addressed. This review article evaluates current available scientific evidence on the various safety issues related to the use of drug-eluting stents.

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether vacuum-assisted closure (VAC) should be routinely used for management of deep sternal wound infection after cardiac surgery. Altogether, 198 papers were identified using the reported search. A further three relevant papers were identified by hand searching reference lists. Thirteen papers represented the best evidence on the topic. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses were tabulated. We conclude that VAC provides a viable and efficacious adjunctive method by which to treat postoperative wound infection after cardiac surgery. It is especially useful for managing sternal osteomyelitis in high-risk patients and is an attractive option as a first-line therapy in this group of patients. However, currently the evidence to endorse its routine use for management of deep sternal wound infection after cardiac surgery is weak. A randomised controlled trial comparing VAC therapy with the conventional treatment is mandatory to validate its safety, efficacy, and cost effectiveness as a routine first-line therapy for management of deep sternal wound infection after cardiac surgery.

There is consensus of opinion that patients with moderately severe to severe (grade 3+ or 4+) ischemic mitral regurgitation (IMR) should undergo mitral valve surgery at the time of coronary artery bypass grafting (CABG), while trace to mild (grade 1+) IMR can probably be left alone. However, the management of moderate (grade 2+) IMR continues to be a subject of constant debate and controversy. In particular, as techniques of valvular repair continue to be refined; many surgeons have advocated mitral valve repair and concomitant CABG for these patients. Others, however, have continued to treat these patients with revascularization alone and close postoperative observation of the mitral valve. In their opinion, degree of concomitant mitral valve dysfunction in this group of patients does not justify the increased operative risks associated with simultaneous mitral valve correction. We are currently practicing in an era of evidence-based medicine (EBM) in which clinical decision-making has to be guided by current best available evidence from scientific, clinical studies. This review article attempts to tackle this controversial issue and find the best approach of dealing with moderate IMR at the time of CABG by evaluating current best available evidence.

Objective: Sildenafil (Viagra, Pfizer) is being increasingly used to treat pulmonary hypertension in children. However, there are limited data available to suggest dosage regimens. The purpose of this study was to determine the effects of escalating doses of sildenafil on hemodynamics and gas exchange in children with pulmonary hypertension because of congenital cardiac defects., Design: Prospective, observational study., Setting: Pediatric intensive care unit in a tertiary care children's hospital., Participants: Ten children with pulmonary hypertension because of congenital cardiac defects who were in the intensive care unit and on nitric oxide after cardiac surgery., Intervention: Patients received sildenafil every 4 hours via a gastric tube in incremental doses of 0.5 mg/kg, 1 mg/kg, 1.5 mg/kg, and 2.0 mg/kg along with nitric oxide during their stay in the intensive care unit until they were extubated. Hemodynamic and arterial blood gas measurements were taken before (baseline) and 60 minutes after the administration of sildenafil., Measurements and Main Results: All doses of sildenafil caused significant reduction in pulmonary artery pressure with no significant effect on systemic arterial and central venous pressures. Arterial partial pressure of oxygen was decreased after a 2.0 mg/kg dose of sildenafil but not significantly. No significant differences were found among the 4 doses., Conclusion: For the treatment of pulmonary hypertension in children with congenital cardiac defects, a 0.5 mg/kg dose of sildenafil every 4 hours is therapeutically as effective as a 2.0 mg/kg dose every 4 hours. However, a large dose-ranging and pharmacokinetic study of sildenafil in children with pulmonary hypertension because of congenital cardiac defects is needed to validate the safety and efficacy of the dose-range and dosing interval suggested by this study.

For more than three decades cardiac surgeons have been used to perform delicate coronary anastomoses on cardiopulmonary bypass (CPB). However, the price of a still and bloodless field is ultimately paid by the patients in the form of sequelae of negative effects of CPB including blood trauma, activation of a series of inflammatory responses, nonpulsatile flow, and possible embolization of air or debris. In an attempt to avoid these deleterious effects of CPB, off-pump coronary artery bypass surgery (OPCAB) has been rediscovered and refined. Although abundant evidence is available to suggest that excellent results can be achieved when CPB is avoided, concerns have been raised about quality of anastomosis and graft patency rates after OPCAB surgery. We are currently practicing in an era of evidence-based medicine that mandates the prospective randomized controlled trial (RCT) as the most accurate tool for determining a treatment benefit compared with a control population. This review article attempts to evaluate the current best available evidence from RCTs on the impact of OPCAB surgery on graft patency.

