Is repair preferable to replacement for ischemic mitral regurgitation?

OBJECTIVE: This study was undertaken to compare mitral valve repair and replacement as treatments for ischemic mitral regurgitation. METHODS: From 1985 through 1997, a total of 482 patients with ischemic mitral regurgitation underwent either valve repair (n = 397) or valve replacement (n = 85). Patients more likely (P < or =.01) to undergo repair had functional mitral regurgitation or coronary revascularization with an internal thoracic artery graft; those more likely to receive valve replacement were in higher New York Heart Association functional classes or underwent emergency operations. These factors were used for multivariable propensity matching. Risk factors for early and late death were identified by multivariable, multiphase hazard function analysis. RESULTS: Within the propensity-matched better-risk group, survivals after valve replacement were 81%, 56%, and 36% at 30 days, 1 year, and 5 years, but survivals after repair were 94%, 82%, and 58% at these intervals (P =.08). In contrast, within the poor-risk group, survivals after repair and replacement were similar (P =.4). Risk factors (P < or =.01) included older age, higher functional class, greater wall motion abnormality, and renal dysfunction. Approximately 70% of patients were predicted to benefit from repair; the benefit lessened or was negated if an internal thoracic artery graft was not used, if a lateral wall motion abnormality was present, or if the mitral regurgitation jet pattern was complex. Freedom from repair failure at 5 years was 91%. CONCLUSION: Late survival is poor after surgery for ischemic mitral regurgitation. Most patients with ischemic mitral regurgitation benefit from mitral valve repair. In the most complex, high-risk settings, survivals after repair and replacement are similar.

Mechanical properties of myxomatous mitral valves.

OBJECTIVE: We sought to characterize the mechanical properties of normal and myxomatous mitral valve tissues. METHODS: We tested 113 mitral valve sections from patients undergoing mitral valve repair or replacement for myxomatous mitral valve prolapse and sections from 33 normal valves obtained at autopsy. RESULTS: Myxomatous mitral valve leaflets were more extensible than normal leaflets when tested parallel to the free edge (41.2% +/- 18.5% vs 17.3% +/- 6.7% circumferential strain [mean +/- SD]; P <.001), as well as perpendicular to the free edge (43.2% +/- 19.4% vs 17.3% +/- 6.7% radial strain; P <.001). Myxoid leaflets were less stiff circumferentially (4.0 +/- 1.6 vs 6.1 +/- 1.4 kN/m; P <.001) and radially (4.5 +/- 1.1 vs 6.1 +/- 1.4 kN/m; P <.001) than normal leaflets. Leaflet strength, however, was similar in both groups. CONCLUSIONS: Myxomatous mitral valve leaflets are physically and mechanically different from normal mitral valve leaflets. They are more extensible and less stiff. Compared with chordae examined previously, however, they are affected much less. Myxomatous mitral valve disease may therefore affect the collagen in the chordae more severely than that in the leaflets.

Age and valve size effect on the long-term durability of the Carpentier-Edwards aortic pericardial bioprosthesis.

BACKGROUND: Bioprosthesis durability decreases with time and younger age. However, the time-scale and determinants of durability of the aortic Carpentier-Edwards stented bovine pericardial prosthesis are incompletely characterized. METHODS: Between September 1981 and January 1984, 267 patients underwent implantation of the pericardial aortic prosthesis at four centers. Mean age at implant was 65 +/- 12 years (range 21 to 86 years). Follow-up averaged 12 +/- 4.5 years. The primary end point was explant for structural valve dysfunction (SVD), which was analyzed multivariably in the context of death as a competing risk. RESULTS: Freedom from explant due to SVD was 99%, 94%, and 77% at 5, 10, and 15 years. Risk of SVD increased exponentially with time and younger age (p = 0.0001) at implantation; an increased risk of small valve size was not reliably demonstrated (p = 0.1). Considering the competing risk of death, patients aged 65 years or older had a less than 10% chance of explant for SVD by 15 years. CONCLUSIONS: Durability of this stented pericardial aortic bioprosthesis is excellent and justifies its use in patients aged 65 or older.

Durability of combined aortic and mitral valve repair.

