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OBJECTIVES The intermediate-term all-cause mortality rate of real-world patients with multivessel disease (MVD) treated with percutaneous coronary intervention (PCI) with new-generation drug-eluting stents or coronary artery bypass grafting (CABG) remains unknown. We sought to compare the intermediate-term all-cause mortality rates of real-world patients with MVD including left main stem disease, treated with CABG or PCI. METHODS All consecutive all-comer patients with MVD undergoing CABG or PCI with second/third generation drug-eluting stents from 2007 to 2015 in Harefield Hospital, UK were included in this study. The revascularization modality was based on heart team discussions. Primary outcome was all-cause mortality. Mean follow-up of the study was 3.3 years. Cox regression analysis and propensity matching were used. RESULTS Of 6383 patients with MVD, 4230 underwent CABG, whereas 2153 had PCI with new-generation stents. In the CABG group, the mean age was 66.4 ± 10 years, whereas in the PCI group it was 65.3 ± 12.1 years (P CONCLUSIONS In this contemporary cohort of real-world patients with MVD, CABG was associated with increased intermediate-term survival compared to PCI with new-generation drug-eluting stents.

Objectives We designed a pilot study to evaluate safety and feasibility of an inexpensive and simple approach to intracoronary hemodilution during primary angioplasty (PPCI) to reduce reperfusion injury. Introduction Early revascularization in acute myocardial infarction decreases infarct size and improves outcomes. However, abrupt restoration of coronary flow results in myocardial reperfusion injury and increased final infarct size. Dilution of coronary blood during revascularization may help reduce this damage. If proved effective, such an approach would need to be simple and suitable for widespread adoption. Methods Ten patients presenting with STEMI underwent intracoronary dilution with room temperature Hartmann's solution delivered through the guiding catheter during primary angioplasty (PPCI). Infusion of perfusate began prior to crossing the occluded artery with the guidewire, continuing until 10 min after completion of the balloon and stenting procedure. Infusion was briefly interrupted for contrast injection and pressure monitoring. The outcome measures were safety, including intracoronary temperature reduction and volume of intracoronary perfusate infused, and technical feasibility. Results There were no significant symptomatic, hemodynamic, ECG ST/T segment or rhythm changes observed during perfusate administration. The median (interquartile range) volume of perfusate administered was 550 mL (350–725 mL) and the median intracoronary temperature reduction observed was 3.4°Celsius. Myocardial salvage was 0.54 (0.43–0.65). Conclusions Transcatheter intracoronary hemodilution with room temperature perfusate during PPCI is feasible and appears safe. Such a strategy is simple and inexpensive, with potential to be widely applied. Further mechanistic and subsequent outcome powered studies are required to evaluate whether this strategy can reduce reperfusion injury in STEMI.

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.

Summary Background Coronary stents improve immediate and late results of balloon angioplasty by tacking up dissections and preventing wall recoil. These goals are achieved within weeks after angioplasty, but with current technology stents permanently remain in the artery, with many limitations including the need for long-term antiplatelet treatment to avoid thrombosis. We report a prospective multicentre clinical trial of coronary implantations of absorbable magnesium stents. Methods We enrolled 63 patients (44 men; mean age 61·3 [SD 9·5 years]) in eight centres with single de novo lesions in a native coronary artery in a multicentre, non-randomised prospective study. Follow-up included coronary angiography and intravascular ultrasound at 4 months and clinical assessment at 6 months and 12 months. The primary endpoint was cardiac death, non-fatal myocardial infarction, or clinically driven target lesion revascularisation at 4 months Findings 71 stents, 10–15 mm in length and 3·0–3·5 mm in diameter, were successfully implanted after pre-dilatation in 63 patients. Diameter stenosis was reduced from 61·5 (SD 13·1%) to 12·6 (5·6%) with an acute gain of 1·41 mm (0·46 mm) and in-stent late loss of 1·08 mm (0·49 mm). The ischaemia-driven target lesion revascularisation rate was 23·8% after 4 months, and the overall target lesion revascularisation rate was 45% after 1 year. No myocardial infarction, subacute or late thrombosis, or death occurred. Angiography at 4 months showed an increased diameter stenosis of 48·4 (17·0%). After serial intravascular ultrasound examinations, only small remnants of the original struts were visible, well embedded into the intima. Neointimal growth and negative remodelling were the main operating mechanisms of restenosis. Interpretation This study shows that biodegradable magnesium stents can achieve an immediate angiographic result similar to the result of other metal stents and can be safely degraded after 4 months. Modifications of stent characteristics with prolonged degradation and drug elution are currently in development.

