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Background: Hybrid coronary revascularization (HCR) is a technique that merges coronary artery bypass grafting surgery and percutaneous coronary intervention (PCI) approaches for the treatment of multivessel coronary artery disease. The surgical component of the procedure is minimally invasive and can be done using robotic technology that avoids the need for sternotomy. Our objective is to study all patients who underwent robotic‐assisted HCR (RHCR) to evaluate the feasibility and safety of the procedure during the establishment phase. Methods: This study is a retrospective chart review conducted at King Faisal Specialist Hospital and Research Centre in Jeddah (KFSRC‐J). The study focuses on patients who underwent RHCR between July 2018 to December 2020. The study was approved by the institutional review board #2020‐103. Results: Robotic‐assisted HCR was performed on 78 patients (mean age, 56 years (range, 43–72 years); 89.75% males) during the study phase. Left internal mammary artery grafting was used in all patients. There was no hospital mortality, and the mean hospital and intensive care unit (ICU) stay were 5.8 and 1.4 days, respectively. We found that 93.6% of the patients had no blood transfusion. There were no major adverse cardiac events (MACE) and perioperative MI recorded. There was a 3.8% rate of postoperative complications. The percentage of surgeries converted to conventional and re‐exploration for bleeding were 1.2% and 2.6%, respectively. The average operation time was 164 min. Conclusion: This study emphasizes on the safety and effectiveness of RHCR in treating patients with multivessel coronary artery disease. Moreover, robotic‐assisted hybrid coronary revascularization offers an alternative, functionally complete revascularization option to a selected group of patients with minimal surgical trauma, short hospital and ICU length of stay, quick recovery, and little to no blood transfusion requirement. [ABSTRACT FROM AUTHOR]

Background: Hybrid coronary revascularization (HCR) is a well-established technique for treating multi-vessel coronary disease. There remains a paucity of discussion assessing the efficacy of HCR with respect to the timing of the surgical component relative to that of the percutaneous coronary intervention (PCI)., Methods: A retrospective review was undertaken of our prospectively collected database from January 2009 to December 2019. Of 395 HCR patients analyzed, we examined the outcomes of 109 pairs of propensity-matched patients who either underwent robotic-assisted minimally-invasive direct coronary artery bypass (MIDCAB) first, or who had PCI prior to surgery., Results: Thirty-day mortality was 0.25% (1 death) for the entire cohort. Mid-term survival for the total 'MIDCAB-first' group was 94.1% (17 deaths), not significantly different to that for the 'PCI-first' cohort (8 deaths, 92.7%), and this was also statistically comparable after propensity matching. Perioperative morbidity was not different between patient groups. Freedom from major adverse cardiac and cerebrovascular events (MACCE) and the incidence of repeat revascularization was similar between the two groups at up to 11-year follow-up. Elevated serum creatinine independently predicted increased MACCE for all patients, irrespective of the sequence of HCR revascularization employed., Conclusions: In appropriately selected patients with multi-vessel coronary disease, HCR is associated with excellent short and longer-term results, irrespective of whether the MIDCAB or PCI procedure is performed first., Competing Interests: Conflicts of Interest: N.C.P. MD is on the scientific advisory board of Vascular Graft Solutions. M.C.K. is a consultant for Boston Scientific, Cardiovascular Systems Inc., Heartflow, and Medtronic, Inc. V.P.S. is a consultant for Abbott, Boston Scientific, and Medtronic, Inc. The other authors have no conflicts of interest to declare., (2024 AME Publishing Company. All rights reserved.)

Purpose: To emphasis the role of MSCT utilizing the remodeling index in assessment of positive coronary remodeling which was associated with plaque rupture and vulnerability. Methods and material: Studied group included 35 patients with positive coronary remodeling. One lesion per patient was assessed, either a solitary lesion or the most significant one. All patients were subjected to history taking and radiological evaluation using a contrast-enhanced 64 MSCT then post processed. Assessment of the plaque causing positive remodeling regarding the site, number (single, kissing, or multiple), relative composition and predominant type in H.U. was performed. Specific measurements at the reference and remodeling segment were taken. Calculation of remodeling index was done. Two comparative groups were made between subjects with remodeling index (RI)

Background: DSE is considered one of the good options in clinical practice but due to some limitations new promising modalities like speckle tracking echocardiography (STE) was introduced. STE is a new imaging technique that allows evaluation of global and regional myocardial function independently from the angle of acquisition and from cardiac translational movements. Objectives: Determine optimal cutoff values for longitudinal, radial and circumferential strains at peak DSE for detection of significant stenosis on CA. Also investigate incremental value of combining strain measurements to wall motion analysis. Methods: The study population comprised 100 patients (age 50 ±9 years) underwent high dose DSE, STE followed by CA. DSE and STE results were compared and added to each other and finally compared to CA result. Results: GLS cutoff points (-16.75%) showed significantly higher accuracy when compared to GCS and GRS, with highest balanced sensitivity and specificity to predict CAD. GLS, GRS and GCS reduced the DSE false positivity by 83%, 72.2% and 66.6% respectively. STE also showed better Agreement with CA than DSE in detecting coronary territorial affection especially LAD (Kappa= 0.775). Conclusions: STE is feasible during DSE, it helps increasing the diagnostic accuracy of DSE and decreasing its false positivity. Both global and segmental longitudinal strain can offer accurate, feasible and non invasive assessment of CAD. [ABSTRACT FROM AUTHOR]

Myocardial ischemia–reperfusion represents a clinically relevant problem associated with thrombolysis, angioplasty and coronary bypass surgery. Injury of myocardium due to ischemia–reperfusion includes cardiac contractile dysfunction, arrhythmias as well as irreversible myocytes damage. A total of 24 Swiss albino adult male mice were randomized into 4 equal groups. Group (1) sham group; Group (2) control group; Group (3) control vehicle (DMSO) group; Group (4) Ferulic acid treated group. Results of this study showed that levels of myocardial IL-6, were increased (p

Purpose To emphasis the role of MSCT utilizing the remodeling index in assessment of positive coronary remodeling which was associated with plaque rupture and vulnerability. Methods and material Studied group included 35 patients with positive coronary remodeling. One lesion per patient was assessed, either a solitary lesion or the most significant one. All patients were subjected to history taking and radiological evaluation using a contrast-enhanced 64 MSCT then post processed. Assessment of the plaque causing positive remodeling regarding the site, number (single, kissing, or multiple), relative composition and predominant type in H.U. was performed. Specific measurements at the reference and remodeling segment were taken. Calculation of remodeling index was done. Two comparative groups were made between subjects with remodeling index (RI) < 1.5 and RI ⩾ 1.5. Results A strong correlation was noted between lipid plaque area, plaque cross sectional area and multiplicity of plaques with remodeling index ( p value < 0.001). There was no correlation between the RI with either the patient coronary risk factors or symptomatology. Conclusion Previous studies had shown that most acute coronary syndromes were initiated by sudden changes of mildly stenotic lesions, commonly found in positively remodeled vessels. Promising comparative results between MSCT and IVUS allowed consideration of MDCT as a useful tool in the noninvasive detection of potentially threatening coronary lesions. In our study, RI ⩾ 1.5 showed a strong correlation between the lipid plaque area, multiplicity of the plaques, and cross sectional area which were prognostic factors for plaque rupture and vulnerability, and thus, early detection of coronary artery disease. Modulation and prevention of positive remodeling by statin could promote to start medical treatment especially in cases where RI exceeds 1.5 and their follow up non-invasively by MDCT to detect reversal of remodeling and response of treatment. [ABSTRACT FROM AUTHOR]

Objectives: This study sought to compare the efficacy of coronary artery bypass graft surgery (CABG) to that of percutaneous coronary intervention (PCI) with first-generation drug-eluting stents among patients with multivessel disease (MVD), unprotected left main (LM) disease, and single-vessel proximal left anterior descending (LAD) disease. Background: The efficacy and safety of CABG versus PCI with drug-eluting stents in patient subgroups remains controversial. Methods: We systematically searched Cardiosource, Circulation, Clinicaltrials.gov, the Cochrane Library, EMBASE, and Medline for articles published through June 2013 for randomized controlled trials comparing CABG with PCI. Primary endpoints included mortality, myocardial infarction, revascularization, and stroke. Data were meta-analyzed with random-effects models. Results: We identified 7 randomized controlled trials (N = 5,835): 2 of MVD (n = 2,410, 100% diabetic), 2 of LM disease (n = 1,206, 29.0% diabetic), 1 of 3-vessel or LM disease (n = 1,900, 25.5% diabetic), and 2 of single-vessel proximal LAD disease (n = 319, 36.3% diabetic). In MVD patients, CABG reduced the risk of mortality (risk ratio [RR]: 0.70, 95% confidence interval [CI]: 0.57 to 0.87), myocardial infarction (RR: 0.47, 95% CI: 0.36 to 0.61), and repeat revascularization (RR: 0.36, 95% CI: 0.24 to 0.52), but increased stroke risk (RR: 1.72, 95% CI: 1.02 to 2.90). In patients with LM disease, CABG reduced revascularization risk (RR: 0.60, 95% CI: 0.46 to 0.78) and increased stroke risk (RR: 2.89, 95% CI: 1.15 to 7.27). Data for patients with single-vessel proximal LAD disease were inconclusive. Conclusions: CABG is more efficacious than is PCI with first-generation drug-eluting stents in patients with LM and MVD, at the cost of increased rates of stroke. No conclusion can be drawn for patients with single-vessel proximal LAD disease. [Copyright &y& Elsevier]

