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OBJECTIVES Left main coronary artery disease (LMCAD) is considered an independent risk factor for clinical events after coronary artery bypass grafting (CABG). We have conducted a subgroup analysis of the multicentre European DuraGraft Registry to investigate clinical event rates at 1 year in patients with and without LMCAD undergoing isolated CABG in contemporary practice. METHODS Patients undergoing isolated CABG were selected. The primary end point was the incidence of a major adverse cardiac event (MACE) defined as the composite of death, myocardial infarction (MI) or repeat revascularization (RR) at 1 year. The secondary end point was major adverse cardiac and cerebrovascular events (MACCE) defined as MACE plus stroke. Propensity score matching was performed to balance for differences in baseline characteristics. RESULTS LMCAD was present in 1033 (41.2%) and absent in 1477 (58.8%) patients. At 1 year, the MACE rate was higher for LMCAD patients (8.2% vs 5.1%, P = 0.002) driven by higher rates of death (5.4% vs 3.4%, P = 0.016), MI (3.0% vs 1.3%, P = 0.002) and numerically higher rates of RR (2.8% vs 1.8%, P = 0.13). The incidence of MACCE was 8.8% vs 6.6%, P = 0.043, with a stroke rate of 1.0% and 2.4%, P = 0.011, for the LMCAD and non-LMCAD groups, respectively. After propensity score matching, the MACE rate was 8.0% vs 5.2%, P = 0.015. The incidence of death was 5.1% vs 3.7%, P = 0.10, MI 3.0% vs 1.4%, P = 0.020, and RR was 2.7% vs 1.6%, P = 0.090, for the LMCAD and non-LMCAD groups, respectively. Less strokes occurred in LMCAD patients (1.0% vs 2.4%, P = 0.017). The MACCE rate was not different, 8.5% vs 6.7%, P = 0.12. CONCLUSIONS In this large registry, LMCAD was demonstrated to be an independent risk factor for MACE after isolated CABG. Conversely, the risk of stroke was lower in LMCAD patients. Clinical trial registration number ClinicalTrials.gov NCT02922088.

Introducción y objetivos: la oxigenación con membrana extracorpórea (ECMO) ha resultado ser una opción terapéutica en los pacientes con insuficiencia respiratoria y/o cardiaca severa por COVID-19. Las indicaciones y manejo de estos pacientes están aún por determinar. Nuestro objetivo es evaluar los resultados de la terapia ECMO en pacientes COVID-19 incluidos en un registro prospectivo e intentar optimizar los resultados. Métodos: en marzo de 2020 se inició un registro multicéntrico anónimo prospectivo de pacientes COVID-19 tratados mediante ECMO veno-arterial (V- A) o veno-venosa (V-V). Se registraron las variables clínicas, analíticas y respiratorias pre-implante, datos de implante y evolución de la terapia. El evento primario fue la mortalidad hospitalaria de cualquier causa y los eventos secundarios fueron la recuperación funcional y el evento combinado de recuperación funcional y mortalidad de cualquier causa a partir de los 3 meses de seguimiento post-alta. Resultados: se analizaron un total de 365 pacientes procedentes de 25 hospitales, 347 V-V y 18 V-A (edad media 52.7 y 49.4 años respectivamente). Los pacientes con ECMO V-V fueron más obesos, presentaban menos fracaso orgánico diferente al pulmonar y precisaron menos terapia inotrópica previa al implante. El 33.3% y 34.9% de los pacientes con ECMO V-A y V-V respectivamente fueron dados de alta del hospital (p=NS) y la mortalidad fue similar, del 56.2% y 50.9% de los casos respectivamente, la inmensa mayoría durante la ECMO y predominantemente por fracaso multiorgánico. El 14.0% (51 pacientes) permanecían ingresados. El seguimiento medio fue de 196+/-101.7 días. En el análisis multivariante, resultaron protectores de evento primario en pacientes con ECMO V-V el peso corporal (OR 0.967, IC 95% 0.95-0.99, p=0.004) y la procedencia del propio hospital (OR 0.48, IC 95% 0.27-0.88, p=0.018), mientras que la edad (OR 1.063, IC 95% 1.005-1.12, p=0.032), la hipertensión arterial (3.593, IC 95% 1.06-12.19, p=0.04) y las complicaciones en ECMO globales (2.44, IC 95% 0.27-0.88, p=0.019), digestivas (OR 4,23, IC 95% 1.27-14.07, p=0.019) y neurológicas (OR 4.66, IC 95% 1.39-15.62, p=0.013) fueron predictores independientes de mortalidad. El único predictor independiente de aparición de los eventos secundarios resultó el momento de seguimiento del paciente. Conclusiones: la terapia con ECMO permite supervivencias hospitalarias hasta del 50% en pacientes con COVID-19 grave. La edad, la HTA y las complicaciones en ECMO son los predictores de mortalidad hospitalaria en pacientes con ECMO V-V. Un mayor peso corporal y la procedencia del propio hospital son factores protectores. La recuperación funcional sólo se ve influenciada por el tiempo de seguimiento transcurrido tras el alta. La estandarización de los criterios de implante y manejo del paciente con COVID grave, mejoraría los resultados y la futura investigación clínica