Minimally invasive direct coronary artery bypass (MIDCAB) surgery has been shown to be a promising technique for surgical treatment of single or double vessel disease. However, little is known about quality of life, mood state or coping in this group of patients. The records of 55 consecutive patients who underwent MIDCAB surgery at Harefield Hospital between April 1999 and May 2001 were reviewed. In order to assess quality of life, mood state and coping, patients were contacted by telephone to conduct a semi-structured interview and were subsequently sent four questionnaires. The measures used were the Hospital Anxiety and Depression Scale, the Short Form Health Survey, the WHOQoL-BREF and the COPE. Forty-eight patients were contacted by telephone, forty-four of whom returned the completed questionnaires. Overall ratings of quality of life were excellent for the majority of patients, and rates of anxiety and depression were lower than previously found following coronary artery bypass surgery. It is concluded that following MIDCAB surgery quality of life and mood state outcomes are encouraging. However, a prospective, longitudinal study is now required to further elucidate the relationship between quality of life, mood state and coping and to identify predictive factors for physical and psychological outcome following this new surgical technique.

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.

Y-grafting is a common coronary grafting technique for performing composite coronary grafts. The outcome and efficacy of this technique have not been studied in detail in the literature. We report a case of an occlusion in the proximal limb of a Y-graft, changing it into a C-shaped conduit and causing a steal syndrome. Our aim is to raise the level of caution when performing this type of composite graft and to suggest how this complication can be managed postoperatively.

The aim of the study was to investigate the relationship between myocardial collagen and regional echo amplitude in humans with non-fibrotic myocardium. The ratio of myocardial collagen to total myocardial protein was determined as the hydroxyproline/leucine ratio in endoniyocardial biopsies obtained from the right ventricular side of the interventricular septum in orthotopically transplanted hearts. Regional echo amplitude was measured in the interventricular septum. Patients were studied prospectively. Twenty-five patients (five female, 20 male) who had undergone orthotopic cardiac transplantation were studied 355 to 2939 days (1009±718, mean±SD) post-transplantation at the time of annual cardiac catheterization and endomyocardial biopsy. Patient ages varied from 22 to 62 years (46±11). Donor ages were 14 to 47 years (25±8) and the ischaemic time, 90 to 245 min (151±42). Cardiac transplantation was performed for end-stage cardiac failure in all patients. The aetiology of cardiac failure was valvular heart disease in three, dilated cardiomyopathy in eight and ischaemic heart disease in the remainder. Echo amplitude studies were performed within 24 h of endomyocardial biopsy. All but one patient were on an immunosuppressive regime consisting of cyclosporine A and azathioprine with additional steroids in three. The remaining patient, who was the longest surviving patient in the study group, had never been treated with cyclosporine. This patient was maintained on steroids and azathioprine alone. No patient had clinical or histological evidence for acute cardiac rejection and all were clinically well. Five patients had angiographic evidence of coronary artery disease. All subject studies were performed at Harefield Hospital. Echo amplitude analysis was performed at the Royal Brompton Hospital. Myocardial collagen analysis was performed in the Biochemistry Unit at the National Heart and Lung Institute. End-diastolic echo amplitude was measured in the interventricular septum. A micro-analytical technique was used to measure the myocardial hydroxyproline/leucine ratio. There was a weak but significant correlation between the estimate of myocardial collagen measured by the hydroxyproline/leucmne ratio and end-diastolic echo amplitude (r = 0.41, P = 0.04, y = 3.66x + 4.24). If the five patients with angiographically documented coronary artery disease were excluded from analysis the correlation was substantially improved (r = 0.51, P = 0.02, y=4.19x+3.89). These findings suggest that the variation in collagen in the myocardium is responsible for approximately 20% of the observed variation in myocardial backscatter signal in non-fibrotic hearts. This supports clinical studies which have shown increases in myocardial ultrasonic backscatter in conditions where myocardial fibrosis occurs and also indicates the importance of myocardial collagen in determining the ultrasonic backscatter signal in normal hearts.