BACKGROUND: This study was undertaken to determine the durability of combined aortic and mitral valve repair. METHODS: From 1979 through 1999, 158 patients underwent simultaneous aortic and mitral valve repair. Multivariable, multi-phase hazard function analysis was used to determine risk factors for the outcomes of death and reoperation. RESULTS: Hospital mortality was 3%. Survival after operation was 97%, 93%, 82%, and 62% after 30 days and 1, 5, and 10 years, respectively. Risk factors for late death included aortic stenosis (p = 0.0001), older age (p = 0.002), and abnormal left ventricular function (p = 0.007). Thirty-six patients required reoperation for valvular dysfunction, and freedom from reoperation was 94%, 82%, and 65% after 1, 5, and 10 years, respectively. Risk factors for reoperation included severe aortic regurgitation (p = 0.004), aortic cusp shaving (p = 0.05), mitral valve chordal transfer (p = 0.004), and bovine pericardial annuloplasty (p = 0.002). Five-year freedoms from endocarditis, thromboembolism, and hemorrhage were 97%, 98%, and 99%, respectively, with freedom from any of these valve-related morbidities of 99%, 95%, and 94% after 1, 5, and 10 years, respectively. CONCLUSIONS: Double valve repair is associated with acceptable late survival and excellent freedom from valve-related morbidity, but limited durability. Therefore, double valve repair should be reserved for patients who cannot be anticoagulated, and should be used with caution in patients with aortic stenosis, rheumatic valve disease, or anterior mitral leaflet pathology.

Clinical experience with 202 adults receiving extracorporeal membrane oxygenation for cardiac failure: survival at five years.

OBJECTIVES: We sought to determine 5-year survival after extracorporeal membrane oxygenation for cardiac failure and its predictors, to assess survival and its predictors after bridging to transplantation or weaning from extracorporeal membrane oxygenation, and to identify factors influencing the likelihood of these outcomes. METHODS: Two hundred two adults (mean age, 55 +/- 14 years) were supported with extracorporeal membrane oxygenation between 1992 and July 1999 after cardiac failure. Follow-up extended to 7.5 years (mean, 3.8 +/- 2 years). Multivariable hazard function analysis identified predictors of survival, and logistic regression identified the determinants of bridging or weaning. RESULTS: Survival at 3 days, 30 days, and 5 years was 76%, 38%, and 24%, respectively. Patients surviving 30 days had a 63% 5-year survival. Risk factors (P <.1) included older age, reoperation, and thoracic aorta repair. Forty-eight patients were bridged to transplantation, and 71 were weaned with intent for survival. Survival was similar after either outcome (44% vs 40% 5-year survival, respectively). Failure to bridge or wean included (P <.03) renal and hepatic failure on extracorporeal membrane oxygenator support, occurrence of a neurologic event, and absence of infection. The dominant modes of death were cardiac failure and multisystem organ failure. CONCLUSIONS: Extracorporeal membrane oxygenation is versatile and salvages some patients who would otherwise die. Improvement in intermediate-term outcome will require a multidisciplinary approach to protect organ function and limit organ injury before and during this support.

A numerical model and spreadsheet interface for pumping test analysis.

Curve-matching techniques have been the standard method of aquifer test analysis for several decades. A variety of techniques provide the capability of evaluating test data from confined, unconfined, leaky aquitard, and other conditions. Each technique, however, is accompanied by a set of assumptions, and evaluation of a combination of conditions can be complicated or impossible due to intractable mathematics or nonuniqueness of the solution. Numerical modeling of pumping tests provides two major advantages: (1) the user can choose which properties to calibrate and what assumptions to make; and (2) in the calibration process the user is gaining insights into the conceptual model of the flow system and uncertainties in the analysis. Routine numerical modeling of pumping tests is now practical due to computer hardware and software advances of the last decade. The RADFLOW model and spreadsheet interface presented in this paper is an easy-to-use numerical model for estimation of aquifer properties from pumping test data. Layered conceptual models and their properties are evaluated in a trial-and-error estimation procedure. The RADFLOW model can treat most combinations of confined, unconfined, leaky aquitard, partial penetration, and borehole storage conditions. RADFLOW is especially useful in stratified aquifer systems with no identifiable lateral boundaries. It has been verified to several analytical solutions and has been applied in the Snake River Plain Aquifer to develop and test conceptual models and provide estimates of aquifer properties. Because the model assumes axially symmetrical flow, it is limited to representing multiple aquifer layers that are laterally continuous.

Double valve endocarditis.