Objectives: This study sought to examine the diagnostic accuracy of the instantaneous wave-free ratio (iFR) and resting distal coronary artery pressure/aortic pressure (P d /P a ) with respect to hyperemic fractional flow reserve (FFR) in a core laboratory–based multicenter collaborative study. Background: FFR is an index of the severity of coronary stenosis that has been clinically validated in 3 prospective randomized trials. iFR and P d /P a are nonhyperemic pressure-derived indices of the severity of stenosis with discordant reports regarding their accuracy with respect to FFR. Methods: iFR, resting P d /P a , and FFR were measured in 1,768 patients from 15 clinical sites. An independent physiology core laboratory performed blinded off-line analysis of all raw data. The primary objectives were to determine specific iFR and P d /P a thresholds with ≥90% accuracy in predicting ischemic versus nonischemic FFR (on the basis of an FFR cut point of 0.80) and the proportion of patients falling beyond those thresholds. Results: Of 1,974 submitted lesions, 381 (19.3%) were excluded because of suboptimal acquisition, leaving 1,593 for final analysis. On receiver-operating characteristic analysis, the optimal iFR cut point for FFR ≤0.80 was 0.90 (C statistic: 0.81 [95% confidence interval: 0.79 to 0.83]; overall accuracy: 80.4%) and for P d /P a was 0.92 (C statistic: 0.82 [95% confidence interval: 0.80 to 0.84]; overall accuracy: 81.5%), with no significant difference between these resting measures. iFR and P d /P a had ≥90% accuracy to predict a positive or negative FFR in 64.9% (62.6% to 67.3%) and 48.3% (45.6% to 50.5%) of lesions, respectively. Conclusions: This comprehensive core laboratory analysis comparing iFR and P d /P a with FFR demonstrated an overall accuracy of ∼80% for both nonhyperemic indices, which can be improved to ≥90% in a subset of lesions. Clinical outcome studies are required to determine whether the use of iFR or P d /P a might obviate the need for hyperemia in selected patients. [ABSTRACT FROM AUTHOR]

Objectives: The purpose of this study was to evaluate the diagnostic value of a positron emission tomography (PET)/computed tomography (CT)–determined longitudinal decrease in myocardial blood flow (MBF) gradient during hyperemia and myocardial flow reserve (MFR) for the identification of epicardial stenosis ≥50%. Background: Although PET-determined reductions in MFR are increasingly applied to identify epicardial lesions in coronary artery disease (CAD), it may be seen as a suboptimal approach due to the nonspecific origin of decreases in MFR. Methods: In 24 patients with suspected or known CAD, MBF was measured with 13N-ammonia and PET/CT in ml/g/min at rest, during dipyridamole stimulation, and the corresponding MFR was calculated. MBF was also determined in the mid and mid-distal myocardium of the left ventricle (LV). A decrease in MBF from mid to mid-distal LV myocardium was defined as longitudinal MBF gradient. MBF parameters were determined in the myocardial region with stress-induced perfusion defect and with stenosis ≥50% (territory 1), without defect but with stenosis ≥50% (territory 2), or without stenosis ≥50% (territory 3). Results: In territories 1 and 2 with focal stenosis ≥50%, the severity of epicardial artery stenosis correlated with the Δlongitudinal MBF gradient (stress-rest) (r = 0.52; p < 0.0001), while this association was less pronounced for corresponding MFR (r = −0.40; p < 0.003). On a vessel-based analysis, the sensitivity and specificity of the Δlongitudinal MBF gradient in the identification of epicardial lesions was higher than those for MFR (88% vs. 71%, p ≤ 0.044; and 81% vs. 63%, p = 0.134, respectively). Combining both parameters resulted in an optimal sensitivity of 100% and intermediate specificity of 75%. The diagnostic accuracy was highest for the combined analysis than for the Δlongitudinal MBF gradient or MFR alone (94% vs. 86%, p ≤ 0.003; and 94% vs. 70%, p ≤ 0.0002). Conclusions: The combined evaluation of a Δlongitudinal MBF gradient and MFR may evolve as a new promising analytic approach to further optimize the identification of CAD lesions. [Copyright &y& Elsevier]

Objective: Thrombin has been reported to play a pivotal role in the initiation of angiogenesis by indirectly regulating and organizing a network of angiogenic molecules. On the basis of these reports, we investigated the angiogenic action of thrombin in a rabbit model of acute myocardial infarction. Methods: A rabbit model of acute myocardial infarction was established by ligation of the left anterior descending coronary branch. Subjects were then divided into 2 groups and treated with intramyocardial administration of thrombin (2500 IU; n = 13) or an equal volume of normal saline (n = 13). Four weeks later, animals were euthanized and histopathologic analysis, immunohistochemical staining for endothelial markers CD31 and vascular endothelial growth factor-A, and electron microscopy examination were performed on excised hearts. Electrocardiography, cardiac enzymes, and assessment of cardiac function by measuring left ventricular end-diastolic pressure and ejection fraction were recorded before and after myocardial infarction, and both left ventricular end-diastolic pressure and ejection fraction were further measured on the day of euthanasia (n = 5-8 in each case). Results: Increased levels of troponin, ST elevation, and histopathologically confirmed myocardial infarction were observed in all animals. A significant increase of microvessel density at the infarct border zone, as evaluated by CD31 immunohistochemistry, was observed in the thrombin-treated group compared with the control group (30.3 ± 12.8 vs 12.6 ± 4.8, P = .0065). A significantly higher number of vascular endothelial growth factor-A–positive vessels at the infarct border zone was observed in the thrombin-treated animals compared with the control group (21.8 ± 8.9 vs 5.6 ± 4.4; P = .0009). The thrombin-treated animals showed a statistically significant reduction in left ventricular end-diastolic pressure values (6.9 ± 1.8 mm Hg vs 12.7 ± 2.2 mm Hg, P = .0002) and significant improvement in left ventricular ejection fraction (59.8% ± 3.1% vs 42.2% ± 6.14%, P = .002) on the day of euthanasia compared with the post-infarct day, reflecting significantly improved cardiac function compared with control subjects that showed no significant change. Conclusions: Intramyocardial administration of thrombin seems to promote angiogenesis and improve cardiac function of the ischemic myocardium, which may provide a new therapeutic approach in patients with myocardial ischemia. [Copyright &y& Elsevier]

Objectives: Higher rates of incomplete revascularization (IR) and reduced patency are possible drawbacks of off-pump coronary artery bypass grafting (OPCAB); both may adversely affect outcome after surgery. This study was conducted to shed light on the relationships among IR, angiographic patency, and midterm results after OPCAB surgery. Methods: A total of 1604 consecutive patients underwent OPCAB during a 6-year period; 1581 patients (95%) underwent systematic postoperative angiography. Complete follow-up was achieved in 99.5% (median, 3.2 years; up to 6.5 years). A total of 216 patients had IR (13%), and 225 had at least 1 graft failure (FitzGibbon B or O). Results: All the event-free survival rates for all-cause mortality (P < .001), cardiac death (P = .020), and major adverse cardiac and cerebrovascular events (P < .001) were lower in the IR group. By using the Cox proportional hazards model, IR was an independent risk factor for all-cause mortality (hazard ratio [HR], 1.80; 95% confidence interval [CI], 1.15-2.81). Of those who underwent postoperative angiography, the patients with graft failure experienced reintervention more frequently than those with all grafts patent (HR, 5.49; 95% CI, 3.43-8.77). Even with excluding patients who had undergone reintervention immediately after angiography, graft failure was still an independent risk factor for reintervention afterwards (HR, 2.41; 95% CI, 1.30-4.47). Conclusions: Incomplete revascularization was relevant to higher midterm mortality after OPCAB, whereas the risk of reintervention was higher for patients with occluded grafts. Complete revascularization, coupled with achievement of a higher patency rate, could be expected to improve follow-up outcomes after OPCAB surgery. [Copyright &y& Elsevier]

Background: Modulation of the autonomic nervous system has been used to treat refractory ventricular tachycardia (VT). Renal artery denervation (RDN) is under investigation for the treatment of sympathetic-driven cardiovascular diseases. Objective: The purpose of this study was to report the largest case series to date using RDN as adjunctive therapy for refractory VT in patients with underlying cardiomyopathy. Methods: Four patients with cardiomyopathy (2 nonischemic, 2 ischemic) with recurrent VT despite maximized antiarrhythmic therapy and prior endocardial (n = 2) or endocardial/epicardial (n = 2) ablation underwent RDN ± repeat VT ablation. RDN was performed spirally along each main renal artery with either a nonirrigated (6 W at 50°C for 60 seconds) or an open irrigated ablation catheter (10–12 W for 30–60 seconds). Renal arteriography was performed before and after RDN. Results: RDN was well tolerated acutely and demonstrated no clinically significant complications during follow-up of 8.8 ± 2.6 months (range 5.0–11.0 months). No hemodynamic deterioration or worsening of renal function was observed. The number of VT episodes was decreased from 11.0 ± 4.2 (5.0–14.0) during the month before ablation to 0.3 ± 0.1 (0.2–0.4) per month after ablation. All VT episodes occurred in the first 4 months after ablation (2.6 ± 1.5 months). The responses to RDN were similar for ischemic and nonischemic patients. Conclusion: This case series provides promising preliminary data on the safety and effectiveness of RDN as an adjunctive therapy in the treatment of patients with cardiomyopathy and VT resistant to standard interventions. [Copyright &y& Elsevier]