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To determine the efficacy and safety of liposorber D low-density lipoprotein (LDL) apheresis system in high-risk cardiac patients.Retrospective analysis of 466 treatments undertaken in eight patients with coronary heart disease. Five patients had severe heterozygous familial hypercholesterolaemia (FH), one had severe hypertriglyceridaemia and two were cardiac transplant recipients with FH intolerant to statins. Acute reductions during single sessions and preprocedural long-term changes in lipoprotein subfractions, laboratory safety parameters, adverse events and clinical outcome were recorded.In 352 treatments performed in seven patients, acute reductions averaged 52.8% (standard deviation: 8.61%) for total cholesterol (TC), 61.8% (10.13%) for LDL-cholesterol (LDL-C), 21.1% (9.66%) for high-density lipoprotein cholesterol (HDL-C), 71.1% (median) for lipoprotein (a) [Lp(a)] and 44.5% (14.42%) for triglycerides (p0.05). Long-term reductions of TC, LDL-C, Lp(a) and triglycerides by 18.1%, 21.7%, 9.4% (median) and 19.8%, respectively, were achieved. HDL-C was increased by 7.5%. Results from the patient with severe hypertriglyceridaemia were analysed separately because of markedly elevated TC and triglycerides. Technical and clinical complications were mild and showed an incidence of 16.65% and 12.45% respectively. The most common clinical event was transient hypotension (5.8%), whereas vascular access difficulties (11.3%) represented a common technical problem. All patients demonstrated clinical improvement. However, two patients treated via a central line developed septicaemia, resulting in endocarditis in one of them.Liposorber D is a simple, safe and effective modality in reducing atherogenic lipoproteins in dyslipidaemic high-risk cardiac patients. The treatment via an arteriovenous fistula is the preferred vascular access in this type of patient.

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 Collateral channels can protect from infarction, even in the presence of a total or sub-total occlusion. Acute re-occlusion following restoration of flow may still lead to ischaemia or infarction. It is unclear whether collaterals respond differently to tachycardia-induced stress and balloon inflation. This study compared the response of collateral-dependent viable myocardium to repetitive atrial pacing with the response to multiple balloon occlusions during percutaneous transluminal coronary angioplasty (PTCA). METHODS AND RESULTS Fifteen patients undergoing elective single vessel PTCA with well-developed collateral channels supplying the target vessel were recruited. Patients underwent two periods of incremental atrial pacing (P(1); P(2)) followed by two 90-s balloon inflations (I(1); I(2)). Collateral flow velocity was assessed by Doppler flow wire across the target lesion. Evidence of ischaemia was obtained from monitoring of surface ST-segments and by chest pain scores recorded on a visual analogue scale. Retrograde and 'aggregate' flow velocities were significantly lower during I(1) and I(2) than either P(1) or P(2). Reduction in flow velocity was most marked during I(1) compared with P(1) or P(2). Chest pain score was lower during P(2) than P(1) (3.8 +/- 3.5 versus 5.5 +/- 3.0, P < 0.02), although flow velocity was unchanged. CONCLUSION Collateral flow velocity is significantly higher during tachycardia-induced stress than balloon occlusion. Restoration of antegrade flow by balloon inflation results in a further reduction in flow during a second inflation, suggesting a functional down-regulation of the collateral channels. Ischaemic symptoms are attenuated with repetitive pacing independent of collateral flow, suggesting an additional preconditioning response.

Objective: Although there has been some evidence supporting the theoretical and practical advantages of off-pump coronary artery bypass (OPCAB) over the conventional coronary artery bypass grafting (CABG) with cardiopulmonary bypass (CPB), it has not yet been determined which group of patients would benefit most from it. It has been advocated recently that high-risk patients could benefit most from avoidance of CPB. The aim of this retrospective study is to assess the efficacy of the OPCAB technique in multi-vessel myocardial revascularization in a large series of high-risk patients. Methods: The records of 1398 consecutive high-risk patients who underwent primary isolated CABG at Harefield Hospital between August 1996 and December 2001 were reviewed retrospectively. Patients were considered as high-risk and included in the study if they had a preoperative EuroSCORE of $5. Two hundred and eighty-six patients were operated on using the OPCAB technique while 1112 patients were operated on using the conventional CABG technique with CPB. The OPCAB patients were significantly older than the CPB patients (68.1 ^ 8.3 vs. 63.7 ^ 9.9 years, respectively, P , 0:001). The OPCAB group included significantly more patients with poor left ventricular (LV) function (ejection fraction (EF) #30%) (P , 0:001) and more patients with renal problems (P , 0:001). Results: There was no significant difference in the number of grafts between the groups. The CPB patients received 2.8 ^ 1.2 grafts per patient while OPCAB patients received 2.8 ^ 0.5 grafts per patient (P ¼ 1). Twenty-one (7.3%) OPCAB patients had one or more major complications, while 158 (14.2%) CPB patients (P ¼ 0:008) developed major complications. Thirty-eight (3.4%) CPB patients developed peri-operative myocardial infarction (MI) while only two (0.7%) OPCAB patients developed peri-operative MI (P ¼ 0:024). The intensive therapy unit (ITU) stay for OPCAB patients was 29.3 ^ 15.4 h while for CPB patients it was 63.6 ^ 167.1 h (P , 0:001). There were ten (3.5%) deaths in the OPCAB patients compared to 78 (7%) deaths in the CPB patients (P ¼ 0:041) within 30 days postoperatively. Conclusions: This retrospective study shows that using the OPCAB technique for multi-vessel myocardial revascularization in high-risk patients significantly reduces the incidence of peri-operative MI and other major complications, ITU stay and mortality. Even though the OPCAB group included a significantly higher proportion of older patients with poor LV function (EF #30%) and renal problems, the beneficial effect of OPCAB was evident. q 2002 Elsevier Science B.V. All rights reserved.