Leaflet escape in contemporary mechanical valves is an extremely rare and potentially lethal condition. We report the case of a 77-year-old man who presented with embolization of a leaflet from an On-X mitral valve (CryoLife, Kennesaw, GA) with Conform-X Sewing Ring prosthesis (CryoLife) after exercise. The patient recovered completely 6 months after surgery, and he is currently asymptomatic.

Aims We aimed to determine whether treatment with sildenafil improves outcomes of patients with persistent pulmonary hypertension (PH) after correction of valvular heart disease (VHD). Methods and results The sildenafil for improving outcomes after valvular correction (SIOVAC) study was a multricentric, randomized, parallel, and placebo-controlled trial that enrolled stable adults with mean pulmonary artery pressure ≥ 30 mmHg who had undergone a successful valve replacement or repair procedure at least 1 year before inclusion. We assigned 200 patients to receive sildenafil (40 mg three times daily, n = 104) or placebo (n = 96) for 6 months. The primary endpoint was the composite clinical score combining death, hospital admission for heart failure (HF), change in functional class, and patient global self-assessment. Only 27 patients receiving sildenafil improved their composite clinical score, as compared with 44 patients receiving placebo; in contrast 33 patients in the sildenafil group worsened their composite score, as compared with 14 in the placebo group [odds ratio 0.39; 95% confidence interval (CI) 0.22–0.67; P

La cirugía coronaria tiene un carácter paliativo y los pacientes intervenidos necesitan a menudo nuevos procedimientos de revascularización. Las causas más frecuentes de la reaparición de la isquemia son la progresión de la enfermedad coronaria nativa y las estenosis u oclusiones de los injertos, especialmente los de vena safena. Aunque cada vez más pacientes con isquemia recurrente son tratados con técnicas de revascularización percutánea, las reintervenciones siguen constituyendo un porcentaje no despreciable del total de la cirugía coronaria. A diferencia de lo que ocurre con una primera operación, el manejo de los pacientes intervenidos está menos estandarizado. Además, la población que se somete a una reintervención tiene unas características anatómicas y clínicas más desfavorables.La cirugía iterativa es técnicamente más compleja y su desarrollo menos predecible. Debe planificarse de manera individualizada y contemplar alternativas para afrontar las eventuales complicaciones. Al igual que en las primeras intervenciones, cada vez más cirujanos realizan las reintervenciones sin circulación extracorpórea, aunque las ventajas de cada una de las estrategias están por definir. En pacientes seleccionados es también posible realizar un abordaje limitado por técnicas poco invasivas.En general, la mortalidad precoz y la incidencia de complicaciones postoperatorias son mayores que tras una primera intervención. También la calidad de la revascularización tiende a ser peor en los segundos o terceros procedimientos. Lo mismo sucede con la supervivencia a largo plazo y los resultados funcionales. Sin embargo, con suficiente experiencia, se puede igualar el riesgo y los resultados de una primera intervención.Coronary artery bypass is a palliative therapy so operated patients often need further revascularization procedures. The most frequent causes of recurrence of ischemia are the progression of the native coronary disease and the stenosis or graft occlusion, especially saphenous vein grafts. Although more and more patients with recurrent angina are nowadays treated with percutaneous techniques, reoperative surgery still represents a non neglectable percentage of the coronary surgical procedures. In contrast with what happens at first operation, the therapeutic options in the previously operated patients are not so well standardized. Also, the population that needs a reoperation shows worse anatomical and clinical characteristics.Reoperative surgery is technically more demanding and its course is less predictable. Reoperation should be planned on an individualized way and contemplate alternatives to confront all the eventual complications. As it is the case with first interventions, more surgeons carry out reoperations without extracorporeal circulation. Nevertheless, the advantages of each strategy are still to be defined. In selected patients it is also possible to carry out the reoperation through a minimally invasive approach.In general, early mortality and the incidence of postoperative complications are higher after reoperations than after a first surgery. Also, the quality of the revascularization is usually worse in a second or third procedure. Long term survival and functional results are also less favourable. However, with increasing experience, the operative risk and the results of a first intervention are expected o be equalled.

