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OBJECTIVES Despite society guideline recommendations, intraoperative high-frequency ultrasound (HFUS) and transit-time flow measurement (TTFM) use in coronary artery bypass grafting (CABG) has not been widely adopted worldwide. This retrospective review of the REQUEST (REgistry for QUality assESsmenT with Ultrasound Imaging and TTFM in Cardiac Bypass Surgery) study assesses the impact of protocolled high-frequency ultrasound/TTFM use in specific technical circumstances of CABG. METHODS Three REQUEST study sub-analyses were examined: (i) For off-pump (OPCAB) versus on-pump (ONCAB) procedures: strategy changes from preoperative plans for the aorta, conduits, coronary targets and graft revisions; and for all REQUEST patients, revision rates in: (ii) arterial versus venous grafts; and (iii) grafts to different cardiac territories. RESULTS Four hundred and two (39.6%) of 1016 patients undergoing elective isolated CABG for multivessel disease underwent OPCAB procedures. Compared to ONCAB, OPCAB patients experienced more strategy changes regarding the aorta [14.7% vs 3.4%; odds ratios (OR) = 4.03; confidence interval (CI) = 2.32–7.20], less regarding conduits (0.2% vs 2.8%; OR = 0.09; CI = 0.01–0.56), with no differences in coronary target changes or graft revisions (4.1% vs 3.5%; OR = 1.19; CI = 0.78–1.81). In all REQUEST patients, revisions were more common for arterial versus venous grafts (4.7% vs 2.4%; OR = 2.05; CI = 1.29–3.37), and inferior versus anterior (5.1% vs 2.9%; OR = 1.77; CI = 1.08–2.89) and lateral (5.1% vs 2.8%; OR = 1.83; CI = 1.04–3.27) territory grafts. CONCLUSIONS High-frequency ultrasound/TTFM use differentially impacts strategy changes and graft revision rates in different technical circumstances of CABG. Notably, patients undergoing OPCAB experienced 4 times more changes related to the ascending aorta than ONCAB patients. These findings may indicate where intraoperative assessment is most usefully applied. Clinical trial registration number ClinicalTrials.gov: NCT02385344

Funding Acknowledgements Type of funding sources: Public Institution(s). Main funding source(s): Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK) Background Co-existence of atrial fibrillation (AF) and heart failure with preserved ejection fraction (HFpEF) is common and severely affects morbidity and prognosis. Purpose This study evaluates outcome after cryoballoon-ablation for AF in HFpEF compared to patients without heart failure employing multiple diagnostic modalities. Methods A total of 102 patients scheduled for cryoablation of AF with LVEF≥50% were prospectively enrolled. Baseline evaluation included echocardiography, stress echocardiography, six-minute-walk-test, biomarker measurements and quality of life assessment (SF-36). HFpEF was diagnosed according to current guidelines and confirmed applying the HFA-PEFF-Score. Procedural parameters as well as clinical, functional and echocardiographic endpoints at follow-up ≥12 months after AF-ablation were compared between patients with and without HFpEF. Results Patients with HFpEF (n=24) were older (median: 73.5 years [Q25: 66.5 years; Q75: 75.8 years] vs. 64.5 years [Q25: 55.0 years; Q75: 71.3 years], P Conclusion Patients with HFpEF constitute a distinct subgroup with an elevated risk for arrhythmia recurrence after cryoablation of AF. Functional hallmarks and heart-failure related symptoms of HFpEF persisted in our cohort, irrespective of rhythm-status at follow-up. Future research is needed to optimize tailored treatment strategies in HFpEF.

Dissection of the left main coronary artery during coronary artery bypass graft (CABG) surgery is a rare, potentially lethal complication, usually diagnosed at post-mortem. During the cross-clamp period of a 4-vessel coronary artery bypass graft procedure in a 74-year old hypertensive woman, retrograde dissection occurred in a diffusely diseased marginal artery when perfused with cardioplegic solution at a pressure of 140-150 mmHg through a vein graft. The dissection extended back to the left main artery, included the posterior proximal ascending aorta and then down the left anterior descending artery (LAD). Transoesophageal echocardiography (TOE) confirmed the left main dissection and showed anterior-septal-lateral akinesis in a previously normally functioning left ventricle (LV). The circumferentially calcified proximal LAD was grafted with a saphenous vein by carving an oval area of calcium creating an elliptical opening in the artery wall. Normal LV function returned and, in the area of the left main dissection, there was only thickening with no colour flow. Eight months postoperatively cardiac catheterization showed normal LV function, patent vein grafts to the right coronary artery and proximal LAD, left internal mammary artery to distal LAD and an occluded sequential marginal vein graft. Twelve years postoperatively, the patient is well with Class I angina, on medication. There is no previous documentation of a diagnosed and successfully treated left main dissection during CABG surgery. Since this case using the technique of creating an oval opening in a circumferentially calcified coronary artery (with an otherwise satisfactory lumen), the author has been using this technique to bypass otherwise non-bypassable arteries; this technique may be useful to help patients with severe calcific coronary artery disease.