The management of aortic valve disease in children and young adults is often a controversial and complex problem. The Ross operation has become an important option for aortic valve replacement in patients with both congenital and acquired disease of the left ventricular outflow tract (LVOT). The acceptance of this procedure has been slow because of the technical demands of the operation and the inherent need for reconstruction of the right ventricular out-flow tract (RVOT), thereby placing two valves at risk. Although more than three decades have passed since the Ross operation was first described, it is only during the past 10 years that it has been increasingly considered for pediatric patients with a wide spectrum of congenital abnormalities of the LVOT. The advantages of the autograft valve include growth potential, optimal hemodynamic performance, and freedom from anticoagulation and hemolysis. However, concerns regarding potential dilatation of the autograft, reoperation for autograft dysfunction, and replacement of RVOT conduits persist. Further, doubts have been expressed by others regarding the indications for the Ross operation in patients with a bicuspid aortic valve and with aortic valve insufficiency. This review evaluates existing evidence on the safety and efficacy of Ross procedure for pediatric and adolescent patients.

In the last decade, there has been an upsurge of interest in less invasive alternatives to standard coronary artery bypass grafting performed with cardiopulmonary bypass. Off-pump coronary artery bypass grafting is one such less invasive alternative that has seen a resurgence in the last 10 years. The development and application of the technology required has largely been driven by the hope of decreasing the incidence and/or severity of the adverse outcomes associated with cardiopulmonary bypass, the idea being to perform coronary artery bypass grafting without cardiopulmonary bypass. A number of studies that have reported the safety and efficacy of off-pump coronary artery bypass surgery have provided the impetus for the development of this technology over the last decade. Despite tremendous enthusiasm on the part of cardiac surgeons, patients, industry and the media, skepticism still exists about the actual impact of off-pump coronary artery bypass grafting on the outcomes after coronary artery bypass grafting. The only means of countering this skepticism is to validate the safety and efficacy of off-pump coronary artery bypass surgery through the explicit and conscientious assessment of current best evidence. This review article attempts to evaluate the current best evidence available from randomized, controlled trials in order to compare the outcomes of off-pump coronary artery bypass surgery and conventional coronary artery bypass grafting.

The development of drug-eluting coronary stents has proved to be a quantum advance in interventional cardiology, rivaling the impact of stenting itself. Drug-eluting coronary stents deliver effective local concentrations of antiproliferative drugs (thus avoiding systemic toxicities), without substantially modifying the technique of percutaneous coronary intervention. Studies involving several different stent platforms and antiproliferative drug coatings have recently demonstrated dramatic reductions in restenosis rates, compared to conventional bare metal stents. Although the clinical benefits of drug-eluting stents are increasingly evident, important concerns about their long-term safety and costs have been raised. Furthermore, drug-eluting stents are being claimed to replace coronary artery bypass surgery in the near future. This review article evaluates the current best available evidence on the efficacy and safety of drug-eluting stents with a focus on the impact of this "revolutionary" new technology on the practice of coronary artery bypass surgery.