La revascularización completa con injertos arteriales pretende garantizar una perfusión duradera de todas las arterias coronarias enfermas para minimizar la recurrencia de la isquemia miocárdica. Esta estrategia resulta técnicamente factible en la mayoría de los pacientes con enf°medad multivaso utilizando una o dos arterias mamarias en combinación con la arteria radial o la gastroepiploica, ya sea como conductos simples, secuenciales o compuestos. Sin embargo, hay pacientes en los que no todos estos conductos pueden o deben utilizarse.La revascularización arterial puede realizarse tanto con circulación extracorpórea como sin ella. Es un procedimiento técnicamente más exigente y prolonga el tiempo quirúrgico. Sin embargo, con suficiente experiencia, puede llevarse a cabo con una mortalidad y una incidencia de complicaciones mayores similar a la de la cirugía coronaria convencional.Aunque la capacidad de flujo de los conductos arteriales es suficiente en la mayoría de los casos, hay evidencias que sugieren que aumenta el riesgo de isquemia residual, especialmente en el postoperatorio inmediato y cuando se utilizan injertos compuestos. Tampoco está claro que la permeabilidad de algunos conductos arteriales distintos a la arteria mamaria sea claramente mejor que la de la vena safena en todos los supuestos anatómicos.Aunque muchas publicaciones avalan la seguridad y eficacia de la revascularización arterial completa, no se dispone todavía de información concluyente que demuestre los beneficios clínicos a largo plazo en todos los tipos de pacientes. Son necesarios estudios prospectivos a gran escala para conocer los resultados a largo plazo y aclarar definitivamente sus indicaciones.Complete arterial revascularization pretends to provide a durable perfusion of all the ischemic myocardium to minimize the recurrence of ischemia. This surgical strategy is technically feasible in most of the patients with multi-vessel disease using one or two mammary arteries in combination with the radial or the gastroepiploic arteries, either as simple, sequential or composite grafts. Nevertheless, there are conditions that preclude the use of some of these conduits in certain groups of patients.Complete arterial revascularization can be carried out both with extracorporeal circulation or off-pump. It is technically more demanding than conventional coronary surgery and prolongs surgical time. However, with enough experience, it can be carried out with both a mortality and a incidence of complications similar to that of the conventional surgery.The flow capacity of the arterial conduits is enough to meet the myocardial demands in most of the cases. However, some evidences suggest that it increases the risk of residual ischemia, especially early after the operation and whenever composite arterial grafts are used. Neither it is clear that the patency of some arterial conduits other than the mammary artery is better than that of saphenous vein in all the anatomical situations.Although many publications endorse the security and effectiveness of the complete arterial revascularization, conclusive information demonstrating long-term clinical benefits in all the types of patients is still lacking. Large scale prospective studies are necessary to know the long-term resultsof complete arterial revascularization and to clarify the indications of this strategy definitively.

