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Acute kidney injury (AKI) after cardiac bypass surgery (CABG) is common and carries a significant association with morbidity and mortality. Since minocycline therapy attenuates kidney injury in animal models of AKI, we tested its effects in patients undergoing CABG. This is a randomized, double-blinded, placebo-controlled, multi-center study. We screened high risk patients who were scheduled to undergo CABG in two medical centers between Jan 2008 and June 2011. 40 patients were randomized and 19 patients in each group completed the study. Minocycline prophylaxis was given twice daily, at least for four doses prior to CABG. Primary outcome was defined as AKI [0.3 mg/dl increase in creatinine (Cr)] within 5 days after surgery. Daily serum Cr for 5 days, various clinical and hemodynamic measures and length of stay were recorded. The two groups had similar baseline and intra-operative characteristics. The primary outcome occurred in 52.6 % of patients in the minocycline group as compared to 36.8 % of patients in the placebo group (p = 0.51). Peak Cr was 1.6 ± 0.7 vs. 1.5 ± 0.7 mg/dl (p = 0.45) in minocycline and placebo groups, respectively. Death at 30 days occurred in 0 vs. 10.5 % in the minocycline and placebo groups, respectively (p = 0.48). There were no differences in post-operative length of stay, and cardiovascular events between the two groups. There was a trend towards lower diastolic pulmonary artery pressure [16.8 ± 4.7 vs. 20.7 ± 6.6 mmHg (p = 0.059)] and central venous pressure [11.8 ± 4.3 vs. 14.6 ± 5.6 mmHg (p = 0.13)] in the minocycline group compared to placebo on the first day after surgery. Minocycline did not protect against AKI post-CABG.

Strategic planning is integral to any operation but complexity varies immensely and therefore the effort necessary to create the optimal plan. The previous three reports have discussed individual conduits and herein is an attempt to present approaches to common situations which the author favors. Although much has been learned over 45 years about use and subsequent behavior of venous and arterial grafts we continue to learn and, as a result, evolve new strategies or modify those now popular. Thus the reader must recognize that in spite of trying to be balanced and inclusive all surgeons have personal opinions and also prejudices which influence the approach taken and which may not be the optimal one for others or for the patient.

This is the third in a series on coronary artery bypass which reviews three alternative arterial conduits. The radial artery has become the most widely used of the three and accumulating experience demonstrates better patency at 10 years versus saphenous vein. Drawbacks are a long incision on the forearm, the propensity for spasm and persistent sensory disturbance in about 10%. The first is answered by endoscopic harvest which may yield a shorter conduit but reduces sensory nerve injury. Spasm is managed pharmacologically and by less harvest trauma. The gastroepiploic artery is used in situ and free and although the abdominal cavity is entered complications are minimal and patency compares favorably with the radial artery. Use of the inferior epigastric artery remains minimal and its similar length often requires composite use but limited patency data are supportive. Other arteries have had rare use and this is unlikely to change because the three presented here have significant advantages and acceptance.

The saphenous vein has been the principal conduit for coronary bypass grafting from the beginning, circa 1970. This report briefly traces this history and concomitantly presents one surgeons experience and personal views on use of the vein graft. As such it is not exhaustive but meant to be practical with a modest number of references. The focus is that of providing guidance and perspective which may be at variance with that of others and recognizing that there may be many ways to accomplish the task at hand. Hopefully the surgeon in training/early career may find this instructive on the journey to surgical maturity.

Coronary artery bypass in 150 patients with angina has been accomplished with 225 IMA grafts and 85 saphenous vein grafts. There were 7 (4.7%) hospital deaths. Posterative catheterization in 85% of patients revealed that 9 (4.7%) IMA grafts and 11 (15%) vein graft had thrombosed. One-year catheterization in 32 patients (38 IMA grafts and 13 vein grafts) revealed no additional graft failures. The better patency of the IMA grafts appears to be related to their smaller size and therfore greater velocity of blood flow and freedom from intimal proliferation.

Enthusiasm for new therapeutic modalities frequently results in a ground swell of overuse, which recedes to leave a trough of negativism before a definitive level is established. In the case of CABG, the ground swell has become a 10-year flood tide, without an ebb, although ripples have marred the surface. It is generally agreed that suitable control populations are needed to determine the role of a therapy and that the best controls would arise from randomized prospective trials. At present, the best randomized trial is the VA study which has shown that operation does not enhance longevity for single vessel disease, but clearly does for left main coronary disease. In those individuals with two- and three-vessel disease, the VA study has not shown that surgical therapy is better than medical treatment. However, three other studies containing patients selected by the VA criteria indicate that operation provides significantly greater longevity for patients in these two categories. Acceptance of this position requires acknowlegement of the validity of the VA study and the comparison of extramural concurrent surgical series.