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether warfarin should be routinely prescribed for the first three months after a bioprosthetic valve replacement either for the aortic or mitral position. Altogether 620 papers were identified using the below-mentioned search. In addition, all major international guidelines were included. Fifteen papers presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group, relevant outcomes and weaknesses were tabulated. We conclude that all guidelines, the available evidence and current practice support the use of warfarin at an INR of 2-3 for 3 months for bioprosthetic mitral valve replacement (MVR). However, it must be acknowledged that this recommendation is based on only a small number of non-randomized cohort studies and on expert consensus. For patients without high risk factors undergoing a bioprosthetic aortic valve replacement (AVR), the European Society of Cardiology (ESC), the American College of Chest Physicians (ACCP) and the Scottish Intercollegiate Guidelines Network (SIGN) all recommend warfarin for 3 months after surgery. However, the American Heart Association (AHA/ACC) guidelines and the British Society for Haematology (BSH) regard aspirin alone as adequate therapy. In addition, two large surveys show that the majority of surgeons worldwide now use only antiplatelet therapy. The evidence from clinical studies to support the use of warfarin post-bioprosthetic AVR is very weak and out-dated, and therefore, we feel that it is certainly safe to use antiplatelet therapy alone post-bioprosthetic AVR.

A variety of congenital cardiac anomalies with severe right ventricular outflow tract (RVOT) obstruction or RVOT interruption require surgical reconstruction from the infundibulum up to the pulmonary artery bifurcation or even into the branches of the pulmonary arteries. Ideally, the conduit or valve required for such reconstruction has to be formed of autologous tissue that grows, resists infection, lasts for the life span of the patient and is readily available in all sizes. Such conduits, however, are not available and although several alternatives have been used, none of which are without potential drawbacks. Contegra valved bovine internal jugular vein conduit (Medtronic Inc., MN, USA) has recently emerged as a promising option for pediatric RVOT reconstruction and has been advocated for its 'off-the-shelf' availability in sizes ranging from 12 to 22 mm, surgical pliability and encouraging short- and mid-term success in experimental animal, as well as clinical studies. This review focuses on the current outcomes of Contegra conduit and highlights some of the major concerns related to the use of this conduit and strategies to tackle these concerns.

Cardiopulmonary bypass is a double-edged sword. Without it, corrective cardiac surgery would not be possible in the majority of children with congenital heart disease. However, much of the perioperative morbidity that occurs after cardiac surgery can be attributed to a large extent to pathophysiologic processes engendered by extracorporeal circulation. One of the challenges that has confronted pediatric cardiac surgeons has been to minimize the consequences of cardiopulmonary bypass. Ultrafiltration is a strategy that has been used for many years in an effort to attenuate the effects of hemodilution that occur when small children undergo surgery with cardiopulmonary bypass. Over the past several years, a modified technique of ultrafiltration, commonly known as modified ultrafiltration, has been used with increasing enthusiasm. Multiple studies have been undertaken to assess the effects of modified ultrafiltration on organ function and postoperative morbidity following repair of congenital heart defects. This review attempts to evaluate current available scientific evidence on the impact of modified ultrafiltration on organ function and morbidity after pediatric cardiac surgery.

Renal dysfunction is a serious complication after coronary artery bypass surgery with cardiopulmonary bypass. Cardiopulmonary bypass-related non-pulsatile flow, hypothermia, haemolysis, systemic inflammatory reactions and emboli are mentioned as possible causes for this postoperative renal dysfunction. In an attempt to avoid these deleterious effects of cardiopulmonary bypass, off-pump coronary artery bypass surgery has been rediscovered. Resurgence of interest in off-pump coronary artery bypass surgery is associated with the expectation that avoiding deleterious effects of the cardiopulmonary bypass leads to better outcomes and possibly decreased costs and resource use. We are currently practising in an era of evidence-based medicine that mandates the prospective randomized controlled trial as the most accurate tool for determining a treatment benefit compared with a control population. The present review article attempts to evaluate the current best available evidence from randomized controlled trials on the impact of off-pump coronary artery bypass surgery on postoperative renal dysfunction.