The aim of public health systems is to ensure that patients receive effective and efficient health care within a reasonable period. In Spain, running of the health care system has recently been transferred to the autonomous regions. Most of these regions have sufficient infrastructure to cover the needs of their population for the most common cardiovascular diseases such as ischemic heart disease. However, some health systems still refer a variable number of their patients to hospitals in the private sector, either referring patients for certain specialties to a private center or referring patients directly from waiting lists for public hospitals. The reasons for such referrals are usually excessive time spent on the waiting list or certain shortcomings in the number or facilities of public hospitals in certain regions. Comparison of the cost and the outcomes of care processes in public and private hospitals has always been subject to controversy. This comparison is fully justified, and indeed is an obligation when the public health service finances operations in private hospitals. In an article in this issue of the journal, Ribera et al1 publish the results of a study financed by the Catalonian public health system. The study compared early mortality after coronary artery bypass grafting (CABG) in patients from the public health system who underwent operations in both public and private hospitals. They then compared the results with those of a similar study published 6 years ago.2 Although the objective is worthy of praise, objective comparison between the public and private sectors for outcomes is difficult because substantial structural and functional differences exist between the 2 systems and these differences effect to a greater or lesser extent the individual outcomes of the health care. Does Nature of Hospital Financing Influence Early Mortality After Coronary Artery Bypass Grafting

Los conductos arteriales son, hoy dia, elementos fundamentales de la cirugia coronaria. Las indiscutibles ventajas de la revascularizacion de la descendente anterior con la arteria mamaria izquierda han impulsado la utilizacion de otras arterias en territorios diferentes. La arteria mamaria derecha y la arteria radial se disputan el papel de segundo conducto. Ademas, la arteria gastroepiploica derecha y la epigastrica inferior, aunque menos populares, permiten conseguir una revascularizacion completa utilizando exclusivamente injertos arteriales en la mayoria de los pacientes. La mayoria de las publicaciones al respecto avalan el uso extensivo de los conductos arteriales. Sin embargo, gran parte de esta informacion esta basada en estudios observacionales y los datos angiograficos se refieren fundamentalmente a pacientes sintomaticos, por lo que las indicaciones de las diferentes tecnicas no estan estandarizadas. Por otra parte, la permeabilidad de los injertos de vena safena en nuestros dias ha mejorado con respecto a la de epocas anteriores. En este articulo se describen las caracteristicas anatomicas e histologicas de los conductos arteriales. Se comentan las diferentes opciones tecnicas con sus indicaciones, ventajas e inconvenientes. Tambien se analizan los resultados, tanto clinicos como angiograficos, y el papel de los injertos arteriales en los distintos escenarios anatomicos y clinicos. Por ultimo, se discuten las perspectivas futuras de este tipo de cirugia.

At present, arterial conduits are the key elements of coronary bypass surgery. The clear benefits of using the left internal mammary artery for revascularization of the left anterior descending coronary artery have encouraged the use of other arteries in different areas. The right internal mammary artery and the radial artery are competing for the role as the second most useful conduit. Moreover, use of the right gastroepiploic artery or the inferior epigastric artery, although both are less popular, enables complete revascularization to be carried out using only arterial grafts in most patients. The majority of publications on the subject endorse the extensive use of arterial conduits. However, most findings are based on observational and angiographic data that are derived essentially from studies on symptomatic patients. Consequently, indications for the different techniques have not been standardized. On the other hand, the patency of saphenous vein grafts has improved recently. This article describes the anatomical and histologic characteristics of arterial conduits. The indications for, and advantages and limitations of, the different techniques available are reviewed. In addition, the clinical and angiographic results achieved are considered, as is the role of arterial conduits in different anatomical and clinical settings. Finally, the future application of this type of surgery is discussed.