Background. The left internal thoracic artery (LITA) graft to the left anterior descending (LAD) artery became the gold standard graft in coronary surgery. Subsequently, the right internal thoracic artery (RITA) graft was increasingly used. However, there is still some debate about the optimal way of using this conduit. The aim of the present study was to assess our experience in grafting the pedicled RITA graft to LAD in 212 consecutive patients. Methods. The records of 212 consecutive patients who underwent isolated coronary artery bypass grafting with the pedicled RITA graft to the LAD artery at Harefield Hospital between January 1998 and May 2001 were retrospectively reviewed. We approached the last 35 consecutive patients to obtain an angiographic control group. All 35 patients (16.5%) consented and, before discharge, underwent angiography to look at the quality of anastomoses and the patency of grafts. Results. Successful catheterization and engagement of the RITA grafts was performed in 32 patients. Angiography showed that 32/32 (100%) of the RITA grafts were widely patent with excellent flow. The distal anastomoses of these RITA grafts were also satisfactory. There were no deaths among the study patients. Conclusions. Our results show that the use of the pedicled RITA graft to the LAD artery provides a good early clinical and angiographic outcome, and suggests that the pedicled RITA graft to the LAD artery is a good alternative to the pedicled LITA graft to the LAD artery.

ObjectivesWe sought to evaluate the in vivo endothelial function of the radial artery (RA) used as a coronary graft.BackgroundThe RA is becoming a recognized alternative coronary bypass conduit. In vivo endothelial function is a possible predictor of long-term performance.MethodsSixty consecutive patients underwent coronary artery bypass graft surgery (CABG); all received RA and left internal mammary artery (LIMA) grafts. Three weeks after CABG, 36 patients underwent angiography under basal conditions, during pacing and after intragraft injection of glyceryl trinitrate (GTN). Angiography was repeated at six months in 20 patients.ResultsThe estimated mean difference of 66 segments of the radial graft on the first QCA study was 0.170 mm (95% confidence interval [CI] 0.101 to 0.258, p < 0.001) between baseline and pacing, and 0.310 mm (CI 0.225 to 0.401, p < 0.001) between baseline and GTN. At six months, the differences between baseline and pacing and baseline and GTN were 0.112 mm (CI 0.062 to 0.162, p < 0.001) and 0.274 (CI 0.192 to 0.353, p < 0.001), respectively. The difference between baseline values at three weeks and six months was 0.416 mm (CI 0.236 to 0.603, p < 0.001). In the LIMA segments, the difference between baseline and pacing and baseline and GTN were 0.206 mm (CI 0.136 to 0.278, p < 0.001) and 0.304 mm (CI 0.213 to 0.396, p < 0.001), respectively. At six months, the differences between baseline and pacing and baseline and GTN were 0.098 mm (CI 0.014 to 0.173, p < 0.001) and 0.218 mm (CI 0.130 to 0.298, p < 0.001). The difference between baseline values at three weeks and six months was 0.061 mm (CI 0.064 to 0.176, p > 0.05).ConclusionsIn vivo flow-mediated dilation of the RA is comparable to that of pedicled LIMA. The increased dilation both at baseline and after pacing at six months represents a time-related improvement in the vasomotor function of the RA, which could have implications for its performance as a coronary conduit.