The success of coronary artery bypass grafting, the gold standard for the treatment of multivessel coronary artery disease, is limited by poor long-term vein-graft patency. By contrast, the left internal mammary artery has been demonstrated to have a superior graft patency rate and has provided excellent clinical results. This suggests that the use of arterial conduits for coronary artery bypass grafting may be beneficial for long-term results. Recently, there has been an upsurge in the use of arterial grafts for myocardial revascularization based on the clinical advantage of the use of the left internal mammary artery as a bypass conduit. Many retrospective studies have supported the safety and the effectiveness of arterial grafting, and it has become apparent that the free arterial graft can be used as a branched or a lengthened conduit to the in situ arterial graft by adopting one or more of the several composite grafting techniques. Arterial composite grafts with or without sequential grafting techniques appear an attractive strategy as increased number of distal coronary anastomoses can be performed, with a limited number of grafts, avoiding proximal aortic anastomoses. However, concerns regarding the total dependence of the coronary bypass flow on the flow of one in situ arterial graft and technical error, resulting in compromised flow in one or both limbs of the composite graft have prevented composite arterial grafting from being universally adopted. It is expected that in the near future a prospective, multi-institutional, randomized controlled trial, to compare the short- and long-term outcomes of exclusive arterial grafting using composite and conventional aortocoronary revascularization strategies, will be undertaken to validate the safety and efficacy of composite arterial grafting.

Past four decades have seen a gradual evolution in aortic valve replacement surgery. The ideal valve substitute should combine central flow, low transvalvular gradient, low thrombogenicity, durability, easy availability, resistance to infection, freedom from anticoagulation, and easy implantability. Although there are several types of valves available to replace the diseased aortic valve-autograft, allograft, xenograft, mechanical, and bioprosthetic valves-none is ideal. On one end of the spectrum is the pulmonary autograft, which comes closest to achieving these goals, but creates a double valve procedure for single valve disease, while on the other end are the mechanical valves and stented tissue valves, which allow easy "off the shelf" availability as well as easy implantability but are limited by the potential drawback of causing intrinsic obstruction to some extent because of the space occupied by the stent and sewing ring. Stentless xenograft aortic valves have been developed as a compromise between these ends of the valve spectrum. Stentless aortic valves have been reported to provide more physiologic hemodynamic behavior and cause more timely and thorough regression of ventricular hypertrophy. This review article attempts to evaluate current best available evidence from randomized controlled trials to assess the impact of stentless aortic valves on left ventricular function and hypertrophy.

Recent upsurge in referral of patients with high perioperative risk or compromised left ventricular function for cardiac surgery has lead to an increasing use of pharmacologic support in the form of vasodilator and inotropic therapy to achieve improvement of tissue perfusion in the perioperative period or to support weaning from cardiopulmonary bypass. Traditionally, perioperatively used inotropic agents, epinephrine, dobutamine, and milrinone, are limited by significant increases in myocardial oxygen consumption, proarrhythmia, or neurohormonal activation. Levosimendan, a new inodilator for the treatment of decompensated heart failure, has also shown promise in elective therapy of cardiac surgical patients with high perioperative risk or compromised left ventricular function, as well as in rescue therapy of patients with difficult weaning from cardiopulmonary bypass. This review article briefly discusses the pharmacology of levosimendan and evaluates current best available evidence to assess the safety and efficacy of levosimendan usage in cardiac surgery.

The treatment of patients with coronary artery disease continues to evolve. Recent, exciting data on the use of drug-eluting stents in diseased coronary vessels has generated immense enthusiasm within the interventional community leading to claims that "drug-eluting stents will put bypass surgeons out of business." However, despite promising short-term and midterm outcomes of this revolutionary new technology, valid concerns regarding long-term safety and efficacy of drug-eluting stents persist. This review article evaluates current status of drug-eluting stents with special emphasis on real and potential drawbacks of this emerging percutaneous coronary interventional modality and its impact on the practice of coronary artery bypass surgery.

A best evidence topic in pediatric cardiac surgery was written according to a structured protocol. The question addressed was whether sildenafil was effective in treating postoperative pulmonary hypertension after pediatric heart surgery. Altogether 28 papers were found using the reported search, of which three represented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses were tabulated. We conclude that oral sildenafil may be useful in reducing pulmonary vascular resistance and can be considered for treatment of postoperative pulmonary hypertension after pediatric heart surgery. However, evidence from a large, multicenter, randomized controlled trial is needed to validate the safety and efficacy of sildenafil for use in postoperative pediatric cardiac surgical patients.