Objectives: The goal of this study was to define the role of FMS-like tyrosine kinase 3 (FLT3) in the heart. Background: FLT3 is a prominent target of receptor tyrosine kinase inhibitors (TKIs) used for anticancer therapy. TKIs can cause cardiomyopathy but understanding of the mechanisms is incomplete, partly because the roles of specific TKI target receptors in the heart are still obscure. Methods: Myocardial infarction was induced in mice by permanent ligation of the left anterior descending coronary artery followed by intramyocardial injection of FLT3 ligand (FL) or vehicle into the infarct border zone. Cardiac morphology and function were assessed by echocardiography and histological analysis 1 week after infarction. In addition, FLT3 expression and regulation, as well as molecular mechanisms of FLT3 action, were examined in cardiomyocytes in vitro. Results: The intramyocardial injection of FL into the infarct border zone decreased infarct size and ameliorated post-myocardial infarction remodeling and function in mice. This beneficial effect was associated with reduced apoptosis, including myocytes in the infarct border zone. Cardiomyocytes expressed functional FLT3, and FLT3 messenger ribonucleic acid and protein were up-regulated under oxidative stress, identifying cardiomyocytes as FL target cells. FLT3 activation with FL protected cardiomyocytes from oxidative stress–induced apoptosis via an Akt-dependent mechanism involving Bcl-2 family protein regulation and inhibition of the mitochondrial death pathway. Conclusions: FLT3 is a cytoprotective system in the heart and a potential therapeutic target in ischemic cardiac injury. The protective mechanisms uncovered here may be further explored in view of potential cardiotoxic effects of FLT3-targeting anticancer therapy, particularly in patients with ischemic heart disease. [Copyright &y& Elsevier]

Background: The mammalian target of rapamycin (mTOR) pathway is a major regulator of cell immunity and metabolism. mTOR is a well-known suppressor of tissue rejection in organ transplantation. However, it has other nonimmune functions: in the cardiovascular system, it is a regulator of heart hypertrophy and locally, in coated vascular stents, it inhibits vascular wall cell growth and hence neointimal formation/restenosis. Because the mTOR pathway plays major roles in normal cell growth, metabolism, and survival, we hypothesized that inhibiting it with rapamycin before an acute myocardial ischemia-reperfusion injury (IRI) would confer cardioprotection by virtue of slowing down cardiac function and metabolism. Methods: Yorkshire pigs received either placebo or 4 mg/d rapamycin orally for 7 days before the IRI. All animals underwent median sternotomy, and the mid-left anterior descending coronary artery was occluded for 60 minutes followed by 120 minutes of reperfusion. Left ventricular pressure-volume data were collected throughout the operation. The ischemic and infarcted areas were determined by monastral blue and triphenyltetrazolium chloride staining, respectively, and plasma cardiac troponin I concentration. mTOR kinase activities were monitored in remote cardiac tissue by Western blotting with specific antibodies against mTOR substrates phosphorylating sites. Results: Rapamycin before treatment impaired endothelial-dependent vasorelaxation, attenuated cardiac function during IRI, and increased myocardial necrosis. Western blotting confirmed effective inhibition of myocardial mTOR kinase activities. Conclusions: Acute myocardial IRI, in healthy pigs treated with rapamycin, is associated with decreased cardiac function and higher myocardial necrosis. [Copyright &y& Elsevier]

Objectives: The aim of this study was to investigate the modulatory effect of the coxsackie and adenovirus receptor (CAR) on ventricular conduction and arrhythmia vulnerability in the setting of myocardial ischemia. Background: A heritable component in the risk of ventricular fibrillation during myocardial infarction has been well established. A recent genome-wide association study of ventricular fibrillation during acute myocardial infarction led to the identification of a locus on chromosome 21q21 (rs2824292) in the vicinity of the CXADR gene. CXADR encodes the CAR, a cell adhesion molecule predominantly located at the intercalated disks of the cardiomyocyte. Methods: The correlation between CAR transcript levels and rs2824292 genotype was investigated in human left ventricular samples. Electrophysiological studies and molecular analyses were performed using CAR haploinsufficient (CAR+/−) mice. Results: In human left ventricular samples, the risk allele at the chr21q21 genome-wide association study locus was associated with lower CXADR messenger ribonucleic acid levels, suggesting that decreased cardiac levels of CAR predispose to ischemia-induced ventricular fibrillation. Hearts from CAR+/− mice displayed slowing of ventricular conduction in addition to an earlier onset of ventricular arrhythmias during the early phase of acute myocardial ischemia after ligation of the left anterior descending artery. Expression and distribution of connexin 43 were unaffected, but CAR+/− hearts displayed increased arrhythmia susceptibility on pharmacological electrical uncoupling. Patch-clamp analysis of isolated CAR+/− myocytes showed reduced sodium current magnitude specifically at the intercalated disk. Moreover, CAR coprecipitated with NaV1.5 in vitro, suggesting that CAR affects sodium channel function through a physical interaction with NaV1.5. Conclusions: CAR is a novel modifier of ventricular conduction and arrhythmia vulnerability in the setting of myocardial ischemia. Genetic determinants of arrhythmia susceptibility (such as CAR) may constitute future targets for risk stratification of potentially lethal ventricular arrhythmias in patients with coronary artery disease. [ABSTRACT FROM AUTHOR]

Objectives: The aim of this proof-of-principle study is to validate the accuracy of fusion imaging for percutaneous transapical access (TA). Background: Structural heart disease interventions, including TA, are commonly obtained under fluoroscopic guidance, which lacks important spatial information. Computed tomographic angiography (CTA)-fluoroscopy fusion imaging can provide the 3-dimensional information necessary for improved accuracy in planning and guidance of these interventions. Methods: Twenty consecutive patients scheduled for percutaneous left ventricular puncture and device closure using CTA-fluoroscopy fusion guidance were prospectively recruited. The HeartNavigator software (Philips Healthcare, Best, the Netherlands) was used to landmark the left ventricular epicardium for TA (planned puncture site [PPS]). The PPS landmark was compared with the position of the TA closure device on post-procedure CTA (actual puncture site). The distance between the PPS and actual puncture site was calculated from 2 fixed reference points (left main ostium and mitral prosthesis center) in 3 planes (x, y, and z). The distance from the left anterior descending artery at the same z-plane was also assessed. TA-related complications associated with fusion imaging were recorded. Results: The median (interquartile range [IQR]) TA distance difference between the PPS and actual puncture site from the referenced left main ostium and mitral prosthesis center was 5.00 mm (IQR: 1.98 to 12.64 mm) and 3.27 mm (IQR: 1.88 to 11.24 mm) in the x-plane, 4.48 mm (IQR: 1.98 to 13.08 mm) and 4.00 mm (IQR: 1.62 to 11.86 mm) in the y-plane, and 5.57 mm (IQR: 3.89 to 13.62 mm) and 4.96 mm (IQR: 1.92 to 11.76 mm) in the z-plane. The mean TA distance to the left anterior descending artery was 15.5 ± 7.8 mm and 22.7 ± 13.7 mm in the x- and y-planes. No TA-related complications were identified, including evidence of coronary artery laceration. Conclusions: With the use of CTA-fluoroscopy fusion imaging to guide TA, the actual puncture site can be approximated near the PPS. Moreover, fusion imaging can help maintain an adequate access distance from the left anterior descending artery, thereby, potentially reducing TA-related complications. [Copyright &y& Elsevier]

Objective: The aim of our study was to evaluate the long-term outcome of patients exclusively undergoing total arterial revascularization off-pump coronary artery bypass grafting and to compare the performance of the radial artery and the right internal thoracic artery as a second conduit. Methods: We studied a consecutive series of 1700 patients undergoing off-pump coronary artery bypass grafting, receiving a radial artery or right internal thoracic artery as a second graft for total arterial revascularization, between 2003 and 2010. A total of 1447 patients (85.11%) received bilateral internal thoracic artery grafting, and 253 patients (14.89%) received left internal thoracic artery and radial artery grafting. A propensity score–matched analysis was performed to compare the 2 groups, bilateral internal thoracic artery and left internal thoracic artery and radial artery, relative to overall survival, morbidity, and combined end points event–free survival. Hazard ratios (HRs) and their 95% confidence intervals (CIs) were estimated by Cox regression. Results: In the full unmatched patient population, the postoperative survival (HR, 0.59; 95% CI, 0.38-0.92; P = .021), incidence of reintervention/readmission (HR, 0.42; 95% CI, 0.28-0.61; P < .001), and combined end points (HR, 0.47; 95% CI, 0.35-0.63; P < .001) were significantly better in the bilateral internal thoracic artery group. In the propensity score–matched patient population, the incidence of reintervention/readmission (HR, 0.40; 95% CI, 0.18-0.88; P = .02) and combined end points (HR, 0.54; 95% CI, 0.32-0.92; P = .02) were significantly better in the bilateral internal thoracic artery group compared with the left internal thoracic artery–radial artery group. Conclusions: The results of our study provide evidence for the superiority of the right internal thoracic artery graft compared with the radial artery as a second conduit in total arterial revascularization off-pump coronary artery bypass grafting. [Copyright &y& Elsevier]

Objective: Joint guidelines on myocardial revascularization were published by the European Society of Cardiology and European Association for Cardiothoracic Surgery: Patients with left main stem, proximal left anterior descending, or 3-vessel disease should be discussed with a surgeon before revascularization, and ad hoc percutaneous coronary intervention has no elective indication in these categories. We assess the impact of the guidelines on referral patterns to a cardiac surgery service at a large-volume cardiac center in the United Kingdom. Methods: Joint guidelines were published in August 2010. All patients with severe disease undergoing percutaneous coronary intervention at one institution were identified 6 months before (January to June 2010) and 6 months after (January to June 2011) their introduction. Decision-making and surgical referral were determined from minutes of multidisciplinary meeting. Results: A total of 197 patients underwent elective percutaneous coronary intervention pre-guidelines, of whom 62 had severe disease. Only 6 patients (9%) were discussed at a multidisciplinary meeting before intervention. After introduction of the guidelines, elective percutaneous coronary interventions were performed in 164 patients, of whom 42 had surgical disease. Only 8 patients (17%) were discussed at a multidisciplinary meeting before intervention (P = not significant). Follow-up was a median of 480 (380-514) days for the pre-guideline group and 104 (31-183) days for the post-guideline group. Ad hoc percutaneous coronary intervention in surgical disease occurred in 8 patients (14%) pre-guidelines and was unchanged for 9 patients (26%) post-guidelines (P = not significant). Conclusions: Despite recommendation by both cardiology and cardiac surgical bodies and widespread publicity, a significant number of patients in this single-center study are not receiving optimal treatment recommended by these guidelines. [Copyright &y& Elsevier]