La cardiomioplastia celular con mioblastos en pacientes puede producir una mejoría de la función cardíaca.Material y métodosDieciséis pacientes con antecedente de infarto de miocardio antiguo y enfermedad coronaria han sido tratados con cirugía de revascularización coronaria e implante de mioblastos cultivados en suero autólogo. Este grupo fue comparado con 14 pacientes de características similares, tratados con cirugía de revascularización sin implante de mioblastos. Los estudios incluyen función cardíaca, viabilidad y perfusión miocárdica con 18F-FDG y 13N-amonio.ResultadosTodos los pacientes han sido dados de alta del hospital y están vivos. La implantación de los mioblastos no se ha asociado a arritmias. El índice de motilidad regional mejoró en todos los segmentos con una diferencia mayor en los segmentos tratados con mioblastos (segmentos tratados = 2,92 ± 0,1 vs 1,3 ± 0,2, p

Rev Esp Cardiol 2004;57(1):7-11 7 A pesar de los continuos avances tecnologicos, aun no se ha desarrollado el dispositivo ideal para sustituir las valvulas cardiacas humanas. En el caso de la valvula aortica, no cabe duda de que la opcion que mas se aproxima es la sustitucion por otra valvula humana; el autoinjerto de valvula pulmonar (operacion de Ross) proporciona una hemodinamica muy parecida a la de la valvula aortica nativa y evita al paciente la carga de la anticoagulacion. Ademas, es capaz de crecer, es mas resistente a la infeccion que las protesis valvulares y no produce hemolisis. Todas estas ventajas la convierten en el procedimiento teoricamente ideal para sustituir la valvula aortica en ninos, adolescentes y adultos jovenes. Sin embargo, esta tecnica implica la implantacion de un homoinjerto pulmonar criopreservado para restablecer la continuidad ventriculopulmonar y es tecnicamente mucho mas compleja que una sustitucion valvular aortica convencional. Esta ultima circunstancia es la causa principal de que el autoinjerto pulmonar sea todavia poco utilizado en nuestro medio. Segun los datos del Registro Nacional, en Espana se realizan unas 40 operaciones de Ross al ano1. Esto supone que solo poco mas del 1% de los mas de 3.000 pacientes que cada ano son intervenidos de una valvulopatia aortica aislada se pueden beneficiar del autoinjerto pulmonar. La intervencion de Ross puede realizarse hoy dia con una mortalidad muy baja, entre un 1 y un 3%, como cabe exigir a un procedimiento que se practica, generalmente, en pacientes jovenes y sin comorbilidad. La mortalidad precoz que se recoge en el ultimo Registro Nacional1, que incluye a 169 pacientes intervenidos en 15 centros, es del 2,4%, cifra que coincide con el 2,5% del Registro Internacional, en el que se incluyen mas de 2.500 casos2. A pesar de la complejidad tecnica del procedimiento, la incidencia de complicaciones perioperatorias es igualmente baja. ED I TO R I A L E S

Despite continuous technological advances, we have yet to develop the perfect means of replacing human heart valves. In the case of the aortic valve, there can be no doubt that the best option available is replacement by another human valve. Pulmonary autograft (the Ross operation) ensures hemodynamic performance very similar to that of the native aortic valve and freedom from anticoagulation. Moreover, the autograft will grow, is more resistant to infection than prosthetic valves and does not cause hemolysis. In theory, all of these advantages make the Ross operation ideal for aortic valve replacement in children, adolescents and young adults. However, the procedure involves implanting a cryopreserved pulmonary homograft to reconstruct the pulmonary outflow tract and is technically much more complex than conventional aortic valve replacement. This complexity is the principal reason few Ross operations are performed in Spain. The Spanish National Register records just 40 Ross operations a year, 1 which means that of the over 3000 patients operated yearly for single aortic valve disease only slightly more than 1% benefit from pulmonary autograft. Today, the Ross operation can be accomplished with very low mortality (1%-3%) as should be the case with a procedure for patients who are usually young and who present no comorbidity. The Spanish National Register reports 2.4% early mortality among 169 patients at 15 centers. 1 This figure concurs with 2.5% early mortality among more than 2500 patients recorded in the International Registry. 2 In spite of the technical complexity of the procedure, the incidence of perioperative complications is equally low.