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.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 programme for cardiothoracic training and were trained by a single consultant trainer in a cardiac unit after it has had an established recent experience in performing non-selective OPCAB for all coming-in patients. Five (7.8%) patients (with 17 distal anastomoses) consented and underwent early postoperative angiography to check the quality of the grafts and anastomoses.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 satisfactory seventeen (100%) distal anastomoses.With appropriate training, it is possible for trainees to learn OPCAB and perform multi-vessel revascularization in relatively high-risk patients with good results.

Objectives The aim of this study was to assess the influence of valve substitute (homograft vs prosthetic valve) on the long-term survival and late valve-related complication rates following aortic valve replacement in patients with aortic valve disease and congestive heart failure. Background The effect of choice of valve substitute on outcome after aortic valve replacement in patients with pre-operative heart failure is unknown. The superior haemodynamic profile of homografts may be of particular benefit. Methods We retrospectively analysed pre-operative, operative and follow-up data on 518 adults in functional classes III and IV, who, over the 25 years 1969–1993, had their initial aortic valve replacement at Harefield hospital. Follow-up conducted during 1996 to April 1997 and totalling 4439 patient-years was 96·1% complete. Using multivariate analysis, independent risk factors for different complications and mortality were defined. Results Overall 5-, 10- and 20-year survival was 80±2%, 62±2% and 30±3%, respectively, with no significant difference between valve types. However, homografts (n=381) independently reduced the rate of serious complications and cardiac death, whereas mechanical valves were an independent adverse risk factor for late mortality. The rates of anticoagulant-related bleeding and thromboembolism were increased by mechanical valves, whereas primary tissue failure was the main complication of homografts. Conclusions Long-term outcome of homograft aortic valve replacement in patients with congestive heart failure is acceptable, with a reduced rate of serious complications and cardiac death. Further improvements would be expected if the rate of primary tissue failure could be reduced.

BACKGROUND AND PURPOSE Heterotopic cardiac transplantation is a valuable surgical technique that maximizes the use of donor organs. However, recipient heart function may decline steadily postoperatively with resulting clinical deterioration. Paced linkage has the potential of reducing afterload and enhancing coronary flow of both hearts, thereby improving recipient- and donor-heart function. This may have long-term as well as short-term benefits. METHODS AND RESULTS The study was performed on 11 heterotopic transplant recipients. The two hearts were linked with a pacemaker (paced linkage) to produce recipient heart systole during different periods of donor-heart diastole. The recipient ventricular contraction was timed to occur during early, mid, and late diastole of the donor heart. Hemodynamic baseline measurements were compared with the optimal counterpulsated data. Paced linkage produced significant improvements in total cardiac output, 5.0 +/- 0.9 compared with baseline 4.5 +/- 0.8 L/min (P = .021); recipient coronary sinus flow, 278 +/- 145 versus 186 +/- 108 mL/min (P = .022); and aortic systolic pressure, 135 +/- 27 versus 123 +/- 27 mm Hg (P = .005). There was an overall improvement in systolic ventricular performance in the recipient heart when pace linked, as evidenced by a significant increase in left ventricular systolic pressure of 118 +/- 36 compared with the baseline value of 108 +/- 33 mm Hg (P = .016), an increase in ejection period from 174 +/- 30 versus 203 +/- 48 (P = .046), and a decrease in the pre-ejection period of 147 +/- 37 when paced versus 181 +/- 39 milliseconds (P = .013). The metabolic studies showed a significant decrease in hypoxanthine release from a baseline level of 0.4 mumol/L to a paced value of -0.06 mumol/L (P = .002); these very low values would suggest that there is no evidence of ischemia. Hemodynamic changes in the donor heart included a significant reduction in the left ventricular end-diastolic pressure from 6.8 +/- 4.4 versus baseline of 10.5 +/- 5.8 mm Hg (P = .029) and in maximum -dP/dT from 3.2 +/- 1.7 versus baseline of 2.1 +/- 1.1. CONCLUSIONS Paced linkage after heterotopic cardiac transplant produces significant functional improvements in both hearts. Permanent pacemaker implantation may sustain these acute benefits and prevent the premature deterioration of the recipient heart.