Objectives: This study sought to determine whether computational modeling can be used to predict the functional outcome of coronary stenting by virtual stenting of ischemia-causing stenoses identified on the pre-treatment model. Background: Computed tomography (CT)-derived fractional flow reserve (FFR) is a novel noninvasive technology that can provide computed (FFRct) using standard coronary CT angiography protocols. Methods: We prospectively enrolled 44 patients (48 lesions) who had coronary CT angiography before angiography and stenting, and invasively measured FFR before and after stenting. FFRct was computed in blinded fashion using coronary CT angiography and computational fluid dynamics before and after virtual coronary stenting. Virtual stenting was performed by modification of the computational model to restore the area of the target lesion according to the proximal and distal reference areas. Results: Before intervention, invasive FFR was 0.70 ± 0.14 and noninvasive FFRct was 0.70 ± 0.15. FFR after stenting and FFRct after virtual stenting were 0.90 ± 0.05 and 0.88 ± 0.05, respectively (R = 0.55, p < 0.001). The mean difference between FFRct and FFR was 0.006 for pre-intervention (95% limit of agreement: –0.27 to 0.28) and 0.024 for post-intervention (95% limit of agreement: –0.08 to 0.13). Diagnostic accuracy of FFRct to predict ischemia (FFR ≤0.8) prior to stenting was 77% (sensitivity: 85.3%, specificity: 57.1%, positive predictive value: 83%, and negative predictive value: 62%) and after stenting was 96% (sensitivity: 100%, specificity: 96% positive predictive value: 50%, and negative predictive value: 100%). Conclusions: Virtual coronary stenting of CT-derived computational models is feasible, and this novel noninvasive technology may be useful in predicting functional outcome after coronary stenting. (Virtual Coronary Intervention and Noninvasive Fractional Flow Reserve [FFR]; NCT01478100) [Copyright &y& Elsevier]

Objectives: Intracoronary shunts have been developed for a bloodless field and preserved forward flow preventing ischemia during off-pump coronary artery bypass (OPCAB) surgery. However, reports directly measuring the forward flow through the shunt in clinical settings are lacking. Methods: Using a 7.5-MHz Doppler probe, we investigated the coronary flow through a 1.5-mm shunt inserted into the left anterior descending artery (LAD) for anastomosis with the internal thoracic artery during OPCAB in 30 consecutive patients. The following Doppler flow parameters were obtained before and after shunting: peak velocity, mean velocity, time-velocity integral, and flow. Results: No patients developed significant electrocardiographic changes and the peak value of postoperative myocardial band of creatine kinase was 17 ± 16 IU/L. All Doppler flow parameters of the LAD decreased significantly after shunting; peal velocity: 71.3 ± 34.6 cm/second to 54.5 ± 25.3 cm/second (−24% ± 27%), mean velocity: 33.3 ± 18.3 cm/second to 26.3 ± 14.0 cm/second (−21% ± 23%), and time-velocity integral: 28.7 ± 12.1 cm to 19.0 ± 7.1 cm (−28% ± 14%), and flow: 38.7 ± 16.8 mL/minute to 25.0 ± 9.5 mL/minute (−31% ± 13%) (P < .01). Conclusions: The LAD flow is preserved at least 50% through a 1.5-mm intracoronary shunt, although the flow pattern was attenuated, during OPCAB anastomosis. The Doppler evaluation of the coronary artery flow before and after shunting is useful to justify the protective use of the shunt on myocardial perfusion during OPCAB. [Copyright &y& Elsevier]

Objective: Minimally invasive coronary artery bypass grafting is safe and widely applicable, and may be associated with fewer transfusions and infections, and better recovery than standard coronary artery bypass grafting. However, graft patency rates remain unknown. The Minimally Invasive Coronary Artery Bypass Grafting Patency Study prospectively evaluated angiographic graft patency 6 months after minimally invasive coronary artery bypass grafting. Methods: In this dual-center study, 91 patients were prospectively enrolled to undergo minimally invasive coronary artery bypass grafting via a 4- to 7-cm left thoracotomy approach. The left internal thoracic artery, the ascending aorta for proximal anastomoses, and all coronary targets were directly accessed without endoscopic or robotic assistance. The study primary outcome was graft patency at 6 months, using 64-slice computed tomography angiography. Secondary outcomes included conversions to sternotomy and major adverse cardiovascular events (Clinical Trial Registration Unique identifier: NCT01334866). Results: The mean age of patients was 64 ± 8 years, the mean ejection fraction was 51% ± 11%, and there were 10 female patients (11%) in the study. Surgeries were performed entirely off-pump in 68 patients (76%). Complete revascularization was achieved in all patients, and the median number of grafts was 3. There was no perioperative mortality, no conversion to sternotomy, and 2 reopenings for bleeding. Transfusion occurred in 24 patients (26%). The median length of hospital stay was 4 days, and all patients were followed to 6 months, with no mortality or major adverse cardiovascular events. Six-month computed tomography angiographic graft patency was 92% for all grafts and 100% for left internal thoracic artery grafts. Conclusions: Minimally invasive coronary artery bypass grafting is safe, feasible, and associated with excellent outcomes and graft patency at 6 months post-surgery. [Copyright &y& Elsevier]

Objective: Robotic-assisted coronary artery bypass grafting has emerged as an alternative to traditional coronary artery bypass grafting or percutaneous intervention for patients with coronary artery disease. However, the safety and efficacy of this minimally invasive procedure have not been established in large series. Methods: From October 2009 to September 2012, 307 consecutive robotic-assisted coronary artery bypass grafting procedures were performed at a single US institution by 2 surgeons. Isolated, off-pump, left internal thoracic artery to left anterior descending coronary artery grafting was planned via a 3- to 4-cm non–rib-spreading minithoracotomy after robotic left internal thoracic artery harvest in all patients. Hybrid coronary revascularization was planned in 159 patients (51.8%). Of the 199 angiograms (64.8%) performed before discharge, 63 were performed as completion angiograms in a hybrid suite immediately after left internal thoracic artery–left anterior descending artery grafting. Results: Thirty-day mortality occurred in 4 patients (1.3%), conversion to sternotomy occurred in 16 patients (5.2%), postoperative myocardial infarction occurred in 5 patients (1.6%), and reexploration for bleeding occurred in 7 patients (2.3%). There was 1 (0.3%) postoperative stroke. For the 199 patients with follow-up angiography before discharge, the left internal thoracic artery was confirmed to be patent (<50% stenosis) in 189 patients (95.0%). Among the 10 patients with significant (≥50% stenosis) defects, 5 had graft occlusion or distal left anterior descending occlusion, 2 had poor flow distal to the anastomosis, and 3 had anastomotic lesions (≥50% stenosis). Among the 63 patients with intraoperative completion angiography, 5 patients underwent surgical graft revision, 3 patients underwent minithoracotomy, and 2 patients underwent conversion to sternotomy. Conclusions: Robotic-assisted coronary artery bypass grafting is an effective alternative to traditional coronary artery bypass grafting for patients with single or multivessel coronary artery disease, with comparable short-term clinical and angiographic results. [Copyright &y& Elsevier]

Objective: Coronary artery bypass grafting (CABG) with incomplete revascularization (ICR) is thought to decrease survival. We studied the survival of patients with ICR undergoing total arterial grafting. Methods: In a consecutive series of all-comer 1000 patients with isolated CABG, operative and midterm survival were assessed for patients undergoing complete versus ICR, with odds ratios and hazard ratios, adjusted for European System for Cardiac Operative Risk Evaluation category, CABG urgency, age, and comorbidities. Results: In this series of 1000 patients with 98% arterial grafts (2922 arterial, 59 vein grafts), 73% of patients with multivessel disease received bilateral internal mammary artery grafts. ICR occurred in 140 patients (14%). Operative mortality was 3.8% overall, 8.6% for patients with ICR, and 3.2% for patients with complete revascularization (P = .008). For operative mortality using multivariable logistic regression, after controlling for European System for Cardiac Operative Risk Evaluation category (P < .001) and CABG urgency (P = .03), there was no evidence of a statistically significant increased risk of death due to ICR (odds ratio, 1.73; 95% confidence interval, 0.80-3.77). For midterm follow-up (median, 54 months [interquartile range, 27-85 months]), after controlling for European System for Cardiac Operative Risk Evaluation category (P < .001) and comorbidities (P = .017) there was a significant interaction between age ≥ 80 years and ICR (P = .017) in predicting mortality. The adjusted hazard ratio associated with ICR for patients older than age 80 years was 5.7 (95% confidence interval, 1.8-18.0) versus 1.2 (95% confidence interval, 0.7-2.1) for younger patients. Conclusions: This is the first study to suggest that ICR in patients with mostly arterial grafts is not associated with decreased survival perioperatively and at midterm in patients younger than age 80 years. Arterial grafting, because of longevity, may balance survival between complete revascularization and ICR. [Copyright &y& Elsevier]