Currently, 15% to 30% of the patients that undergo coronary artery surgery are diabetics. As a group, they have less favorable anatomic and clinical characteristics than the general population. Specifically, diabetics have more extensive coronary disease, more vessels involved, and more diffuse stenosis, so they need a higher number of distal anastomoses to achieve complete revascularization. In spite of these drawbacks, they can undergo coronary artery bypass procedures with an operative mortality similar to that of non-diabetic patients. However, some postoperative complications are significantly more prevalent among diabetics, mainly renal failure, neurological accidents, sternal dehiscence, and infection. In early studies of the late results of surgical revascularization, mainly based on venous grafts, late survival and clinical improvement were less satisfactory in diabetics than in non-diabetics. However, in recent experiences, in which the internal mammary artery has been used extensively, the clinical outcome of diabetics has been similar to that of non-diabetics, confirming this procedure as the preferred one in revascularizing the coronary arteries of diabetics with multivessel disease. Off-pump surgery and extensive use of arterial grafts are becoming established strategies for reducing operative risk and improving longterm clinical results. However, continuous, strict medical management of hyperglycemia and other known coronary risk factors, especially lipid levels, is essential.

Introduccion Mediante la revascularizacion de la descendente anterior con la arteria mamaria se consigue una mayor supervivencia y reduccion de acontecimientos cardiologicos. Existen, sin embargo, resultados discrepantes sobre los beneficios de ambas mamarias. Objetivos Comparar los resultados del empleo de ambas mamarias frente a una. Pacientes y metodo Estudio de cohortes retrospectivo, con un seguimiento medio de 9,0 ± 4,2 anos, en el que se han incluido 108 pacientes consecutivos en los que se emplearon ambas mamarias (II), y 108 elegidos aleatoriamente de aquellos en los que se empleo una mamaria (I). Resultados Ambos grupos fueron homogeneos. No hubo diferencias en la morbimortalidad operatoria. La supervivencia a los 10 anos fue similar (II: 84,61 ± 4%; I: 85,18 ± 3,8%), mientras que la recurrencia de angina (II: 29,63 ± 5,3; I: 47,55 ± 5,6%) (p = 0,012), la necesidad de angioplastia percutanea (II: 3,98 ± 2%; I: 12,99 ± 4,1%) (p = 0,009) y el acontecimiento cardiologico (II: 33,48 ± 5,5%; I: 48,48 ± 5,5%) (p = 0,022) fueron inferiores en el grupo de dos mamarias. En el analisis multivariante, el empleo de ambas mamarias resulto ser un factor protector independiente para la recurrencia de angina (RR = 0,54), angioplastia (RR = 0,18) y acontecimiento cardiologico (RR = 0,60). Conclusiones El empleo de ambas mamarias no incrementa la morbimortalidad operatoria y reduce la recurrencia de angina, la necesidad de angioplastia y los acontecimientos cardiologicos en el seguimiento, por lo que su uso parece justificado.

Valvular heart diseases, which continue to be a major cause of morbidity and mortality world wide, have undergone radical changes since the first valve prostheses were implanted 40 years ago. These changes have been the result of both scientific progress and improved standard of living in developed countries. The availability of penicillin to treat streptococcal pharyngitis and less crowded living conditions have now made rheumatic fever uncommon in these countries. However, other forms of valve impairment have appeared over the past several years. The etiology of some of these valvular diseases remains obscure (e. g. myxomatous mitral valve); others, such as the senile type of calcific aortic valve stenosis, seem to be the price to be paid for the extension of life expectancy. With regard to diagnosis, echocardiography has constituted a formidable tool for visualizing anatomic valve changes, interpreting complex hemodynamic derangements, and evaluating repercussion on the left ventricle. In addition, the iteration of this non-invasive examination has allowed a much better understanding of the natural history of non-severe valvular disease and therefore of the precise timing for surgical intervention, without awaiting, in most cases, the appearance of advanced symptomatology. This has also been possible because of the great advances in cardiac surgery which can be summarised as: a) the improvement in extracorporeal circulation and myocardial preservation techniques; b) the greatly improved biologic and mechanic valve substitutes; c) the introduction of imaginative mitral valve repair procedures, and d) the use of intraoperative transesophageal echocardiography to assess the adequacy of valve repair. At the same time, percutaneous catheter balloon valvuloplasty has emerged as a valid alternative to mitral surgical commissurotomy for mitral stenosis. All these changes, and many more that can not be described in this brief summary, make a review of the management of patients with valve heart disease appropriate.