Cardiopulmonary bypass (CPB) is a prerequisite for open-heart surgery, and is a procedure routinely used. CPB exposes blood to artificial surfaces, to mechanical trauma from the pump, to alterations in temperature, and to dilution with fluids, whole blood, plasma products, and drugs, and leads to the activation of platelets, coagulation, and fibrinolysis. Coagulopathy during cardiac surgery with CPB results in impairment in hemostasis and subsequently higher morbidity and mortality. Recent advances in surgical techniques and postoperative management have aimed at reducing postoperative morbidity and mortality. Off-pump coronary artery bypass (OPCAB) surgery is one such advance that attempts to avoid the deleterious effects of extracorporeal circulation by performing myocardial revascularization without CPB. Emerging evidence from several randomized controlled trials (RCTs) as well as large registries such as the Society of Thoracic Surgeons (STS) database suggests that OPCAB reduces the postoperative morbidity and mortality. This review article attempts to evaluate the current best available evidence from RCTs on the impact of OPCAB on postoperative bleeding and transfusion requirements.

Pulmonary dysfunction is a well-recognized complication associated with cardiopulmonary bypass (CPB) and a major cause of morbidity and mortality in cardiac surgery. Off-pump coronary artery bypass (OPCAB) surgery has been gaining in popularity in the last few years. Resurgence of interest in OPCAB is associated with the expectation that avoiding deleterious effects of the CPB pump leads to better outcomes and possibly decreased costs and resource utilization. This review article attempts to evaluate the current best available evidence from randomized controlled trials on the impact of OPCAB on postoperative pulmonary dysfunction.

Myocardial ischemia-reperfusion injury occurs in a wide spectrum of patients, ranging from survivors of out-of-hospital cardiac arrest to acute myocardial infarction victims as well as patients undergoing cardiac surgery, and represents a major public health burden. This injury contributes significantly to morbidity and mortality, despite meticulous adherence to presently known principles of myocardial protection. Despite the considerable progress that has been made in the field of myocardial protection, high-risk subsets of patients continue to exhibit ischemia-reperfusion-related complications, including prolonged contractile dysfunction (stunning), low-output syndrome, perioperative myocardial infarction, and cardiac failure, requiring prolonged intensive care. Sildenafil, a phosphodiesterase 5 inhibitor, currently licensed for the treatment of erectile dysfunction and pulmonary hypertension has shown great promise in animal studies as a possible pharmacologic agent for cardioprotection. This review article discusses the pharmacology of sildenafil and focuses on the available evidence from animal studies on the potential role of sildenafil for treating ischemia-reperfusion injury with its implications for clinical practice.

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether skeletonised internal mammary artery (IMA) is better than pedicle IMA in coronary artery bypass grafting? Altogether 106 papers were found using the reported search, of which 12 presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these papers are tabulated. We conclude that skeletonisation increases the length of conduit by around 3 cm and may also increase flow and conduit diameter. Skeletonisation should be the technique of choice for diabetics in whom BIMA harvest is desired, but at the expense of an extra 15-20 min per operation, no convincing outcome benefits have been shown for single IMA harvest.

Cardiac surgery and cardiopulmonary bypass initiate a systemic inflammatory response largely determined by blood contact with foreign surfaces and the activation of complement. It is generally accepted that cardiopulmonary bypass initiates a whole-body inflammatory reaction. The magnitude of this inflammatory reaction varies, but the persistence of any degree of inflammation may be considered potentially harmful to the cardiac patient. The development of strategies to control the inflammatory response following cardiac surgery is currently the focus of considerable research efforts. Diverse techniques including maintenance of hemodynamic stability, minimization of exposure to cardiopulmonary bypass circuitry, and pharmacologic and immunomodulatory agents have been examined in clinical studies. This article briefly reviews the current concepts of the systemic inflammatory response following cardiac surgery, and the various therapeutic strategies being used to modulate this response.

