Is tranexamic acid safe in patients undergoing coronary endarterectomy?

BACKGROUND: Patients undergoing coronary endarterectomy during coronary artery bypass grafting (CABG) are at increased risk of perioperative myocardial infarction due to coronary intimal disruption. Data assessing the safety of the antifibrinolytic drug tranexamic acid (TA) in patients undergoing this procedure are lacking. METHODS: From September 1997 to December 1999, 221 patients underwent nonemergency primary CABG with endarterectomy of the right coronary artery alone in 149, the left anterior descending in 35, or both right and left anterior descending in 27. TA was administered intraoperatively to 87 patients (TA group: average total dose 62 +/- 4.4 mg/kg; range 20 to 109 mg/kg), and was not administered to 134 patients (No TA group). RESULTS: The patient characteristics of the 2 groups were similar. In-hospital mortality consisted of 2 patients in the TA group and 4 patients in the No TA group. Perioperative myocardial infarction rates were 2% and 5% in the TA and No TA groups, respectively (p = 0.49). The relative risk for any type of perioperative cardiac ischemic event in the TA group versus the No TA group was 0.77 (95% CI; 0.4, 1.2). Patients in the TA group had a significant reduction in postoperative chest tube drainage (685 versus 894 mL in the TA versus No TA groups, respectively) and in the use of fresh-frozen plasma (p = 0.03). CONCLUSIONS: These results suggest that the clinical effectiveness of tranexamic acid in reducing postoperative blood loss in patients undergoing coronary endarterectomy is not associated with a higher incidence of myocardial ischemia-related complications.

Comparative clinical outcomes with St. Jude Medical, Medtronic Hall and CarboMedics mechanical heart valves.

BACKGROUND AND AIM OF THE STUDY: Whether the St. Jude Medical (SJM), Medtronic Hall (MH) or CarboMedics (CM) heart valves confer any relative benefits to patient outcome remains controversial. While numerous studies have analyzed clinical results with a single brand, and a few studies have compared two brands, there are no single-center trials comparing all three valves. METHODS: Our experience with patients who had either a SJM, MH or CM mechanical valve in isolated aortic valve (AVR) or mitral valve (MVR) replacement was reviewed. AVR was performed in 953 patients (SJM = 394, MH = 314, CM = 245) and MVR in 591 patients (SJM = 193, MH = 264, CM = 134). Survivors were assessed annually; follow up consisted of 3336 patient-years (pt-yr) after AVR and 1693 pt-yr after MVR. RESULTS: Preoperatively, in the AVR group, more MH patients had previous valve surgery (p = 0.001) or were in NYHA class III/IV (p = 0.03), and more CM patients had a concomitant surgical procedure (p = 0.005). The hospital mortality after AVR with SJM, MH and CM valves was 3.8, 4.7 and 5.3%, respectively (p = 0.65). In the MVR group, there were more males in the CM group (p = 0.011), more CM patients had concomitant surgery (p = 0.001), and more MH patients had previous surgery (p = 0.006). The hospital mortality after MVR with SJM, MH and CM valves was 8.3, 10.2 and 6.0%, respectively (p = 0.35). There was no late survival advantage in either the AVR or MVR group according to the valve used (p = 0.24 and p = 0.90, respectively). For the AVR group the five-year actuarial freedom from thromboembolism was: SJM 85.8 +/- 2.5%, MH 80.1 +/- 2.7% and CM 85.9 +/- 3.5% (p = 0.04), and for MVR it was: SJM 84.2 +/- 4.0%, MH 77.5 +/- 3.4% and CM 86.9 +/- 5.2% (p = 0.27). Bleeding occurred with a similar frequency in the AVR (p = 0.36) and MVR (p = 0.70) groups. No cases of structural failure were identified in this study. At follow up, among AVR patients NYHA class III/IV was present in: SJM 5%, MH 6% and CM 3% (p = 0.50), while among MVR patients this was identified in: SJM 7%, MH 10% and CM 4% (p = 0.22). CONCLUSION: It is concluded that the SJM, MH and CM mechanical valves offer similar clinical results when used for isolated AVR or MVR. While there is a suggestion of an advantage with bileaflet valves, any differences detected may simply reflect differences in the preoperative patient variables.

The HeartSaver left ventricular assist device: an update.