BACKGROUND: There are little data concerning surgical outcomes in patients with native valve endocarditis affecting both the aortic and mitral valves. METHODS: From 1977 to 1998, 54 patients had simultaneous aortic and mitral valve grafting for native valve endocarditis. In 78%, mitral valve involvement was limited to the anterior leaflet, suggesting a jet lesion from the aortic valve. Surgical strategies included 31 valve repairs and valve replacement with mechanical (34), bioprosthetic (34), or allograft (9) prostheses. Three hundred twenty-five patient-years of follow-up were available for analysis (mean 6.0 +/- 4.8 years). RESULTS: There were no hospital deaths. Ten-year survival was 73%. Ten-year freedom from recurrent endocarditis was 84%, with risk peaking at 3 months, followed by a constant risk of 1.3%/yr. Choice of valvar procedure did not influence mortality or reinfection risk. CONCLUSIONS: The most common pattern of double valve infection was a jet lesion on the anterior mitral leaflet. Surgical treatment has late survival and freedom from reinfection similar to those of patients with single heart valve infection.

Short-term hemodynamic performance of the mitral Carpentier-Edwards PERIMOUNT pericardial valve. Carpentier-Edwards PERIMOUNT Investigators.

BACKGROUND: Although long-term durability data exist, little data are available concerning the hemodynamic performance of the Carpentier-Edwards PERIMOUNT pericardial valve in the mitral position. METHODS: Sixty-nine patients who were implanted with mitral PERIMOUNT valves at seven international centers between January 1996 and February 1997 consented to participate in a short-term echocardiography follow-up. Echocardiographs were collected at a mean of 600+/-133 days after implantation (range, 110 to 889 days); all underwent blinded core lab analysis. RESULTS: At follow-up, peak gradients were 9.09+/-3.43 mm Hg (mean, 4.36+/-1.79 mm Hg) and varied inversely with valve size (p < 0.05). The effective orifice areas were 2.5+/-0.6 cm2 and tended to increase with valve size (p = 0.08). Trace mitral regurgitation (MR) was common (n = 48), 9 patients had mild MR, 1 had moderate MR, none had severe MR. All MR was central (n = 55) or indeterminate (n = 3). No paravalvular leaks were observed. Mitral regurgitation flow areas were 3.4+/-2.8 cm2 and were without significant volumes. CONCLUSIONS: In this multicenter study, these mitral valves are associated with trace, although physiologically insignificant, central MR. Despite known echocardiographic limitations, the PERIMOUNT mitral valves exhibit similar hemodynamics to other prosthetic valves.

Myxomatous mitral valve chordae. I: Mechanical properties.

BACKGROUND AND AIM OF THE STUDY: Chordal rupture is the most common reason for severe mitral regurgitation requiring surgery. The features that predispose myxomatous chordae to rupture, however, have not been studied. Thus, the physical and mechanical properties of normal and myxomatous mitral valve chordae were measured. METHODS: Chordae from 24 normal and 59 myxomatous mitral valves were cut into 10 mm-long segments and mechanically tested to measure extensibility, modulus, failure stress, failure strain, and failure load. After testing, the specimens were weighed and their cross-sectional area and volume measured. RESULTS: Chordae from myxoid mitral valves were larger (1.9 +/- 0.1 mm2 versus 0.8 +/- 0.1 mm2, p < or = 0.001) and heavier (16.6 +/- 1.0 mg versus 6.5 +/- 0.4 mg, p < or = 0.001) than normal chordae. Myxoid chordae had significantly lower moduli (40.4 +/- 10.2 MPa versus 132 +/- 15 MPa, p < or = 0.001) and failed at significantly lower tensile stress (6.0 +/- 0.6 MPa versus 25.7 +/- 1.8 MPa, p < or = 0.001) and absolute load (728 +/- 50 g versus 1,450 +/- 135 g, p < or = 0.001) than normal chordae. Normal and myxoid chordae had similar measurements of extensibility and failure strain. CONCLUSION: Myxomatous degeneration severely affects the mechanical properties of mitral valve chordae. Most notably, myxoid chordae failed at loads one-half of those of normal chordae. This may explain why chordal rupture is the main indication for repair of myxoid mitral valves. These findings also suggest that chordal preservation should be carried out with caution, as myxoid chordae are clearly abnormal with compromised mechanical strength.