Reconstruction of the right ventricular outflow tract (RVOT) is needed in a wide variety of congenital heart diseases at the time of primary repair, or later for replacement of existing valves or conduits. Ideally, the conduit or valve needed for such reconstruction should be formed of autologous tissue that grows, resists infection, lasts for the life span of the patient, and is readily available in all sizes. Such a conduit is not available, though several alternatives have been used, none of which is without potential drawbacks. One alternative--the Contegra bovine jugular vein conduit (Medtronic, Inc., Minneapolis, MN, USA)--was introduced in 1999 and has gained widespread application, with increasing enthusiasm for its use. The Contegra conduit consists of a bovine jugular vein with an incorporated trileaflet valve. The conduit tissue is extremely pliable and offers optimal conditions for surgical handling. Moreover, the proximal tubular segment allows construction of the proximal anastomosis to the right ventricle, without the use of additional material. Increasingly, experience with the Contegra conduit is being published; hence, a literature search was conducted to evaluate available evidence on current use of the device in pediatric RVOT reconstruction.

Without intervention, babies born with transposed great arteries (TGA) are doomed to a rapid death. Jatene and coworkers deserve the credit for performing the first successful arterial switch operation (ASO) in a patient with TGA and ventricular septal defect (VSD) in 1975. Since then ASO has become the procedure of choice in most medical centers. This review article summarizes the historical aspects of arterial switch operation and assesses this procedure's outcomes.

The internal thoracic artery has been the most reliable graft material used in coronary artery bypass grafting with an excellent long-term patency rate. Complete myocardial revascularization with internal thoracic arteries improves long-term survival and decreases the rate of repeat operations compared with vein grafts. Adequate length of the graft in coronary artery bypass graft surgery is essential for providing complete arterial revascularization. In the last decade or so, technique of skeletonization of internal thoracic artery has been proposed to achieve extra length. Skeletonization of the internal thoracic artery allows the preparation of longer conduits with a superior free flow and can reduce the incidence of postoperative pulmonary and sternal complications. However, concerns about vasoreactivity of skeletonized internal thoracic artery grafts, the functional consequences of surgical trauma, the possible loss of innervation, and vasa vasorum perfusion in the skeletonized conduits have prevented this technique from being universally accepted. Presently available evidence from retrospective studies (level 3 evidence) suggests that skeletonization is a safe and effective technique for myocardial revascularization. However, there is a need for conducting multicenter, randomized controlled trials comparing the skeletonized and pedicled internal thoracic arteries with special emphasis on long-term patency to conclusively validate the safety and efficacy of skeletonization technique.

Coronary artery bypass grafting has been performed predominantly with the use of cardiopulmonary bypass and cardioplegic arrest, which allows optimization of the surgical field and consistent placement of grafts. However, the use of cardiopulmonary bypass is also associated with numerous complications. A surgical technique avoiding cardiopulmonary bypass should, in theory, reduce the incidence of such complications and lead to improved patient outcomes. This assumption has rekindled interest in performing off-pump coronary artery bypass surgery, which is currently the focus of scientific scrutiny. The existing world medical literature contains a staggering amount of research related to this technique. Although the available evidence from a large number of randomized clinical trials, nonrandomized clinical trials, propensity-matched analyses, and experimental data suggests that outcomes are better after off-pump than after on-pump coronary artery bypass surgery, skepticism still exists about the safety and efficacy of the off-pump technique. In the present era of evidence-based medicine, results from randomized clinical trials are given the highest recognition. This review attempts to evaluate the best currently available evidence from clinical trials about the safety and efficacy of off-pump coronary artery bypass surgery.

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether off-pump coronary artery surgery reduces the incidence of postoperative atrial fibrillation. Altogether 107 papers were found using the reported search, of which 18 presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these papers are tabulated. We conclude that off-pump coronary artery surgery significantly reduces the incidence of postoperative atrial fibrillation with a number needed to treat of 20 to prevent one case of AF.