BACKGROUND: Ventricular assist devices have been shown to be effective as bridges to transplantation and recovery for patients with end-stage heart failure. Current technology has been limited because of the need for percutaneous connections with controllers. The HeartSaver ventricular assist device (VAD) (World Heart Corporation, Ottawa, Ontario, Canada) was developed with the intention of having a completely implantable, portable VAD system. The system consists of an electrohydraulic blood pump, internal and external battery power, and a transcutaneous energy transfer and telemetry unit that allows for power transmission through the skin. Control of the device may be achieved locally or remotely through a variety of communication systems. METHODS: The device has been modified with the Series II preclinical version being available for in vitro (mock loop) and in vivo (bovine model) testing. RESULTS: Seventeen Series II devices have been functional on mock loops or other testing trials for an accumulated 900 days of operation. There have been eight acute experiments using a bovine model to test various components as they have become available from manufacturing. Mean pump output was 10.4 +/- 1.1 L/min in full-fill/full-eject mode. Changes in the last 24 months include (1) cannula redesign for better port alignment and integration of tissue valves; (2) battery redesign to convert to new lithium-ion cells; (3) optimized infrared information and electromagnetic inductance energy transmission through various skin thicknesses and pigmentation; and (4) improved reliability of internal and external controller hardware and software. CONCLUSIONS: Modifications have been required to optimize the HeartSaver VAD's performance. The final HeartSaver VAD design will be produced in the near future to allow for formal in vitro and in vivo testing before clinical implantation.

Endoglin is overexpressed after arterial injury and is required for transforming growth factor-beta-induced inhibition of smooth muscle cell migration.

Endoglin is a homodimeric membrane glycoprotein primarily expressed on endothelial cells. In association with transforming growth factor (TGF)-ss receptors I and II, it can bind TGF-beta1 and -beta3 and form a functional receptor complex. There is increasing evidence that endoglin can modulate the cellular response to TGF-beta, a factor implicated in vascular lesion formation in human and experimental models. The purpose of this study was to analyze the expression of endoglin in normal and balloon-injured porcine coronary arteries and in normal and atherosclerotic human coronary arteries and to determine its ability to mediate the effects of TGF-beta on the migration of vascular smooth muscle cells (SMCs). In normal porcine coronary arteries, endoglin was of low abundance and was found primarily on endothelial cells and adventitial fibroblasts, as well as on a minority of medial SMCs. On days 3, 7, and 14 after angioplasty, endoglin was present not only on endothelial cells but also on adventitial myofibroblasts and medial SMCs of porcine coronary arteries. By day 28, few or no cells expressed endoglin. In situ hybridization revealed that endoglin mRNA expression appeared to be highest in endothelial cells on days 3, 7, and 14 days after injury and absent thereafter. With a second balloon injury, a similar pattern of endoglin protein and mRNA expression was observed. In human vascular tissue, endoglin immunolabeling was higher in endarterectomy specimens removed from diseased coronary arteries than in normal internal mammary arteries. In vitro, antisense oligonucleotides to endoglin decreased its expression and antagonized the TGF-beta-mediated inhibition of human and porcine SMC migration. In summary, upregulation of endoglin occurs during arterial repair and in established atherosclerotic plaques and may be required for modulation of SMC migration by TGF-beta.

Early and follow-up angiography in minimally invasive coronary bypass without mechanical stabilization.

BACKGROUND: This study was undertaken to assess the early and late outcome of coronary anastomosis constructed on a beating heart without the help of mechanical stabilization. METHODS: All consecutive patients (51) from January 1996 to September 1997 who had bypass done by one surgeon using a left minithoracotomy (39) or median sternotomy (12) on a beating heart with occlusive local snares without mechanical stabilization underwent follow-up angiography early (100%) (within 6 hours) and late (63.5%) at a mean of 9.6+/-4.48 months (range, 3.3 to 19.1 months). RESULTS: The cumulative late patency was 95.4% (83 of 87 patients), with two early and two late occlusions. There was no early or late mortality or perioperative myocardial infarction. Two patients (3.9%) developed recurrent angina. Four anastomotic irregularities (4 of 32 patients, 12.6%) have cleared up on follow-up angiography. There was no evidence of late stenosis at the snare sites used for local occlusion. CONCLUSIONS: Minimally invasive coronary bypass is safe and effective. Early angiographic abnormalities should be interpreted with caution and we could not demonstrate any long-term deleterious effects of local snaring.