Introduction. Ischemic heart disease is a major public health problem in western countries. Appropriate animal experimental models of chronic myocardial infarction is an essential first step in order to investigate and develop new therapeutic interventions. Aim. The aim of this study was to find an optimal place for a coronary artery ligation to induce an optimal chronic myocardial infarction and also a new heart approach that will not require oro-tracheal intubation. Material and methods. To achieve these goals we used a group of rabbits and after induction of anesthesia and cardiac exposure by rib osteotomy (rib III, IV and V) at the costo-sternal junction level on the right side we performed three different left anterior descending artery (LAD) ligation at different distances (5, 10 and 15 mm) in relation to the apex. Thirty days after the acute myocardial infarction, we correlated laboratory investigations (serology, ECG, cardiac ultrasound) with histopathological findings. Results. Heart approach achieved by rib osteotomy (rib III, IV and V) at the costo-sternal junction level on the right side, maintains the integrity of the ribcage, allowing it to take part in respiratory movements and the animal model does not need oro-tracheal intubation. Ligation of LAD at 15 mm from the apex was incompatible with life; ligation of LAD at 5 mm from the apex does not achieved transmural myocardial infarction and ligation of LAD at 10 mm from the apex achieved a transmural myocardial infarction of the left ventricle which also involved the distal part of the interventricular septum. Conclusion. Ligation of LAD at 10 mm from the apex achieved a transmural myocardial infarction of the left ventricle,is in an easily accessible area from technical point of view, it is sufficiently expanded to induce hemodynamic effects that can be quantified with paraclinical examination and also it is compatible with the experimental animal life. If the heart is approached by rib III, IV and V osteotomy at the costo-sternal junction level on the right side combined with neuroleptic anaesthesia, the animal does not need assisted ventilation [ABSTRACT FROM AUTHOR]

Abstract: Background: Patients who present to the emergency department (ED) complaining of acute chest pain are of clinical concern because a small percentage will have acute coronary syndrome (ACS). The American College of Cardiology (ACC) and the American Heart Association (AHA) recommend hospitalization for patients with a low-to-intermediate risk of ACS who have initial negative ECG and enzyme test results. A negative coronary CT angiography (CCTA) during the triage has a very high negative predictive value for ruling out ACS decreasing the length of hospital stay. Recent techniques e.g. ASiR in CCTA should be used to decrease the radiation dose as low as possible. Objective: The aim of this study is to evaluate the role of low radiation dose CCTA with ASiR in triage of low-risk patients with acute chest pain in emergency department. A negative CCTA early in the workup may enable a shorter length of stay. Subjects and methods: We studied 54 selected patients (55.6% men; mean age 48±6years) with chest pain who were awaiting hospital admission to rule out ACS despite the absence of diagnostic ECG changes and normal cardiac enzymes on ED presentation. Patients underwent CCTA before hospital admission. Afterward, patients received standard clinical care (SCC). ER physicians involved in the patient’s care were blinded to the results of CCTA. An expert panel established the presence or absence of ACS based on AHA guidelines. The CCTA images were evaluated for the presence of significant coronary artery stenosis (diameter reduction >50%) and were used to make a triage decision. Results: Four patients (7.4%) with chest pain had at least one significant coronary stenosis on CCTA (sensitivity 100%, specificity 96%, accuracy 96.3%, positive predictive value (PPV) 66.7% and negative predictive value (NPV) 100%). Significant coronary stenosis was excluded in 48 of the 54 patients by CCTA (88.9%), potentially saving about 71.6% of unnecessary hospital admission hours. Conclusion: CCTA based detection of significant coronary stenosis has potential role to decrease the length of hospital stay , without reducing appropriate patient care, in low risk patients with acute chest pain. CCTA should be done with lowest radiation possible using recent techniques. [Copyright &y& Elsevier]

Phosphodiesterase 3A (PDE3A) is a major regulator of cAMP in cardiomyocytes. PDE3 inhibitors are used for acute treatment of congestive heart failure, but are associated with increased incidence of arrhythmias and sudden death with long-term use. We previously reported that chronic PDE3A downregulation or inhibition induced myocyte apoptosis in vitro. However, the cardiac protective effect of PDE3A has not been demonstrated in vivo in disease models. In this study, we examined the role of PDE3A in regulating myocardial function and survival in vivo using genetically engineered transgenic mice with myocardial overexpression of the PDE3A1 isozyme (TG). TG mice have reduced cardiac function characterized by reduced heart rate and ejection fraction (52.5±7.8% vs. 83.9±4.7%) as well as compensatory expansion of left ventricular diameter (4.19±0.19mm vs. 3.10±0.18mm). However, there was no maladaptive increase of fibrosis and apoptosis in TG hearts compared to wild type (WT) hearts, and the survival rates also remained the same. The diminution of cardiac contractile function is very likely attributed to a decrease in beta-adrenergic receptor (β-AR) response in TG mice. Importantly, the myocardial infarct size (4.0±1.8% vs. 24.6±3.8%) and apoptotic cell number (1.3±1.0% vs. 5.6±1.5%) induced by ischemia/reperfusion (I/R) injury were significantly attenuated in TG mice. This was associated with decreased expression of inducible cAMP early repressor (ICER) and increased expression of anti-apoptotic protein BCL-2. To further verify the anti-apoptotic effects of PDE3A1, we performed in vitro apoptosis study in isolated adult TG and WT cardiomyocytes. We found that the apoptotic rates stimulated by hypoxia/reoxygenation or H2O2 were indeed significantly reduced in TG myocytes, and the differences between TG and WT myocytes were completely reversed in the presence of the PDE3 inhibitor milrinone. These together indicate that PDE3A1 negatively regulates β-AR signaling and protects against I/R injury by inhibiting cardiomyocyte apoptosis. [ABSTRACT FROM AUTHOR]

Introduction: Data on right ventricular (RV) involvement in anterior myocardial infarction are scarce. The presence of RV microvascular obstruction (MVO) in this context has not been analyzed yet. The aim of the present study was to characterize the presence of MVO in the RV in a controlled experimental swine model of reperfused anterior myocardial infarction. Materials and Methods: Left anterior descending (LAD) artery-perfused area (thioflavin-S staining after selective infusion in LAD artery), infarct size (lack of triphenyltetrazolium-chloride staining) and MVO (lack of thioflavin-S staining in the core of the infarcted area) in the RV were studied. A quantitative (% of the ventricular volume) and semiquantitative (number of segments involved) analysis was carried out both in the RV and LV in a 90-min left anterior descending balloon occlusion and 3-day reperfusion model in swine (n=15). Results: RV infarction and RV MVO (>1 segment) were detected in 9 (60%) and 6 (40%) cases respectively. Mean LAD-perfused area, infarct size and MVO in the RV were 33.8±13%, 13.53±11.7% and 3.4±4.5%. Haematoxylin and eosin stains and electron microscopy of the RV-MVO areas demonstrated generalized cardiomyocyte necrosis and inflammatory infiltration along with patched hemorrhagic areas. Ex-vivo nuclear magnetic resonance (T2* sequences) microimaging of RV-MVO showed, in comparison with remote non-infarcted territories, marked hypointense zones (corresponding to necrosis, inflammation and hemorrhage) in the core of hyperintense regions (corresponding to edema). Conclusions: In reperfused anterior myocardial infarction, MVO is frequently present in the RV. It is associated with severe histologic repercussion on the RV wall. Nuclear magnetic resonance appears as a promising technique for the noninvasive detection of this phenomenon. Further studies are warranted to evaluate the pathophysiological and clinical implications. [ABSTRACT FROM AUTHOR]

Objectives: One of the potential drawbacks of off-pump coronary artery bypass is reduced patency compared with conventional coronary artery bypass. This study examined the systematic angiographic evaluation after off-pump coronary artery bypass. Methods: Of the 1604 consecutive patients who underwent off-pump coronary artery bypass over 6 years, 1422 (89%) who underwent postoperative angiography were analyzed. Generalized estimating equations logistic analyses were used to investigate potential predictors of graft failure (FitzGibbon B or O). Results: Bilateral internal thoracic arteries were used in 78% of the patients. The mean number of distal anastomoses was 3.7 ± 1.2. The in-hospital mortality rate was 0.4%. Recipient coronary diameter less than 1.5 mm (odds ratio [OR], 1.62; 95% confidence interval [CI], 1.24-2.11) was an independent predictor of graft failure, whereas percent stenosis diameter greater than 75% (OR, 0.71; 95% CI, 0.53-0.93), sequential graft (OR, 0.69; 95% CI, 0.51-0.94), and left main disease (OR, 0.72; 95% CI, 0.53-0.96) were protective factors. In the subanalyses for each conduit, percent stenosis diameter was protective against left internal thoracic artery failure (OR, 0.61), whereas smaller recipient coronary diameter was associated with right gastroepiploic artery and saphenous vein graft failure (OR, 2.37 and 2.36, respectively). Left circumflex artery was associated with gastroepiploic artery graft failure, whereas sequential graft was again protective for the gastroepiploic artery (OR, 4.39 and 0.33, respectively). Conclusions: Smaller coronary diameter would be a predictor of graft failure, whereas percent stenosis diameter greater than 75%, sequential graft, and left main disease would be protective factors for off-pump bypass grafts. [Copyright &y& Elsevier]

The radial artery (RA) can be used as part of an arterial revascularization strategy in coronary artery bypass grafting (CABG). It is easy to harvest. and several randomized controlled trials and meta-analyses have reported superior long-term patency over saphenous vein grafts. However, the RA is not used as frequently as the saphenous vein and questions remain regarding its optimum use as a conduit. This article comprehensively appraises current evidence surrounding outcomes, patient selection, harvesting technique, intraoperative strategy, and graft spasm prophylaxis to provide a contemporary review of the use of the RA as a conduit in CABG. [Copyright &y& Elsevier]