OBJECTIVES: Skeletonization of the internal mammary artery (IMA) facilitates arterial grafting and has been shown to reduce deep sternal infection but is more time-consuming and tedious than pedicle harvest. We wished to determine if use of harmonic technology (HT) facilitates skeletonization of the IMA and is as safe as the conventional technique of skeletonization. METHODS: In a consecutive series of 1057 patients with isolated coronary artery bypass graft (CABG) surgery from 2003 to 2013, adverse events and recorded harvest times were compared between harmonic (965 patients) and non-harmonic patients (86 patients). RESULTS: HT was used to harvest 1640 IMAs in 965 (91%) of 1057 consecutive CABG patients and skeletonization with the traditional technique (use of an electrocautery tip as a dissector) was used to harvest 147 IMAs in 86 patients. Six patients had no IMA harvested with this surgery (4 patients had an IMA used from a previous CABG, 1 had no disease of the left anterior descending coronary artery and 1 patient was in cardiogenic shock precluding IMA use). Excluding patients with single-vessel disease, 730/987 (74%) of patients received bilateral IMAs. Demographics of patients with and without harmonic skeletonization, respectively, were the following: mean age: 64.7 vs 67.7 years; diabetes: 33 vs 34%; women: 21 vs 26% and median European System for Cardiac Operative Risk Evaluation: 2.9 vs 3.2. The mean harvest time for 77 non-harmonic skeletonized mammary arteries (49 surgeries) was 32.2 min (95% confidence interval (CI): 30.1, 34.3), for harmonic skeletonized arteries after 450 surgeries was 28.4 min, (95% CI: 27.8, 29.1) and in the last 100 IMAs harvested for the isolated harmonic device use/mammary was 15.4 min (95% CI: 14.0, 16.7). Major adverse events for patients with and without harmonic skeletonization, respectively, were: reoperation for bleeding: 2.7 vs 3.5% (difference = 0.8%, 95% CI: −3.2, 4.8); damaged mammaries: 0.4 vs 0.7% (difference = 0.3%, 95% CI: −1.0, 1.7); deep sternal infection: 1.6 vs 1.2% (difference = −0.4%, 95% CI: −2.8, 2.0) and perioperative infarction: 1.7 vs 2.3% (difference = 0.7%, 95% CI: −2.6, 4.0). CONCLUSION: In this largest series to date of harmonic IMA skeletonization, this technique results in rare damage, is quicker and with a comparable adverse event rate compared with the non-harmonic method.

Objective: Endothelial dysfunction, specifically endothelium-derived contracting factors have been implicated in the development of arterial conduit vasospasm. The potent vasoconstrictor endothelin-1 (ET-1) has received much attention in this regard. The present study was designed to evaluate the role of ET-1 in the development of endothelial dysfunction in human internal mammary arteries (IMA). To this aim, we examined the effects of specific and non-specific ET-receptor antagonists on endothelial function (assessed using acetylcholine (ACh)-induced vasodilation) in segments of IMA obtained during coronary artery bypass graft (CABG) surgery. Methods: Vascular segments of IMA were obtained from 51 patients undergoing elective coronary artery bypass graft (CABG) surgery and in vitro endothelium-dependent and -independent responses to ACh and sodium nitroprusside (SNP) were assessed. Isometric dose response curves (DRC) to ACh and SNP were constructed in pre-contracted rings in the presence and absence of bosentan (ETA/B receptor antagonist, 3 μM), BQ-123 (ETA antagonist, 1 μM) and BQ-788 (ETB antagonist, 1 μM) using the isolated organ bath apparatus. Percent maximum relaxation (% E max) and sensitivity (pEC50) were compared between interventions. Results: ACh caused dose-dependent endothelium-mediated relaxation in IMA (% E max 43±4, pEC50 6.74±0.12). In the presence of bosentan, BQ-123 and BQ-788 ACh-induced relaxation was significantly augmented (% E max bosentan 60±3, BQ-123 56±4, BQ-788 53±5 vs. control 43±4, P 0.05). Conclusions: These data uncover, for the first time, beneficial effects of ET receptor blockade on endothelial-dependent vasorelaxation in human IMA.

Seven DNA fragments containing putative protein serine/threonine kinase genes were cloned from Streptomyces coelicolor A3(2) by hybridization with a 165-bp amplified polymerase chain reaction product of pkaB containing kinase subdomains VI, VII and VIII. Among them, the nucleotide sequences of three fragments containing subdomains VI, VII and VIII were identical, while those of one fragment were identical with that of afsK, another protein serine/threonine kinase gene. However, these kinase-like genes with very similar nucleotide sequences were distributed on the chromosome of S. coelicolor A3(2).

We thank Collins and Le Manach for their insightful comments on our paper and also for drawing our attention to their article on sample sizes for external validation of prognostic models, which unfortunately was unavailable when our data were analysed. However, their article examined the effect of sample size for proportional hazards models and we used a logistic regression model (with previously published papers more applicable to the assessment of appropriate sample size).

Psychological data from 560 male survivors of acute myocardial infarction (AMI) were documented in the third week after onset of AMI. The psychodiagnostic assessment was designed to detect different forms of depression as well as hyperactive behaviour. A complete follow-up of these patients, which covers a period of 6 months, is available. Our findings indicate that affective disorders play an important role in the post-acute phase after AMI although the extent of myocardial infarction (as defined by an ECG score) and behaviour responses are not significantly related to one another. Different subforms of depression are not influenced by a history of angina pectoris, the degree and location of myocardial infarction, the occurrence of late potentials and age, whereas dyspnoea ( P < 0·001) and the recurrence of myocardial infarction ( P < 0·001) favour depressive mood states. Twelve cardiac deaths and 17 arrhythmic events occurred during the study period; they were significantly predicted by severe forms of post-AMI depression as revealed by univariate analysis. The evidence was stronger for predicting cardiac death ( P < 0·001) than for arrhythmic events ( P = < 0·035). The effect remains of borderline significance for cardiac death if all risk factors with a significant univariate influence are included in a multiple logistic regression model. The effect of depression is illustrated by Kaplan—Meier survival curves separated for patient groups with high as compared to low degrees of depression. Hyperactivity showed no impact on patient survival.