These data would suggest that hypothermia combined with potassium cardioplegia enhances protection of the ischemic myocardium over other available techniques. The ideal conduct of this myocardial protection is not yet apparent but certain aspects are worthy of emphasis. (1) With the onset of ischemia cardioplegia should be immediately induced to abolish contractile activity and conserve energy. An advantage of blood cardioplegia is that there is no ischemia or it is trivial priorto cardioplegia. (2) The greater the degree of myocardial cooling the better. Although a myocardial temperature of 20 degrees C can commonly be achieved with perfusion hypothermia and topical hypothermia, it is possible to reduce myocardial temperature to 10 degrees C or lower with these same modalities. Because perfusion hypothermia provides fairly uniform rapid myocardial cooling, this should be maximally utilized by cooling of the systemic perfusate to 20 degrees C and cooling the cardioplegic infusate to 4-10 degrees C. Cardiac hypothermia should be maintained with crushed ice made from electrolyte solution or irrigation of the pericardial sac with cold electrolyte solution. The greater the degree of systemic hypothermia the less tendency for the myocardium to warm. (3) The ideal concentration of potassium is unknown at this time with a range of 15-40 mEq/l having been utilized without apparent potassium injury. (4) The ideal composition of the vehicle may never be defined and may not be of great importance. Whole blood would appear to offer physiological and pragmatic advantages over asanguinous vehicles. (5) The safe duration of ischemia has been moderately well defined. 1 h is well tolerated in the dog using profound cardiac hypothermia, whereas 30-45 min with lesser degrees of hypothermia is acceptable. When the interval of ischemia is to be 2 or 3 h reinfusion of potassium every 20-30 min has proven safe both experimentally and clinically.

Silvia Scurati1, Franco Frati1, Gianni Passalacqua2, Paola Puccinelli1, Cecile Hilaire1, Cristoforo Incorvaia3, Italian Study Group on SLIT Compliance 1Scientific and Medical Department, Stallergenes, Milan, Italy; 2Allergy and Respiratory Diseases, Department of Internal Medicine, Genoa; 3Allergy/Pulmonary Rehabilitation, ICP Hospital, Milan, ItalyObjectives: Sublingual immunotherapy (SLIT) is a viable alternative to subcutaneous immunotherapy to treat allergic rhinitis and asthma, and is widely used in clinical practice in many European countries. The clinical efficacy of SLIT has been established in a number of clinical trials and meta-analyses. However, because SLIT is self-administered by patients without medical supervision, the degree of patient adherence with treatment is still a concern. The objective of this study was to evaluate the perception by allergists of issues related to SLIT adherence.Methods: We performed a questionnaire-based survey of 296 Italian allergists, based on the adherence issues known from previous studies. The perception of importance of each item was assessed by a VAS scale ranging from 0 to 10.Results: Patient perception of clinical efficacy was considered the most important factor (ranked 1 by 54% of allergists), followed by the possibility of reimbursement (ranked 1 by 34%), and by the absence of side effects (ranked 1 by 21%). Patient education, regular follow-up, and ease of use of SLIT were ranked first by less than 20% of allergists.Conclusion: These findings indicate that clinical efficacy, cost, and side effects are perceived as the major issues influencing patient adherence to SLIT, and that further improvement of adherence is likely to be achieved by improving the patient information provided by prescribers.Keywords: adherence, sublingual immunotherapy, efficacy, cost, side effects

The extent of proximal and distal aortic resection that should be performed for acute type A aortic dissections remains controversial.From 1984 to 1999, 119 patients underwent repair of an acute type A dissection. Distal resection was to the ascending aorta in 78 (66%) and hemiarch in 41 (34%) patients. Proximally, the aortic valve was preserved in 69 (58%) patients, 40 (34%) underwent composite valve grafting, and 10 (8%) underwent separate graft and valve replacement.Operative mortality was higher for separate graft and valve (50%+/-16%) than for valve preservation (16%+/-5%) or composite grafts (20%+/-7%) (p0.05). Hemiarch replacement did not increase operative risk compared to distal reconstruction to the ascending aorta (17%+/-6% versus 22%+/-5%, p0.71). At 10 years, freedom from reoperation was 81%+/-7% and long-term survival was 60%+/-8%, but neither was related to the proximal or distal surgical technique (p0.15). Risk factors for late reoperation included a nonresected primary tear and Marfan syndrome (p0.05).An aggressive surgical approach, including a full root or hemiarch replacement, is not associated with increased operative risk and should be considered when type A dissections extensively involve the valve, sinuses, or arch.