Summary: It has been shown that following heterotopic heart transplantation the recipient letl ventricle ejects more effectively when it contracts out of phase with the donor left ventricle. However, this is rarely the situation, as the two hearts beat independently of one another and the denervated donor heart tends to beat faster than the recipient. In this study the hemodynamic effects of connecting the two hearts by an external temporary dual-chamber pacemaker were evaluated. The donor right ventricle was sensed and the recipient right atrium paced after a timed delay. The delay was adjusted so that recipient systole coincided with donor diastole. Eleven patients were studied in the tirst postoperative day. Pacing resulted in an improvement in cardiac output from 5.0 to 5.6 I/min (p = 0.003) and a reduction in pulmonary capillary wedge pressure from I6 to 12 mmHg (p = 0.0035). This was associated with a 35% reduction in inotrope requirements. It is concluded that sequential pacing ofthe two hearts is a useful adjunct to inotropic support in the postoperative period.

OBJECTIVE--To determine differences in coronary risk factors between women and men and their relation to in-hospital mortality associated with coronary artery bypass grafting. DESIGN--Prospective observational study. SETTING--A regional cardiothoracic centre. PATIENTS--482 (362 (75%) men and 120 (25%) women) consecutive patients who had primary isolated coronary artery bypass grafting. RESULTS--The women were on average three years older than the men (63 v 60 years, P < 0.001). Women more frequently had hypertension (47% v 33%, P < 0.01), diabetes mellitus (21% v 10%, P < 0.005), hypothyroidism (9% v 2%, P < 0.003), and a family history of premature coronary heart disease (49% v 31%, P < 0.0006). More of the men were cigarette smokers (67% v 45%, P > 0.00001). Many of the women and men had dyslipidaemia. Postmenopausal women had a higher concentration of serum total cholesterol than men of a comparable age, (7.3 mmol/l v 6.5 mmol/l, P = 0.0002). Although arterial grafts were often used in both sexes, they were more often used in men than in women (91% v 78% respectively, P = 0.0003). In-hospital mortality was 2.1% (1.4% in men and 4.2% in women, P = 0.14). The estimated one year probability of survival in men who had survived 30 days was 0.99 with 95% confidence interval 0.98 to approximately 1 while that for women was 0.97 with 95% confidence interval 0.91 to approximately 1. Univariate analysis showed that preoperative history of diabetes mellitus was a predictor of mortality (P = 0.03). CONCLUSION--There were differences in the incidence and type of risk factors in men and women who had coronary artery bypass grafting. Preoperative diabetes mellitus was a predictor of in-hospital mortality.

Vein graft atherosclerosis is a common and serious complication of coronary artery bypass grafting (CABG). There is mounting evidence that lipoprotein abnormalities play an equally important role in the development of lesions in saphenous vein grafts after CABG as in native coronary vessel disease. The potential benefit of low-dose lipid lowering combination therapy in these patients has not been investigated. In a randomized, double-blind, placebo-controlled study, we compared the efficacy and safety of a low-dose combination of colestipol 10 g and simvastatin 10 mg/day (CS) to colestipol 10 mg and bezafibrate 400 mg/day (CB) for 2 months in 33 patients with serum total cholesterol > 6.5 mmol/l and triglyceride < 4.5 mmol/l who had undergone CABG for severe coronary artery disease. In the CS group, total cholesterol decreased by 29% and low-density lipoprotein (LDL) cholesterol by 42%; similarly, CB reduced total cholesterol by 17%, LDL cholesterol by 23%, triglyceride by 19%, and increased high-density lipoprotein (HDL) cholesterol by 14%. Lipoprotein (a) and hemostatic factors were unaffected by either therapy in this study. Both combination therapies were well tolerated with no significant clinical or biochemical side effects. We conclude that low-dose combinations of colestipol and simvastatin or colestipol and bezafibrate are effective and well tolerated in the management of moderate hyperlipidemia in patients who had undergone CABG.

Pericardial effusion and coronary dissection are well known complications of percutaneous transluminal coronary angioplasty (PTCA). We report a rare case of sub-epicardial haematoma after PTCA, leading to local compression and cardiogenic shock. We discuss the successful management of this problem.