Myxomatous mitral valve chordae. II: Selective elevation of glycosaminoglycan content.

BACKGROUND AND AIM OF THE STUDY: Chordal rupture in myxomatous mitral valves is the leading cause of leaflet prolapse and regurgitation. Increased glycosaminoglycan (GAG) content has been reported in these valves. Therefore, the biochemical differences between myxomatous and control mitral valve chordae were investigated. METHODS: The contents of hexuronic acid, DNA, water, and collagen in chordae from 45 myxomatous valves and 10 control valves were measured. Collagen and hexuronic acid quantities were normalized to wet and dry weights, and to DNA content. Different GAG classes were measured using fluorophore-assisted carbohydrate electrophoresis (FACE). RESULTS: Myxomatous chordae contained significantly more GAGs than controls after quantities were normalized for wet weight, dry weight, and DNA content. The FACE assay showed that the myxomatous chordae contained significantly more chondroitin/dermatan 6-sulfate when normalized to both wet and dry weight, and slightly more hyaluronan. In contrast to leaflets, which contain predominantly hyaluronan, the predominant GAG class in chordae was chondroitin/dermatan sulfate. Keratan sulfate, a GAG class previously unreported in valve tissues, was also discovered in the chordae. Myxomatous chordae contained more water and less collagen than control chordae, but equal quantities of DNA when normalized for wet weight. CONCLUSION: Cells in the chordae of myxomatous valves may produce more GAGs than cells in the chordae of control valves. The resulting accumulation of GAGs and bound water likely gives myxomatous valves their characteristic thickening and floppy, gelatinous nature, and may account for their reported mechanical weaknesses.

Prediction of coronary artery disease in patients undergoing operations for mitral valve degeneration.

OBJECTIVES: We sought to develop and validate a model that estimates the risk of obstructive coronary artery disease in patients undergoing operations for mitral valve degeneration and to demonstrate its potential clinical utility. METHODS: A total of 722 patients (67% men; age, 61 +/- 12 years) without a history of myocardial infarction, ischemic electrocardiographic changes, or angina who underwent routine coronary angiography before mitral valve prolapse operations between 1989 and 1996 were analyzed. A bootstrap-validated logistic regression model on the basis of clinical risk factors was developed to identify low-risk (< or =5%) patients. Obstructive coronary atherosclerosis was defined as 50% or more luminal narrowing in one or more major epicardial vessels, as determined by means of coronary angiography. RESULTS: One hundred thirty-nine (19%) patients had obstructive coronary atherosclerosis. Independent predictors of coronary artery disease include age, male sex, hypertension, diabetes mellitus,and hyperlipidemia. Two hundred twenty patients were designated as low risk according to the logistic model. Of these patients, only 3 (1.3%) had single-vessel disease, and none had multivessel disease. The model showed good discrimination, with an area under the receiver-operating characteristic curve of 0.84. Cost analysis indicated that application of this model could safely eliminate 30% of coronary angiograms, corresponding to cost savings of $430,000 per 1000 patients without missing any case of high-risk coronary artery disease. CONCLUSION: A model with standard clinical predictors can reliably estimate the prevalence of obstructive coronary atherosclerosis in patients undergoing mitral valve prolapse operations. This model can identify low-risk patients in whom routine preoperative angiography may be safely avoided.

Collective contributions of women to cardiothoracic surgery: a perspective review.

BACKGROUND: Of 5,812 persons boarded by the American Board of Thoracic Surgery (ABTS), 99 (< 2%) are women. This study was designed to collect and report the contributions made by these women in the specialty of cardiothoracic surgery. METHODS: Identification of ABTS board-certified women was obtained from the ABTS. Compilation of data was accomplished through membership databases, medical licensing boards, thoracic surgery residency programs, and residency program attending surgeons. Data were substantiated through hospital medical staff offices, local practitioners, and personal telephone calls. Curricula vitae were requested; practice types (adult, pediatric, cardiac, general thoracic, or transplantation) were established. Data were collated, extrapolated, and tallied. Trends over time were analyzed by logistic regression analyses. RESULTS: Currently, 84 women are actively practicing: 44 have academic appointments and 40 are in private practice. Of the remaining 15 women, 4 are deceased; 4 are retired; 5 are in other professional fields; and 2 are in an unknown practice setting. Accumulated data confirmed that women surgeons are practicing in every type and subgroup of cardiothoracic surgery (adult, pediatric, cardiac, general thoracic, transplantation, and combinations of these). Collectively, they have published 2,292 articles and book chapters. Manuscripts directly related to cardiac topics number 1,220. Women in cardiothoracic surgical research have been awarded $31.9 million in grant funds. Two trends over time were identified. First, the distribution of practice setting (academic or private) was stable compared with year of board certification. Secondly, a statistically significant rise in the annual percentage of board-certified persons who are women (p < 0.0001) has been established. CONCLUSIONS: The percent of ABTS board-certified women surgeons has increased; more than 50% have academic appointments; and a stable trend for women to choose academic cardiothoracic surgery exists.

