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The objective of this study is to evaluate the costs and health benefits of coronary artery bypass grafting (CABG) surgery with and without cardiopulmonary bypass (CPB). Randomized controlled clinical trial is used as the design. The setting is in a single tertiary cardiothoracic center in Middlesex, UK. Participants were 168 patients (27 females) requiring primary isolated CABG surgery. Patients were randomized to have the procedure performed by a single surgeon either with CPB (n = 84) or by an off-pump coronary artery bypass (OPCAB) surgery (n = 84). Health-related quality of life was assessed at baseline, 6 weeks, and 6 months using the World Health Organization Quality-of-Life (WHOQOL-100) questionnaire. Mean total costs of patient management by either technique were calculated using different available key sources. A utility measure, derived from WHOQOL-100, was used to calculate quality-adjusted life year (QALY) gained in each group, on basis of which a cost-effectiveness analysis was performed. The mean total costs of an OPCAB patient was 5859 pounds , whereas for a CPB patient it was 7431 pounds with a mean difference of 1572 pounds (standard error [SE] 674 pounds ; P = 0.02). Three patients died in the CPB group and two in the OPCAB group during the 6-month follow-up period. Mean QALYs over 6 months was 0.379 in the OPCAB group and 0.362 in the CPB group, but the difference was not significant (mean difference 0.017; SE 0.016; P = 0.305). OPCAB surgery offered patients in this randomized trial similar health benefits to CPB over a 6-month period, but at a significantly less cost.

Background: Although the off-pump technique is becoming widely used in coronary bypass surgery, there has been no experimental rat heart model of regional reversible ischemia. The aims of this study were to investigate the optimal duration of coronary occlusion for making reversible ischemia and to examine whether cerivastatin increases myocardial tolerance against prolonged coronary occlusion., Methods: Study 1--Male Sprague-Dawley rats (350 to 450 g) underwent temporary occlusion of either left anterior descending artery (LAD; for 3, 5, 7.5, 10, 12.5, 15, or 20 min) or circumflex artery (CX; for 5, 10, or 15 min). Study 2--Rats were divided into two groups, control and cerivastatin groups, which had 0.1 mg/kg cerivastatin intravenously after anesthesia. LAD was occluded for 10, 15, or 20 minutes. In the both studies, hearts were stained to determine the area at risk (AR) and infarcted (IF) area 24 hours after reperfusion., Results: In LAD occlusion, IF/AR increased in a time dependent manner: 4.5 +/- 3.2%, 9.7 +/- 5.2%, 17.2 +/- 3.0%, 16.8 +/- 2.7%, 23.9 +/- 9.5% (p < 0.01 vs. 3 min), 62.4 +/- 2.9% (p < 0.0001), and 63.4 +/- 2.9% (p < 0.0001) at 3, 5, 7.5, 10, 12.5, 15, and 20 min, respectively. Also in CX, IF/AR increased with time: 14.3 +/- 2.3%, 25.9 +/- 2.1%, and 40.9 +/- 6.2% (p < 0.001 vs. 5 min) at 5, 10, and 15 min, respectively. Cerivastatin significantly reduced IF/AR at 15 minutes (43.7 +/- 6.2%) and at 20 minutes (44.6 +/- 5.3%) compared to control (62.4 +/- 2.9% and 60.6 +/- 2.5%, respectively, p < 0.05)., Conclusion: Cerivastatin increased myocardial tolerance after prolonged coronary occlusion over 10 minutes, which was considered to be the upper limit for creating a regional reversible ischemia in rats.

Objective: The use of the radial artery (RA) as a conduit for coronary artery bypass grafting (CABG) is gaining in popularity worldwide and is being increasingly adopted by many cardiac surgeons. Encouraged by our satisfactory early experience with the use of the RA conduit, we have expanded its use to more than 90% of all coronary surgery patients. The aim of the present study was to review our clinical and angiographic results when the use of the RA conduit was expanded to all patients including those aged 65 years and older and diabetics with different surgical grafting techniques., Methods: The records of 600 consecutive patients who underwent isolated CABG using the RA graft at Harefield Hospital between January 1999 and August 2002 were reviewed retrospectively. Ninety-three (15.5%) patients consented and underwent angiography before discharge at the earliest on the fourth postoperative day, aiming to look at the quality of anastomoses and the patency of the RA grafts., Results: The 600 patients had 613 RA grafts to perform 652 distal RA anastomoses. The proximal ends of 515 (84%) RA grafts were anastomosed to the aorta, 98 (16%) RA grafts were constructed as Y-grafts with 49 (8%) RA off a vein graft hood, and 49 (8%) RA grafts were constructed as T- or Y-grafts off an internal thoracic artery (ITA) graft. The proximal ends of 19 (19/294 or 6.5%) vein grafts were constructed as Y-grafts off the RA grafts. Two hundred and sixty-one (43.5%) patients were above the age of 65 years and 111 (18.5%) patients were diabetics. There were four in-hospital deaths (0.6%) among the study patients. Six (1%) patients developed forearm hematoma/seroma postoperatively. The operation time, the hospital stay, and the incidence of conduit harvest site infection for the patients who had vein grafts in addition to the RA grafts were significantly higher than those of patients who had RA grafts only. On postoperative angiography, 86 out of 93 (92.5%) RA grafts were found to be patent with good quality distal anastomoses. The maximum stenosis of the coronary arteries bypassed by the patent 86 RA grafts was 82.6 +/- 6.2%, while it was 56.3 +/- 15.4% for the coronary arteries bypassed by the occluded seven RA grafts, p < 0.001., Conclusion: The use of the RA can be expanded to all patients with different surgical grafting techniques and provides satisfactory clinical and angiographic outcomes.