Background: Bilateral internal mammary artery (IMA) grafting is associated with an improved long-term survival, low rates of recurrence of angina and late myocardial infarction. However, because of the inadequate length of the conduit, use of bilateral internal thoracic artery grafting occasionally is not suitable for complete revascularization. To overcome this limitation, extra length can be obtained by skeletonization of both IMAs. We decided to prospectively assess the safety of this technique., Methods: One hundred patients with a mean age of 52.5 +/- 13.1 years underwent complete revascularization with skeletonized bilateral internal mammary arteries on cardiopulmonary bypass (CPB). The right internal mammary artery (RIMA) was used as a free graft connected to the in situ left IMA (LIMA) in 88 patients. A free LIMA was attached to in situ RIMA in 12 patients. The average number of grafts was 3.2 per patient (range: 2-4 grafts per patient). Mean left ventricular ejection fraction was 60% (range: 25-80%)., Results: No patient required reexploration for bleeding, and no patient died within 30 days after operation. On the basis of electrocardiographic changes, three patients sustained a perioperative myocardial infarction. One patient had a sternal wound infection. Mean follow-up was 24 months (range: 6-36 months). The actuarial survival rate was 99 +/- 1% at 3 years. No myocardial infarctions were reported during the follow-up. Three patients had recurrent angina with conduit occlusion diagnosed on coronary angiography., Conclusion: Complete myocardial revascularization with skeletonized bilateral internal mammary arteries is a safe and reliable technique with excellent early and mid-term results.

The Ross procedure is being used increasingly to treat aortic valve disease in pediatric patients; however, there is an ongoing dispute about the durability of the autograft. From November 1996 to September 2003, 32 pediatric patients (mean age, 11 +/- 4.5 years) underwent the Ross procedure for various aortic valve diseases, using the root replacement technique. Clinical and echocardiographic follow-up was performed early (within 30 days), at 3 to 6 months, and yearly after surgery. There were no perioperative deaths. The patients were followed-up for up to 7 years with a median interval of 36 months. Actuarial survival at 7 years was 96% +/- 3% and there was 100% freedom from re-operation for autograft valve dysfunction or any other cause. The autograft annulus and sinus increased significantly in size during follow-up and the increase in size paralleled the increase in body surface area, with no evidence of disproportional dilatation. The hemodynamics at the latest follow-up were also similar to those at the time of discharge after surgery. Pulmonary autograft replacement of the aortic valve appears to be the ideal solution in pediatric patients, because of relatively low operative risk, excellent late valve function, and real potential for growth.

We retrospectively evaluated the perioperative results of off-pump coronary artery bypass surgery performed in our center. Over a 5-year period, 520 patients were operated off-pump through a median sternotomy with the aid of a cardiac stabilizer and retractor. A total of 1,117 distal anastomoses were made with a mean of 2.2 +/- 1.0 bypass grafts per patient. Only 12 patients (2.3%) required conversion to cardiopulmonary bypass, while 10 patients (1.9%) were re-operated for bleeding or graft failure. Perioperative myocardial infarction occurred in 10 patients (1.9%), and postoperative stroke in 3 patients (0.6%). The overall operative mortality was 2.5%, while the rate for the 48 patients who had previous bypass surgery was 2.1%. The results show that off-pump coronary surgery produces low mortality and morbidity, even in the treatment of multivessel disease or high-risk patients.

The choice of the graft conduit is crucial to the success of coronary artery bypass grafting (CABG) because the patency of a coronary conduit is closely associated with an uneventful postoperative course and better long-term patient survival. From the beginning of coronary bypass surgery venous conduits particularly the great saphenous veins (GSV) have been the most frequently used coronary conduit from the beginning of the coronary bypass surgery. However, over the last decade or so, coronary bypass graft surgery with arterial revascularization of all diseased coronaries has shown to be efficient because arterial grafts have better long-term patency, especially left internal mammary artery (LIMA), compared with venous grafts. Early vein graft failure coupled with occlusion is the most important limitation of saphenous vein grafts. Nevertheless, vein grafting is still an integral part of cardiac surgical practice. This review provides a summary of the patency rates, technical features and certain characteristics of the venous conduits. It also examines the current understanding and knowledge of venous histology, vein graft pathology and the associated endothelial and smooth muscle cell physiology and pharmacology. In addition, the existing and the emerging strategies to combat and control vein graft intimal hyperplasia and accelerated atherosclerosis are reviewed in detail.