Developing new technology.

The specialty of cardiothoracic surgery should be one of constant innovation. Albert Einstein was a man of vision who said, "Imagination is more important than knowledge." With most technology expected to be obsolete in 5-7 years, thoracic surgeons need to draw from their imaginations to find innovative surgical solutions for the future.

Case report: outer sheath rupture may precede complete chordal rupture in fibrotic mitral valve disease.

Rupture mechanics of mitral valve chordae have been difficult to elucidate because most surgical repairs and pathological examinations are performed after the rupture. In an excised anterior leaflet from a fibrotic mitral valve, chordae were observed in an initial phase of rupture. Microscopic sections showed that thinned, nearly ruptured chordal segments were actually chordal cores, containing highly aligned collagen fibers. The outer sheath of elastic fibers, disorganized circumferentially oriented collagen fibers, and endothelial cells that normally surrounds the collagen core apparently had retracted to the extreme ends of the thinned segment, resulting in a bulbous shape, as noted in the chordal rupture literature. In conclusion, these new observations lead us to propose that the rupture of mitral valve chordae is not spontaneous, but may occur over time. The failure of the outer sheath may represent the first phase in a slow, two-part process leading to eventual chordal rupture.

Comparison of quantitative and semiquantitative methods for assessing mitral regurgitation by transesophageal echocardiography.

Semiquantitative grading of mitral regurgitation (MR) by transesophageal echocardiography (TEE) is widely used for clinical decision making. However, the relation between semiquantitative grading by biplane or multiplane TEE and quantitative measures remains undetermined. Biplane or multiplane TEE was performed in 113 patients in the operating room. MR severity was graded from 1 to 4+ by Doppler color flow mapping. MR was quantified using the thermodilution-Doppler method as mitral regurgitant stroke volume (RSV) derived from the difference between total mitral inflow measured by pulsed Doppler and forward flow measured by thermodilution. Mitral regurgitant orifice area (ROA) was calculated by RSV divided by mitral regurgitant velocity. RSV and ROA were also calculated using the proximal isovelocity surface area method. RSV and ROA significantly correlated with the semiquantitative grading either by TEE or angiogram in a nonlinear fashion, with the best fit being given by an exponential model with correlation coefficients from 0.73 to 0.87 (p <0.001). Substantially increased RSV and ROA were observed in MR grades of > or =3+. In the same grades of 3+ or 4+ MR, the largest RSV was 4 times larger than the smallest (190 to 220 vs 44 to 45 ml), and the largest ROA (1.82 to 2.0 vs 0.26 to 0.27 cm2) was sixfold larger than the smallest. Patients with 2 to 3+ MR had significantly variable RSV and ROA (range 21 to 91 ml and 0.12 to 0.65 cm2, respectively). Color flow mapping by biplane or multiplane TEE or angiography is able to categorize precisely mild (< or =2+) and severe (> or =3+) MR, but cannot accurately determine actual hemodynamic load of MR in more severe degrees of MR.

Safety and efficacy of intraarterial thrombolysis for perioperative stroke after cardiac operation.