Accelerated coronary artery disease following cardiac transplantation remains an important obstacle to long-term survival and the correct management strategy remains unclear. This observational, prospective study was designed to examine the feasibility of using percutaneous transluminal coronary angioplasty (PTCA) in the treatment of post-transplant coronary disease. Thirteen consecutive patients were selected from the total population of 276 transplant recipients who underwent routine coronary angiography between 1987 and 1990. Selection of patients was on angiographic criteria alone and PTCA was performed to all accessible stenoses with more than 80% luminal narrowing. PTCA was performed using standard angioplasty equipment and procedure as considered appropriate for the individual lesion. A successful PTCA was defined as more than 30% reduction in luminal narrowing and a residual narrowing of less than 50%. Restenosis was defined as a loss of 50% or more of the gain achieved at the time of successful PTCA or more than a 30% increase in narrowing at the site of stenosis. A total of 31 lesions were dilated in this group and a successful result was achieved in 29 of these (93%) and in 12 of the 13 patients. The one patient with failed PTCA underwent later successful coronary artery bypass grafting to complete revascularization. Four of the 13 patients have had two angioplasty procedures, two for restenosis and two for disease progression in other sites. One patient died 15 months after the initial PTCA and the remaining 12 were asymptomatic with good exercise tolerance and ventricular function at a mean of 19 months (range 1-39 months) following first PTCA.(ABSTRACT TRUNCATED AT 250 WORDS)

Between 10 and 20% of coronary arteriograms in patients with chest pain show normal vessels, often in association with a history of "atypical" angina. Conventional non-invasive tests are inaccurate in this group of patients compared with those with classical angina. This study prospectively evaluates combined 12 lead exercise electrocardiography and thallium-201 scintigraphy as a screening test in patients with atypical angina in order to determine whether normal arteriograms are avoidable in this important subgroup of patients presenting with chest pain. Sixty seven consecutive patients with atypical angina underwent both maximal exercise testing and thallium scintigraphy before coronary arteriography. Chest pain during exercise was a poor predictor of coronary disease in this group. Eleven (16%) had abnormal arteriography, with the sensitivity of exercise and thallium tests being 45% and 73%, respectively. When both tests were applied the predictive accuracy for normal coronary arteries was 96% (54/56) and that for the presence of coronary disease was 82% (9/11). If coronary arteriography was withheld in patients in whom both the exercise test and thallium scintigraphy were negative, the number of normal coronary arteriograms could be reduced with only a very small risk of failing to detect individuals with coronary disease.

Back of every safety program there stands the industry itself with its precedents, prejudices and traditions. Coal mining, being an old established industry, naturally had many fixed traditions long before electricity and electrical equipment, comparatively new forces, made their appearance.

An acute thrombotic occlusion of a mitral prosthesis in a hemodynamically compromised patient was successfully lysed with intravenous streptokinase. Unfortunately, the patient had a major cerebral embolus, from which she died several days later. A review of the current literature reveals that thrombolytic therapy successfully relieves the obstructing thrombus in 73% of cases, while it is partially successful in another 16% allowing deferral of surgical repair to a more optimal time. Mortality from thrombolytic therapy is 14% while hemorrhage or cerebral emboli occur in a further 11%. Reports of surgical intervention have shown an operative mortality rate of 25%, in those fit to undergo surgery. If hemodynamically unstable patients unfit for surgery are included on an intention to treat basis, overall mortality is 42%. Thus, thrombolytic therapy should be considered primarily in those compromised patients who have a thrombotic occlusion of a valvular prosthesis with a greater risk of operative mortality. Low dose, prolonged infusions should be favoured over rapid, high concentration infusions currently employed for coronary thrombolysis, as the latter regime could have contributed to the fatal cerebral embolus in our patient.

Since May 1981 39 men and 11 women (mean age 55 years) have undergone percutaneous transluminal coronary angioplasty at Dunedin Hospital. Angioplasty was performed in 34 (68%) patients with stable angina, 13 (26%) with unstable angina and in three (6%) patients with acute myocardial infarction. Primary success (reduction in angiographic stenosis without associated myocardial infarction or emergency coronary bypass) was achieved in 77% of those patients with single vessel coronary disease (27 of 35 procedures) and of 62% in those patients with multiple vessel disease (16 of 26 procedures). Successful angioplasty was obtained in 81% (25/31) of those patients with anterior descending disease, 67% (4/6) of those with circumflex disease and 58% 14/24) of patients with right coronary disease. Thirty-four patients (68%) following successful angioplasty were rendered asymptomatic. Five (10%) underwent emergency coronary bypass grafting and one of these patients died. Percutaneous transluminal coronary angioplasty is a useful alternative to coronary artery bypass surgery and may be performed in a majority of patients with symptomatic single vessel coronary artery disease and in selected individuals with multiple vessel coronary disease.