Abstract: N-Acetylcysteine (NAC) and allopurinol (ALP) synergistically reduce myocardial ischemia reperfusion (MI/R) injury in diabetes. However, the mechanism is unclear. We postulated that NAC and ALP attenuated diabetic MI/R injury by up-regulating phosphatidylinositol 3-kinase/Akt (PI3K/Akt) and Janus kinase 2/signal transducer and activator of transcription-3 (JAK2/STAT3) pathways subsequent to adiponectin (APN) activation. Control (C) or streptozotocin-induced diabetic rats (D) were untreated or treated with NAC and ALP followed by MI/R. D rats displayed larger infarct size accompanied by decreased phosphorylation of Akt, STAT3 and decreased cardiac nitric oxide (NO) and APN levels. NAC and ALP decreased MI/R injury in D rats, enhanced phosphorylation of Akt and STAT3, and increased NO and APN. High glucose and hypoxia/reoxygenation exposure induced cell death and Akt and STAT3 inactivation in cultured cardiomyocytes, which were prevented by NAC and ALP. The PI3K inhibitor wortmannin and Jak2 inhibitor AG490 abolished the protection of NAC and ALP. Similarly, APN restored posthypoxic Akt and STAT3 activation and decreased cell death in cardiomyocytes. Gene silencing with AdipoR2 siRNA or STAT3 siRNA but not AdipoR1 siRNA abolished the protection of NAC and ALP. In conclusion, NAC and ALP prevented diabetic MI/R injury through PI3K/Akt and Jak2/STAT3 and cardiac APN may serve as a mediator via AdipoR2 in this process. [Copyright &y& Elsevier]

Objectives: This study sought to evaluate whether remote ischemic post-conditioning (RIPC) could reduce enzymatic infarct size in patients with anterior ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention (pPCI). Background: Myocardial reperfusion injury may attenuate the benefit of pPCI. In animal models, RIPC mitigates myocardial reperfusion injury. Methods: One hundred patients with anterior ST-segment elevation myocardial infarction and occluded left anterior descending artery were randomized to pPCI + RIPC (n = 50) or conventional pPCI (n = 50). RIPC consisted of 3 cycles of 5 min/5 min ischemia/reperfusion by cuff inflation/deflation of the lower limb. The primary endpoint was infarct size assessed by the area under the curve of creatinine kinase-myocardial band release (CK-MB). Secondary endpoints included the following: infarct size assessed by cardiac magnetic resonance delayed enhancement volume; T2-weighted edema volume; ST-segment resolution >50%; TIMI (Thrombolysis In Myocardial Infarction) frame count; and myocardial blush grading. Results: Four patients (2 RIPC, 2 controls) were excluded due to missing samples of CK-MB. A total of 96 patients were analyzed; median area under the curve CK-MB was 8,814 (interquartile range [IQR]: 5,567 to 11,325) arbitrary units in the RIPC group and 10,065 (IQR: 7,465 to 14,004) arbitrary units in control subjects (relative reduction: 20%, 95% confidence interval: 0.2% to 28.7%; p = 0.043). Seventy-seven patients underwent a cardiac magnetic resonance scan 3 to 5 days after randomization, and 66 patients repeated a second scan after 4 months. T2-weighted edema volume was 37 ± 16 cc in RIPC patients and 47 ± 22 cc in control subjects (p = 0.049). ST-segment resolution >50% was 66% in RIPC and 37% in control subjects (p = 0.015). We observed no significant differences in TIMI frame count, myocardial blush grading, and delayed enhancement volume. Conclusions: In patients with anterior ST-segment elevation myocardial infarction, RIPC at the time of pPCI reduced enzymatic infarct size and was also associated with an improvement of T2-weighted edema volume and ST-segment resolution >50%. (Remote Postconditioning in Patients With Acute Myocardial Infarction Treated by Primary Percutaneous Coronary Intervention [PCI] [RemPostCon]; NCT00865722) [Copyright &y& Elsevier]

Objectives: This study sought to investigate whether the everolimus-eluting stent (EES) is superior to the paclitaxel-eluting stent (PES) with respect to long-term individual clinical outcomes. Background: Individual studies have indicated a clinical advantage of coronary EES compared with PES with respect to restenosis and the composite endpoint of major adverse cardiac events. However, these trials were not powered for superiority in low-frequency event rates and have reported limited data beyond 1-year follow-up. Methods: We conducted a meta-analysis of the final 3-year results from the international SPIRIT (Clinical Evaluation of the Xience V Everolimus Eluting Coronary Stent System in the Treatment of Patients With De Novo Native Coronary Artery Lesions) II, III, and IV clinical trials. Individual patient data from 4,989 patients who were prospectively randomized to treatment with EES (n = 3,350) or PES (n = 1,639) were pooled for analysis. Results: At 3-year follow-up, EES was superior to PES in reducing the following event rates: target lesion failure (8.9% vs. 12.5%, hazard ratio [HR]: 0.71, 95% confidence interval [CI]: 0.59 to 0.85; p = 0.0002), all-cause mortality (3.2% vs 5.1%, HR: 0.65, 95% CI: 0.49 to 0.86; p = 0.003), myocardial infarction (3.2% vs. 5.1%, HR: 0.64, 95% CI: 0.48 to 0.85; p = 0.002), cardiac death or myocardial infarction (4.4% vs. 6.3%, HR: 0.70, 95% CI: 0.54 to 0.90; p = 0.005), ischemia-driven target lesion revascularization (6.0% vs. 8.2%, HR: 0.72, 95% CI: 0.58 to 0.90; p = 0.004), stent thrombosis (0.7% vs. 1.7%, HR: 0.45, 95% CI: 0.26 to 0.78; p = 0.003), and major adverse cardiac events (9.4% vs. 13.0%, HR: 0.71, 95% CI: 0.60 to 0.85; p = 0.0002). No interaction was present between stent type and the 3-year relative rates of target lesion failure across a broad range of subgroups, with the exception of diabetes and vessel (left anterior descending vs. other). Conclusions: In this large dataset with 3-year follow-up, coronary implantation of EES compared with PES resulted in reduced rates of all-cause mortality, myocardial infarction, ischemia-driven target lesion revascularization, stent thrombosis, and target lesion failure. Further research is warranted to characterize possible interactions between stent type, diabetes, and vessel. [Copyright &y& Elsevier]

Abstract: Background: Coronary flow reserve (CFR) provides independent prognostic information in diabetic patients with known or suspected coronary artery disease. However, there have been no substantial data to evaluate CFR in prediabetics. Accordingly, we aimed to evaluate CFR in subjects with prediabetes using second harmonic transthoracic Doppler echocardiography. Methods and Results: We measured CFR of 65 subjects with prediabetes, 45 patients with overt type 2 diabetes, and 43 sex and age matched normoglycemic healthy subjects with normal glucose tolerance. Ages, gender, existence of hypertension or hypercholesterolemia, smoking status were similar among the groups. CFR was significantly lower in diabetics (2.15±0.39) than in prediabetics (2.39±0.45) and controls (2.75±0.35); in addition, it was significantly lower in prediabetics than controls. Only 2 (5%) of control subjects had abnormal CFR (<2) but 11 (17%) prediabetic subjects and 19 (42%) diabetic patients had abnormal CFR. We found that only age (β=−0.31, P<0.01) and presence of the diabetes (β=−0.57, P<0.01) were significant predictors of lower CFR in a multivariable model that adjusted for other variables. CFR was significantly and inversely correlated with age (r=−0.15, P =0.04), fasting glucose level (r=−0.27, P =0.001), postprandial glucose level (r=0.43, P <0.001), hemoglobin A1C level (r=−0.34, P <0.001), LDL cholesterol level (r=0.22, P =0.009), mitral A velocity (r=−0.27, P =0.001) and Tei index (r=−0.19, P =0.02), whereas mitral E/A ratio, mitral Em (r=0.18, P =0.02), mitral Em/Am ratio (r=0.23, P =0.004) were significantly and positively correlated with CFR. Conclusion: CFR is impaired in subjects with prediabetics, but this impairment is not as severe as that in diabetics. [Copyright &y& Elsevier]

Abstract: Hydrogen peroxide (H2O2) is an endogenous endothelium-derived hyperpolarizing factor released by flow and involved in the regulation of coronary blood flow. Because opposing vasoactive effects have been reported for H2O2 depending on the vascular bed and experimental conditions, the aim of this study was to assess whether H2O2 may act as a coronary vasoconstrictor and if so to determine the underlying signaling mechanisms. Intramyocardial arteries from male Wistar rats were mounted on microvascular myographs for simultaneous measurements of intracellular Ca2+ ([Ca2+]i) and tension. On coronary arteries precontracted with the thromboxane A2 (TxA2) analogue U46619, H2O2 (1–300μM) elicited further moderate contractions in the proximal arterial segments and relaxed the more distal coronary branches, the contractions being markedly augmented in arteries depolarized by raising extracellular K+. H2O2-elicited vasoconstriction on K+30-precontracted coronary arteries was blunted by catalase and significantly reduced by endothelial cell removal and by inhibitors of cyclooxygenase (COX) and of the TxA2 receptor (TP). H2O2 (50μM) increased by about 10-fold basal superoxide anion (O2 −) production in coronary arteries measured by lucigenin-enhanced chemiluminescence, and H2O2-elicited contractions were reduced by the superoxide dismutase mimetic tempol and by NADPH oxidase inhibition. Furthermore, blockade of the ERK and p38 mitogen-activated protein (MAP) kinases significantly reduced the contractions elicited by high and low concentrations of peroxide, respectively, whereas Rho kinase inhibition nearly abolished these responses. H2O2 (50μM) elicited simultaneous and similar sustained increases in [Ca2+]i and tension that were blunted by blockade of voltage-dependent L-type channels, but resistant to the nonselective Ca2+ channel blocker 2-aminoethoxydiphenyl borate. Moreover, endothelial cell removal reduced the increases in [Ca2+]i and contraction elicited by peroxide. The present data demonstrate that H2O2 is an endothelium-dependent vasoconstrictor in rat coronary arteries that activates smooth muscle Ca2+ entry through L-type and non-L-type channels and various intracellular signaling pathways including the release of a COX-derived TP agonist, stimulation of the MAP and Rho kinase pathways, and production of NADPH oxidase-derived superoxide. [Copyright &y& Elsevier]