Introduccion En los pacientes con cardiopatiaisquemica cronica, una funcion contractil severamentedeprimida se asocia a un mayor riesgo inmediatoy a un peor resultado clinico a largo plazotras la cirugia de revascularizacion miocardica. Sinembargo, cuando existe suficiente miocardio viablela cirugia puede mejorar la funcion ventricular ysobre todo la supervivencia y capacidad funcionalde los pacientes. Objetivos Analizar los resultados a largo plazode una serie amplia de pacientes con fraccion deeyeccion ≤ 0,30 sometidos a cirugia coronaria aisladae investigar los determinantes, fundamentalmenteclinicos, de un resultado favorable, entendiendopor tal la supervivencia en buena situacionfuncional. Pacientes y metodos El grupo estudiado lo forman100 pacientes, 93 varones y 7 mujeres, con unaedad media de 62 ± 8 anos. La manifestacion clinicapredominante fue la angina en 37, la insuficienciacardiaca en 22 y ambas en 41. Setenta y nueve enfermosse encontraban en grado funcional III-IV y19 fueron intervenidos con caracter urgente. Resultados Hubo 10 muertes hospitalarias, 6 deellas en pacientes operados de urgencia. La mortalidadde los casos electivos fue del 4,9%. La edad(p Conclusiones La revascularizacion quirurgica enlos pacientes con disfuncion ventricular cronica severatiene un riesgo operatorio aceptable cuandose lleva a cabo de forma electiva, antes de que ocurraun deterioro clinico importante. Los resultadosa largo plazo son satisfactorios en la mayoria delos pacientes. En este tipo de enfermos, las manifestacionesclinicas tienen poco valor a la hora depredecir el beneficio clinico tras la revascularizacion.

At present, arterial conduits are the key elements of coronary bypass surgery. The clear benefits of using the left internal mammary artery for revascularization of the left anterior descending coronary artery have encouraged the use of other arteries in different areas. The right internal mammary artery and the radial artery are competing for the role as the second most useful conduit. Moreover, use of the right gastroepiploic artery or the inferior epigastric artery, although both are less popular, enables complete revascularization to be carried out using only arterial grafts in most patients. The majority of publications on the subject endorse the extensive use of arterial conduits. However, most findings are based on observational and angiographic data that are derived essentially from studies on symptomatic patients. Consequently, indications for the different techniques have not been standardized. On the other hand, the patency of saphenous vein grafts has improved recently. This article describes the anatomical and histologic characteristics of arterial conduits. The indications for, and advantages and limitations of, the different techniques available are reviewed. In addition, the clinical and angiographic results achieved are considered, as is the role of arterial conduits in different anatomical and clinical settings. Finally, the future application of this type of surgery is discussed.

A 37-year-old man who had suffered a thoracic trauma presented night release of whitish urine 2 years later. Thoracic computed tomography and aortography demonstrated an aneurysm of the thoracic aorta. Lymphography confirmed the compression of the thoracic duct by the aneurysm. After surgical repair the patient has remained asymptomatic.

Currently, 15% to 30% of the patients that undergo coronary artery surgery are diabetics. As a group, they have less favorable anatomic and clinical characteristics than the general population. Specifically, diabetics have more extensive coronary disease, more vessels involved, and more diffuse stenosis, so they need a higher number of distal anastomoses to achieve complete revascularization. In spite of these drawbacks, they can undergo coronary artery bypass procedures with an operative mortality similar to that of non-diabetic patients. However, some postoperative complications are significantly more prevalent among diabetics, mainly renal failure, neurological accidents, sternal dehiscence, and infection. In early studies of the late results of surgical revascularization, mainly based on venous grafts, late survival and clinical improvement were less satisfactory in diabetics than in non-diabetics. However, in recent experiences, in which the internal mammary artery has been used extensively, the clinical outcome of diabetics has been similar to that of non-diabetics, confirming this procedure as the preferred one in revascularizing the coronary arteries of diabetics with multivessel disease. Off-pump surgery and extensive use of arterial grafts are becoming established strategies for reducing operative risk and improving long-term clinical results. However, continuous, strict medical management of hyperglycemia and other known coronary risk factors, especially lipid levels, is essential.