Background . Proximal anastomosis of the radial artery to the side of the internal thoracic artery (ITA) permits complete arterial revascularization in most patients, with the aim of improving long-term results of coronary artery bypass through greater long-term graft patency. The short-term results, however, have yet to be defined. We therefore reviewed our early experience with this grafting strategy. Methods . Between October 1, 1993, and September 1, 1998, 649 patients aged 30 to 85 years (mean, 60 ± 10 years) had primary coronary artery bypass using an ITA and radial artery in a T-graft configuration. Left ventricular function was severely depressed (ejection fraction Results . A total of 937 distal anastomoses were performed with the left ITA (1.4 per patient) and 1,452 with the radial artery (2.2 per patient). There was one perioperative death (0.2%). There were 32 (5%) q-wave myocardial infarctions, and 14 patients (2%) had transient low output syndrome. There was one episode of hypoperfusion corrected by lengthening the left ITA. Angiography for clinical indications in 27 patients 1 to 35 months postoperatively (mean, 9.5 ± 8.3 months) demonstrated a distal anastomotic patency of 100% for ITA and 82% for radial artery grafts. Conclusions . Complete arterial revascularization can be achieved with an ITA and radial artery T-graft with low operative risk and acceptable early patency. These results support the continued investigation of this grafting strategy.

A human sternum with an imbedded arrowhead (Fig 1) from Patagnoia presents a dramatic image fit to make several points regarding life, medicine, and surgery. Things are not always what they seem (the arrow enters the inner side of the sternum and therefore crossed the chest). Life was as fragile then as it is today. New forms of trauma have replaced, but not completely, the arrow, and new diseases, witness acquired immunodeficiency syndrome, continue to arise or be recognized. Although the interval from then to now is great, the messages are timeless. My message is not timeless but focuses on two generations of physicians (dad and me), a decade of change, and the next generation. In less than a decade profound changes in the structure and economics of medical practice have surpassed those of the preceding 150 years. As I look back on my 32 years of practice that came after 13 years in education, training, and military service after college, I thought it might be appropriate to reflect on these changes and how they may affect physicians in the future. I was fortunate to have a father who practiced medicine in a blue collar community of ten thousand people, that was built around a United States naval ship yard. I was well aware of my father’s profession from an early age but did not participate in it as some sons might. I was occasionally exposed to the “evils of socialized medicine” through conversations between my father and other physicians. I also learned that the American Medical Association was solidly against this form of medical practice, which I did not fully comprehend. At that time it seemed a far off possibility and not particularly threatening even as I considered pursuing medicine as a career. It was during college that I decided that medicine would be a good career, for several reasons. I had a personal health problem that I wanted to research and correct for myself and others. There seemed to be a good market for physicians. Providing care was satisfying to one’s own mind and was associated with respect from the community. And if one were diligent and even modestly successful one would not starve. Medical school taught me enough to engender a new respect for my dad, who delivered babies, set fractures in his office, and then developed the x-rays of the same between pediatric patient visits, performed major abdominal or gynecologic operations in the morning before heading to the office, managed to make house calls at mundane as well as odd hours, and speak with patients on the phone in midst of family dinners (the phone was in its place beside the kitchen table where we ate). At that time I could recall Sunday drives in the country when father would point out a farmhouse where he had delivered a baby, where he had treated a patient with heart failure, or relate that he had to back his model-T Ford up the hill to another house as low gear did not provide enough power to make the grade. Mother told me how wonderful it was when the bridge was built across Port Washington Narrows in 1932 so that instead of a 10minute ferry ride it was a short drive across the bridge to make a house call and it saved a 1-hour drive home when dad missed the last ferry in the evening. These vignettes from the practice of a solo practitioner engaged in the great American fee-for-service tradition that existed from the founding of our country until recently are uncommon today except in very rural or remote areas. Occasionally my dad would mention that some patients had no money or not enough to pay for services, which never seemed to be a problem for him. The only vexation that I perceived was on occasion when such a patient would become unusually demanding of his time, such as a lengthy phone call while we were eating. Some less-well-off patients, but also those who did pay, were grateful in other ways by bringing something from the garden, the beach, the water, or something crafted by hand and dropped off at the office or our home. In my clinical years at the University of Washington Presented at the Forty-fifth Annual Meeting of the Southern Thoracic Surgical Association, Orlando, FL, Nov 12–14 1998.