Coronary computed tomography angiography (CTA) has emerged as a noninvasive method for direct visualization of coronary artery disease, with previous studies demonstrating high diagnostic performance of CTA compared with invasive coronary angiography. However, CTA assessment of coronary stenoses tends toward overestimation, and even among CTA-identified severe stenosis confirmed at the time of invasive coronary angiography, only a minority are found to be ischemia causing. Recent advances in computational fluid dynamics and image-based modeling now permit determination of rest and hyperemic coronary flow and pressure from CTA scans, without the need for additional imaging, modification of acquisition protocols, or administration of medications. These techniques have been used to noninvasively compute fractional flow reserve (FFR), which is the ratio of maximal coronary blood flow through a stenotic artery to the blood flow in the hypothetical case that the artery was normal, using CTA images. In the recently reported prospective multicenter DISCOVER-FLOW (Diagnosis of Ischemia-Causing Stenoses Obtained Via Noninvasive Fractional Flow Reserve) study and the DeFACTO (Determination of Fractional Flow Reserve by Anatomic Computed Tomographic Angiography) trial, FFR derived from CTA was demonstrated as superior to measures of CTA stenosis severity for determination of lesion-specific ischemia. Given the significant interest in this novel method for determining the physiological significance of coronary artery disease, we herein present a review on the scientific principles that underlie this technology. [Copyright &y& Elsevier]

Background: Reciprocal ST-segment depression simulating additional subendocardial ischemia is commonly observed in ST-segment elevation myocardial infarction. Objective: To study the mechanism and characterization of the whole reciprocal electrocardiogram (ECG) patterns induced by acute coronary artery occlusion at different locations in the absence of additional subendocardial ischemia in pigs. Methods: Conventional 12-lead ECG and/or local extracellular epicardial, mid-myocardial, and endocardial electrograms were recorded during the acute occlusion of right coronary (RC) and left anterior descending (LAD) coronary arteries in the in situ (n = 9) or in the isolated perfused (n = 5) pig hearts. Results: Mid-RC occlusion induced reciprocal ST-segment depression (−0.43±0.14 mV; P<.01) and S-wave deepening (−0.74±0.23 mV; P<.01) in anterior ECG leads. Mid-LAD occlusion induced reciprocal S-wave deepening (−0.43±0.37 mV; P = .02) but not ST-segment depression in inferior leads. Proximal LAD induced reciprocal ST-segment depression (−0.21±0.20 mV; P = .03) and S-wave deepening (−0.56±0.58 mV; P = .04) in inferior leads. Reciprocal QRS widening was observed only during proximal LAD occlusion. Local extracellular recordings did not show significant reciprocal QRS and ST-segment changes. Conclusions: In the absence of additional subendocardial ischemia, acute coronary artery occlusion induces reciprocal ST-segment and S-wave changes in the 12-lead ECG that allow better differentiation between proximal and mid-LAD occlusion. Reciprocal ECG changes depend on conventional lead system design and not on the transmission of injury currents from the ischemic border zone to distant normal myocardium. [Copyright &y& Elsevier]

Background: Bilateral internal thoracic artery (BITA) grafting with a composite T-graft enables right coronary artery (RCA) system revascularization with the distal end of the free right internal thoracic artery (RITA). This study compares this grafting technique to left-sided BITA grafting and RCA revascularization with the right gastroepiploic artery (RGEA) and saphenous vein grafts (SVG). Methods: From April 1996 to July 1999, 1000 consecutive patients underwent left-sided revascularization with BITA. In 231 patients RCA grafting was performed with free RITA, in 246 with RGEA, in 142 with SVG, and 381 did not receive any graft to the RCA (no-graft group). Results: Female gender, old age (> 70), emergency, and congestive heart failure were less prevalent in the RGEA group, and prior percutaneous transluminal coronary angioplasty was more prevalent in the no-graft group. Thirty-day mortality (3.6%, 4.9%, 2%, and 3.4% in the RITA, SVG, RGEA, and no-graft groups, respectively) and occurrence of perioperative complications (sternal infection, myocardial infarction, cerebrovascular accident, and bleeding) were similar. Overall, however, the trend was toward a higher complication rate in the RITA group (10.3%, 4.9%, 5.6%, and 7.3% respectively, p = 0.06). Midterm follow-up (40 to 78 months) showed similar 6-year survival (Kaplan-Meier) (88%, 87%, 89.5%, and 85.5%, respectively) and similar return of angina (10.8%, 6.3%, 10.6%, and 9.5%, respectively) in the four groups. Conclusions: Early and midterm results in patients undergoing left-sided BITA grafting are not affected by the conduit used for RCA grafting. [Copyright &y& Elsevier]

Objective: This study sought to compare the accuracy of myocardial contrast echocardiography (MCE) and wall motion analysis (WMA) during submaximal and peak dobutamine stress echocardiography (DSE) for the diagnosis of coronary artery disease (CAD). Background: The relative merits of MCE and WMA for the detection of CAD during DSE have not been studied in a large number of patients. Methods: We studied 170 patients who underwent dobutamine (up to 50 μg/kg/min)-atropine stress testing and coronary angiography. The WMA and MCE (using repeated boluses of Optison [Mallinckrodt, St. Louis, Missouri] or Definity [Bristol-Myers Squibb, New York, New York]) were performed at rest, at intermediate stress (65% to 75% of maximal heart rate), and at peak stress. The diagnosis of CAD (≥50% stenosis in ≥1 coronary artery) was based on reversible wall motion and perfusion abnormalities. Results: Coronary artery disease was detected in 127 (75%) patients. Sensitivity of MCE was higher than that of WMA at maximal stress (91% vs. 70%; p = 0.001) and at intermediate stress (84% vs. 20%; p = 0.0001). Specificity was lower for MCE compared with WMA (51% vs. 74%; p = 0.01). Overall accuracy was higher for MCE than for WMA (81% vs. 71%; p = 0.01). Sensitivity for detection of CAD based on abnormalities in ≥2 vascular regions was higher for MCE than for WMA (67% vs. 28%; p < 0.01). Conclusions: The majority of inducible perfusion abnormalities occur at an intermediate phase of the stress test, without wall motion abnormalities. Myocardial contrast echocardiography provides better sensitivity than WMA, particularly in patients with submaximal stress and in identifying patients with multivessel CAD. [Copyright &y& Elsevier]

Objectives: This study defined long-term patency of saphenous vein grafts (SVG) and internal mammary artery (IMA) grafts. Background: This VA Cooperative Studies Trial defined 10-year SVG patency in 1,074 patients and left IMA patency in 457 patients undergoing coronary artery bypass grafting (CABG). Methods: Patients underwent cardiac catheterizations at 1 week and 1, 3, 6, and 10 years after CABG. Results: Patency at 10 years was 61% for SVGs compared with 85% for IMA grafts (p < 0.001). If a SVG or IMA graft was patent at 1 week, that graft had a 68% and 88% chance, respectively, of being patent at 10 years. The SVG patency to the left anterior descending artery (LAD) (69%) was better (p < 0.001) than to the right coronary artery (56%), or circumflex (58%). Recipient vessel size was a significant predictor of graft patency, in vessels >2.0 mm in diameter SVG patency was 88% versus 55% in vessels ≤2.0 mm (p < 0.001). Other positive significant predictors of graft patency were use of aspirin after bypass, older age, lower serum cholesterol, and lowest Canadian Functional Class (p < 0.001 to 0.058). Conclusions: The 10-year patency of IMA grafts is better than SVGs. The 10-year patency for SVGs is better and the 10-year patency for IMA grafts is worse than expected. The 10-year patency of SVGs to the LAD is better than that to the right or circumflex. The best long-term predictors of SVG graft patency are grafting into the LAD and grafting into a vessel that is >2.0 mm in diameter. [Copyright &y& Elsevier]

Objectives: We examined the relationship between coronary endothelium-dependent vasodilation in response to bradykinin (BK) and plasma levels of oxidized low-density lipoprotein (oxLDL) in subjects with normal coronary arteries.Background: It is unclear whether the plasma oxLDL level is a determinant of coronary endothelial function. Bradykinin plays an important role in regulating resting coronary tone and flow-mediated coronary vasomotion.Methods: Coronary blood flow (CBF) in the left anterior descending (LAD) coronary artery was assessed by quantitative angiography and a Doppler flow wire in 94 consecutive subjects with normal coronary arteries. The plasma oxLDL level was measured by enzyme-linked immunosorbent assay using DLH3R, a specific antibody against oxLDL.Results: Plasma levels of oxLDL in diabetic subjects (n = 13) were higher than those in non-diabetic subjects (n = 81). Plasma levels of oxLDL correlated with body mass index (BMI). Bradykinin at doses of 0.2, 0.6, and 2.0 μg/min caused dose-dependent increases in diameter and CBF in the LAD coronary artery. By a univariate analysis, oxLDL levels significantly correlated with epicardial (r = -0.30, p < 0.0001) and resistant (r = -0.36, p = 0.003) coronary vasodilator responses to BK at 2.0 μg/min, whereas total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, and triglycerides were not associated with these coronary responses. In a stepwise multivariate analysis, oxLDL levels were significantly correlated with epicardial and resistant coronary vasomotor responses to BK, independent of age, gender, smoking status, other lipid levels, BMI, hypertension, and diabetes.Conclusions: The plasma level of oxLDL is an appropriate surrogate for assessing coronary endothelial-dependent vasomotor function as estimated by responses to BK compared with conventional risk factors for atherosclerosis. [Copyright &y& Elsevier]