BACKGROUND: Acute ischemic stroke after cardiac operations is a devastating complication with limited therapeutic options. As clinical trials of thrombolysis for acute ischemic stroke exclude patients with recent major surgery, the safety of intraarterial thrombolysis in this setting is unknown. METHODS: Thirteen patients with acute ischemic stroke within 12 days of cardiac operation underwent intraarterial thrombolysis within 6 hours of stroke symptom onset. The National Institutes of Health Stroke Scale was used to assess neurologic recovery. RESULTS: The mean age was 69 years (standard deviation +/-5 years) and 62% were men. Cardiac procedures included valve operations in 6 patients, coronary artery bypass grafting in 4, valve and coronary artery bypass grafting in 2, and left ventricular assist device in 1 patient. Atrial fibrillation occurred in 5 patients (38%). The mean time from operation to stroke was 4.3 days (standard deviation +/- 3 days). Thrombolysis was initiated within 3.6 hours (standard deviation +/-1.6 hours) of stroke symptom onset. Recanalization was complete in 1 patient, partial in 5, and 7 patients had low flow. Neurologic improvement occurred in 5 patients (38%). One patient needed a chest tube for hemothorax, 2 others were transfused for low hemoglobin. No operative intervention for bleeding was necessary. CONCLUSIONS: In select patients with acute ischemic stroke after recent cardiac operation, intraarterial thrombolysis appears to be reasonably safe and may lead to neurologic recovery.

Modified quadrangular resection for mitral valve repair.

Posterior leaflet quadrangular resection is the most commonly performed mitral valve repair procedure for patients with degenerative mitral valve disease. After resection, the remaining leaflet edges must be approximated. When the two leaflet edges are of different heights, modifications are necessary to create a tension-free repair. We present two techniques for posterior leaflet reconstruction when resection results in leaflet edges of different heights.

Echocardiographic assessment of the mechanisms of correction of bileaflet prolapse causing mitral regurgitation with only posterior leaflet repair surgery.

Recent data suggest that posterior leaflet repair alone corrects mitral regurgitation in patients with bileaflet prolapse and normal anterior chordae. The purpose of this study was to use echocardiography to define the anatomic differences between posterior and bileaflet prolapse and to determine if posterior leaflet repair alone leads to correction of bileaflet prolapse. We studied patients who underwent quadrangular resection of the posterior mitral valve leaflet to treat bileaflet prolapse (group I, n = 20) or isolated posterior leaflet prolapse (group II, n = 20). Echocardiographic characteristics were compared before and after the procedure. There were no differences in the left ventricular end-diastolic or end-systolic dimensions or function between the 2 groups. However, anterior leaflet length was greater in patients with bileaflet prolapse (3.3 +/- 0.6 cm vs 2.6 +/- 0.4 cm, p = 0.003). In group I, posterior leaflet repair changed anterior leaflet displacement from -0.8 +/- 0.2 to 0.5 +/- 0.4 cm (p <0.001) and posterior leaflet displacement from -0.8 +/- 0.3 cm below to 0.5 +/- 0.4 cm (p <0.001) in front of the mitral annular plane. In group II, anterior leaflet displacement was unchanged from 0.2 +/- 0.1 to 0.3 +/- 0.2 cm (p = 0.22), whereas posterior leaflet displacement changed from -0.7 +/- 0.2 to 0.4 +/- 0.2 cm (p <0.001). Thus, patients with bileaflet prolapse and no ruptured chords have excessive anterior leaflet length. In such patients, posterior leaflet repair alone corrects anterior and posterior leaflet prolapse.

HDL cholesterol level predicts survival in men after coronary artery bypass graft surgery: 20-year experience from The Cleveland Clinic Foundation.

BACKGROUND: HDL cholesterol (HDL-C) is an important independent predictor of atherosclerosis, yet the role that HDL-C may play in the prediction of long-term survival after CABG remains unclear. The risk associated with a low HDL-C level in post-CABG men has not been delineated in relation to traditional surgical variables such as the use of arterial conduits, left ventricular function, and extent of disease. METHODS AND RESULTS: We performed a prospective, observational study of 432 men who underwent CABG between 1978 and 1979 in whom preoperative HDL-C values were available. Baseline lipid and lipoprotein values, history of diabetes mellitus and hypertension, left ventricular ejection fraction, extent of disease, and use of internal thoracic arteries were recorded. Hazard ratios (HRs) were determined in the patients with and without a low HDL-C level, which was defined as the lowest HDL-C quartile (HDL-C 35 mg/dL) were 50% more likely to survive at 15 years than were patients with low HDL-C level (35 mg/dL were 50% more likely to survive without a subsequent myocardial infarction or revascularization (HR 1.42, P:=0.02). CONCLUSIONS: HDL-C is an important predictor of survival in post-CABG patients. In this study of >8500 patient-years of follow-up, HDL-C was the most important metabolic predictor of post-CABG survival. One third fewer patients survive at 15 years if their HDL-C levels are