Background: There are a number of strategies to restore/preserve endothelial function. We have compared the effects of Cerivastatin (CS) to those of L-arginine (L-ARG) supplementation on the endothelial function of human arterial grafts., Methods: During coronary artery bypass grafting, specimens of radial artery (RA) and left internal thoracic artery (LITA) were obtained. Specimens were divided into vascular rings, which were incubated with either 10(-6) mol/L CS, 10(-3) mol/L L-ARG, or vehicle (control) for 2 or 24 hours. Endothelial function was examined with acethylcholine (10(-9) to 10(-5) mol/L) following contraction by 3 x 10(-8) mol/L endothelin-1., Results: Although no significant differences were observed in the RA at 2 hours, after 24 hours incubation, endothelium-dependent vasodilatation was significantly higher in CS group (68.4 +/- 5.0%; n = 6) compared to L-ARG group (49.9 +/- 5.4%; n = 7, p < 0.05) and control group (33.8 +/- 2.9%; n = 13, p < 0.0001). In addition, there was a significant increase in L-ARG group compared to control (p < 0.01). After 2 hours incubation of the LITA, CS failed to enhance endothelium-dependent vasodilatation compared to control (44.1 +/- 4.9%; n = 9, vs. 40.0 +/- 5.2%; n = 16, respectively, NS), while L-ARG increased it (64.7 +/- 4.9%; n = 7, p < 0.05 vs. CS and p < 0.01 vs. control). However, this increase disappeared at 24 hours although there was a higher trend of endothelium-dependent vasodilatation in CS group (30.3 +/- 3.7%; n = 8 in L-ARG, 56.5 +/- 8.8%; n = 9 in CS and 41.0 +/- 5.5%; n = 18 in control)., Conclusions: CS preserved endothelium-dependent vasodilatation of RA greater than L-ARG. These findings suggest that the use of statins may be an effective therapeutic strategy to preserve endothelial function in the RA grafts, and could have important implications in the clinical practice.

Background: Minimally invasive direct coronary artery bypass (MIDCAB) through a limited anterior small thoracotomy has been shown to be a promising technique of surgical treatment for single or double vessel disease. Little is known about the Health-Related Quality Of Life (HRQOL) in this group of patients., Methods: The records of 75 consecutive patients who underwent MIDCAB procedure at Harefield Hospital between April 2000 and January 2002 were reviewed retrospectively. HRQOL assessment was planned in a cross-sectional design. Patients were contacted by telephone to conduct a semi-structured interview and were sent two questionnaires: the Short Form health survey (SF-36) and the Hospital Anxiety and Depression Scale (HADS)., Results: There was no in-hospital death. Patients stayed in the Intensive Therapy Unit (ITU) for 11.56 +/- 4.55 hours and stayed in hospital for 3 +/- 2.34 days. None of the study patients had perioperative myocardial infarction (MI) or neurological complications including permanent and transient strokes. We were able to contact all the 75 patients by telephone and they also completed the SF-36 and HADS. The SF-36 scores were compared to an age-matched group of normal British people. The MIDCAB group had an excellent general health perception compared to the normal group (p < 0.001), but similar scores otherwise. The HADS scores showed that only 1 patient (1.3%) had mild depression, 5 patients (6.7%) had mild anxiety, and 2 patients (2.6%) had moderate anxiety., Conclusion: MIDCAB is a safe surgical treatment and provides excellent clinical and HRQOL outcomes.

Background: Although Off-Pump Coronary Artery Bypass (OPCAB) surgery is being increasingly explored and practised in many cardiac units worldwide, there have been only few reports documenting the training of surgeons in this new technique. The purpose of this study was to address the reproducibility of the OPCAB in a unit where this technique is used extensively., Methods: Registry data, notes, and charts of 64 patients who were operated on by four trainee cardiac surgeons over a period of thirteen months at Harefield Hospital, were reviewed retrospectively. These trainees were part of an accredited training program for cardiothoracic training and were trained by a single consultant trainer in a cardiac unit after it had an established recent experience in performing nonselective OPCAB for all in-coming patients. Five (7.8%) patients (with 17 distal anastomoses) consented and underwent early postoperative angiography to check the quality of the grafts and anastomoses., Results: The mean age of the study patients was 65.6 and the mean Parsonnet score was 9.4. There was a mean of 2.9 grafts per patient and circumflex territory anastomoses were performed in 48 (75%) patients. No operation required conversion to Cardiopulmonary Bypass (CPB). Angiography of the five patients revealed 17 satisfactory (100%) distal anastomoses., Conclusion: With appropriate training, it is possible for trainees to learn OPCAB and perform multivessel revascularization in relatively high-risk patients with good results.