Objectives: The goal of this study was to investigate the effects of ischemia-reperfusion on myocardial ultrastructure in patients with and without hibernating myocardium.Background: It is generally accepted that chronically dysfunctional, hibernating myocardium may remain nonetheless viable for a long time. It has been postulated that hibernating myocytes may survive, despite being subtended by a severe coronary artery stenosis, as they might be less susceptible to ischemic insults. However, whether hibernating myocardium is indeed more resistant to ischemia has never been investigated.Methods: Myocardial biopsies were taken before cardiac arrest and after reperfusion from the anterior wall of the left ventricle in patients undergoing coronary artery bypass surgery, divided according to presence (n = 7) or absence (n = 7) of hibernating myocardium. Ultrastructural changes were studied by electron microscopy. Because ischemia-reperfusion injury is related to oxidative stress, we also evaluated coronary sinus concentration of the antioxidants alpha-tocopherol, beta-carotene, and ubiquinol, and of lipid peroxidation products pre-ischemia and after reperfusion.Results: Both groups were similar with respect to length of ischemia and changes in the various indexes of oxidative stress. In normally contracting myocardium, ischemia/reperfusion induced moderate overall ultrastructural changes, and marked alterations at the mitochondrial level. In contrast, post-reperfusion biopsies of hibernating myocardium displayed only minor overall ultrastructural changes, and scored significantly better on mitochondrial damage.Conclusions: Despite similar severity of ischemia/reperfusion, hibernating myocardium showed significantly less ultrastructural evidence of cell injury compared with normally contracting myocardium. These data indicate that human hibernating myocardium is intrinsically more resistant to ischemia/reperfusion injury. [Copyright &y& Elsevier]

: ObjectivesThe aim of the present study was to evaluate the diagnostic accuracy in detecting high-grade coronary stenoses in patients with known coronary artery disease (CAD) using multidetector computed tomography (MDCT).: BackgroundThe MDCT systems with electrocardiographic (ECG)-gating permit visualization of the coronary arteries. However, severe calcifications and higher heart rates are known to degrade image quality and limit correct diagnosis.: MethodsSixty-six patients with proven CAD as assessed by conventional coronary angiography (CCA) were studied by MDCT (mean time 24 months postangiography). Total calcium score and all coronary arteries, including distal segments and side branches, were assessed with respect to evaluability, presence of high-grade coronary artery stenoses (>70%), and correct diagnosis. Results were compared to CCA.: ResultsA total of 105 lesions were detected by CCA. The MDCT correctly detected 39 lesions (sensitivity 37%, specificity 99%). The correct clinical diagnosis could be obtained in 24 patients (36%). Artifacts due to elevated heart rates or severe coronary artery calcification were the main cause of degraded image quality inhibiting correct diagnosis. In 21/66 patients (32%) all four major coronary vessel segments could be visualized. A threshold for maximum heart rate and a maximum calcification level were established (65 beats/min and an Agatston Score Equivalent of 335, respectively). A second analysis was made using these thresholds. Of all patients studied, 10/11 (91%) were correctly diagnosed when adhering to these thresholds.: ConclusionsWhen using MDCT as a noninvasive diagnostic modality to assess advanced CAD, it appears to be mandatory to preselect patients in order to achieve reliable results. [Copyright &y& Elsevier]

: ObjectivesThe aim of this study was to determine predictors of left ventricular (LV) function recovery at the time of primary percutaneous coronary intervention (PCI).: BackgroundAngiographic, intracoronary Doppler flow, and electrocardiographic variables have been reported to be predictors of recovery of LV function after acute myocardial infarction (MI). We directly compared the predictive value of Thrombolysis In Myocardial Infarction (TIMI) flow grade, corrected TIMI frame count (cTfc), myocardial blush grade, coronary Doppler flow velocity analysis, and resolution of ST-segment elevation for recovery of LV function in patients undergoing primary PCI for acute MI.: MethodsWe prospectively studied 73 patients who underwent PCI for an acute anterior MI. Recovery of global and regional LV function was measured using an echocardiographic 16-segment wall motion index (WMI) before PCI, at 24 h, at one week, and at six months. Directly after successful PCI, coronary flow velocity reserve (CFR), cTfc, TIMI flow grade, and myocardial blush grade were assessed.: ResultsMean global and regional WMI improved gradually over time from 1.86 ± 0.23 before PCI to 1.54 ± 0.34 at six-month follow-up (p < 0.0001) and from 2.39 ± 0.30 before PCI to 1.87 ± 0.48 at six-month follow-up (p < 0.0001), respectively. Multivariate analysis revealed CFR as the only independent predictor for global and regional recovery of LV function at six months.: ConclusionsDoppler-derived CFR is a better prognostic marker for LV function recovery after anterior MI than other currently used parameters of myocardial reperfusion. [Copyright &y& Elsevier]

: ObjectivesThis study was designed to determine in a dog model of coronary thrombosis whether short-term eptifibatide (Ep) combined with low-dose plasminogen activator (rt-PA) inhibits platelet recruitment at sites of endothelial damage after normalization of platelet function.: BackgroundEp plus reduced-dose rt-PA has not previously been shown to render a recanalized coronary artery resistant to platelet recruitment after normalization of platelet function.: MethodsInhibition of platelet recruitment was studied by scanning electron microscopy (SEM) in a canine model of left anterior descending (LAD) thrombosis. In phase I treatment groups were: 1) Ep (n = 6); 2) Ep + rt-PA (n = 6); 3) rt-PA (n = 6); and 4) placebo (n = 4). Coronary blood flow was monitored and LAD segments excised for SEM after 90-min infusion of study drug. In phase II, dogs were randomized to Ep alone (n = 5) or to Ep + rt-PA (n = 5). Coronary blood flow was monitored during and 120 min after cessation of drug when platelet function had returned to normal and LAD segments were excised.: ResultsAll animals except placebo showed reflow. In phase I, SEM showed an absence of platelet aggregates with Ep alone and with Ep + rt-PA, but not with rt-PA alone. In phase II, SEM showed an intimal surface devoid of mural thrombus and platelet aggregates only in Ep + rt-PA treated arteries. Ep-alone treated arteries showed new platelet aggregates at sites of residual mural thrombus.: ConclusionsShort-term infusion Ep plus low-dose rt-PA acutely neutralizes the ability of damaged endothelial surfaces to recruit new platelets by inhibiting platelet aggregation and eliminating residual mural thrombus. [Copyright &y& Elsevier]

: BackgroundWe prospectively assess if there are any outcome differences between men and women undergoing coronary artery bypass graft surgery.: Study designThis is an eight-year, prospective, hospitalization cohort study. Data were collected on 225 variables concurrently with admission. The main outcome was mortality. In addition, we evaluated 12 morbidity outcomes. To minimize confounding, we controlled for 18 other variables.: ResultsWe analyzed 5,324 patients (1,742 women; 3,582 men). Women were significantly older, with more African Americans and more Medicaid-insured (p < 0.05). Men had significantly higher body surface area, creatinine, tobacco history, prior myocardial infarctions, left ventricular hypertrophy, and cardiac pump time (p < 0.05). Women had significantly more diabetes, hypercholesterolemia, hypertension, previous cerebrovascular disease, urgency of the surgical procedure, fewer arterial grafts, and reduced functional capacity by the New York Heart Association classification (p < 0.05). Using multiple regression analysis there was no difference for mortality, positive bacterial cultures, ICU length of stay, arrhythmias, reoperation for bleeding, pulmonary complications, gastrointestinal complications, and return to the ICU. Women had significantly more intraoperative complications (RR = 2.09, 95% CI 1.35–3.23), length of stay (RR = 1.01, 95% CI 1.002–1.027), and low cardiac output conditions (RR = 1.10, 95% CI 1.01–1.20). Males developed more neurologic complications (RR = 0.85, 95% CI 0.75–0.95).: ConclusionsWomen undergoing coronary artery bypass graft surgery have more comorbidities at surgical presentation compared with men. Women have more unadjusted mortality, which is confounded by the difference in age and body surface area. But, even after multiple adjustments, female gender is a predictor of higher morbidity in patients undergoing coronary artery bypass graft. [Copyright &y& Elsevier]

Background: Ionizing gamma radiation has been shown to reduce neointimal formation and the incidence of restenosis after balloon angioplasty and stenting in clinical trials. However, the long-term effects of this therapy are unknown. The first cohort of patients to receive intracoronary gamma radiation after balloon angioplasty for the prevention of restenosis have completed a 5-year angiographic and clinical follow-up. The outcome of these patients is presented and discussed. Methods: Twenty-one patients with unstable angina (22 arteries) underwent standard balloon angioplasty. Intracoronary radiation therapy was performed immediately after the intervention using an Iridium-192 source wire hand-delivered to the angioplasty site. All patients were followed clinically and Quantitative Coronary Analysis (QCA) was performed at 6, 24, 36 and 60 months. Results: Target lesion revascularization occurred in six lesions, three of which were total occlusions (two early within 30 days and one occurred at 2 years), and one patient had a myocardial infarction attributable to a nontarget vessel. Serial QCA detected a binary restenosis rate of 28.6% (n=6) at 6 months. The late loss (0.29 mm) and loss index (0.25) remained low at 2, 3 and 5 years. Angiographic complications included four aneurysms (two procedure related and two occurring within 3 months). At 2 years, only one aneurysm increased in size (46 vs. 27 mm2); and at 3 and 5 years, all aneurysms remained unchanged. No other angiographic complications were observed. Conclusion: The early clinical and angiographic effects of intracoronary gamma radiation were maintained at 5 years without further increase in the aneurysm formation or apparent new adverse effects related to the radiation therapy between 2 and 5 years. [Copyright &y& Elsevier]

Abstract: Spontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndrome and has been described in young women during the peripartum period. Management of these patients has been controversial. A 35 year old Caucasian female, 11 days postcesarean section delivery presented with acute myocardial infarction. She underwent angiography within a few hours of presentation, which showed dissection of LAD. Repeat angiography six days later showed improvement of dissection. Patient showed clinical improvement on conservative treatment and no recurrence of symptoms over the past two years follow-up. There is no consensus on the treatment and our case is one of the cases managed successfully with conservative treatment. [Copyright &y& Elsevier]