HeartSaver VAD: a totally implantable ventricular assist device. Results of in vivo studies.

Currently, the most widely utilized ventricular assist devices (VADs) require percutaneous connections and are located either externally (e.g., Thoratec, Abiomed) or intra-abdominally (e.g., Novacor, TCI). These attributes have been implicated in a variety of complications (infection, thromboembolic, gastrointestinal, etc.). To address these concerns, a totally implantable VAD that requires no percutaneous connections and can be implanted in the left hemi-thorax has been developed. The developed device has undergone in vivo evaluation as part of the design and development process. A total of 43 implants in the bovine model, with 5 device versions, have been conducted between July 1992 and February 2000. These studies successfully have demonstrated several important aspects of the developed device, including 1) feasibility of a totally implantable system; 2) capability of the device to support a dysfunctional heart; and 3) ability of the device to provide flows up to 10 L/min in a physiological setting. The studies to date have played a vital role in the design and development process as well as demonstrating the feasibility of a totally implantable intrathoracic VAD. Based on these studies, design optimization was conducted, resulting in the development of the pre-clinical version of the device in preparation for clinical trials.

Determinants of hospital survival following reoperative single valve replacement.

OBJECTIVE: To determine the indicators of risk for hospital death, patients undergoing reoperative valve replacement were analyzed METHODS: Four hundred and eighteen consecutive patients undergoing reoperative valve replacement from 1977 to 1994 were reviewed using univariate and multivariate analysis. RESULTS: Overall hospital mortality was 11.2% with 9.4% mortality with aortic valve replacement and 14.2% with mitral valve replacement (P=0.52). Mortality was 9.7% for patients less than 70 years of age compared with 19.4% for older patients (P=0.03), and was 8.5% for those with anoxia times less than 90 mins versus 21.9% for those with longer anoxia times (P=0.001). For first reoperations, 9.5% of patients died, while for patients undergoing second or more reoperation, mortality was 23.2% (P=0.01). While mortality increased from 8.9% to 19.0% with the addition of a concomitant procedure (P=0.008), it was not affected if the additional procedure was a coronary bypass (P=0. 96). The indication for surgery influenced outcome. Mortality was zero for thromboembolism, 9% for structural failure, 23% for nonstructural failure and 22% for endocarditis (P=0.006). For New York Heart Association (NYHA) functional class I patients, mortality was 1.6% compared with 22.3% for those in NYHA class IV (P=0.006). By multivariate analysis, however, only the indication for surgery and the NYHA functional class influenced survival. CONCLUSIONS: Reoperative valve surgery can be performed with a survival (88.8%) that is similar to the initial procedure (91.2%). The indication for surgery and NYHA functional class alone influenced outcome; therefore, possible early reoperation is indicated before clinical deterioration occurs.

Circulatory support for cardiogenic shock due to acute myocardial infarction: a Canadian experience.

BACKGROUND: Cardiogenic shock due to acute myocardial infarction (AMI) is associated with high mortality. Circulatory support devices may be used to assist these patients while they await cardiac transplantation. METHODS AND RESULTS: From 1986 to 1997, 25 patients in cardiogenic shock complicating AMI within 3.6+/-0.7 days of the event were supported with artificial hearts. Of the 25 patients, 21 were men with a mean age of 48.4 +/- 1.8 years. The age range was 26 to 62 years. Patients were considered for a device when the following criteria were met: cardiac index less than 1.8 L/min/m2, wedge pressure greater than 20 mmHg despite one or two inotropes and/or intra-aortic balloon support. They received either a CardioWest total artificial heart (n=13), a Thoratec biventricular assist device (n=6) or left ventricular assist device (LVAD) (n=6). Three patients were not considered transplant candidates and died while on the devices (two with multiorgan failure and one found to have a bronchogenic carcinoma after implant), with 22 undergoing cardiac transplantation within 8.6+/-2.2 days of device implant. Six patients died in hospital after the transplants (27.3% mortality). Complications included bleeding or tamponade in seven (28%), pneumonia in six (24%) and right ventricular failure in three LVAD patients (12%). Post-transplant actuarial one-, two- and five-year survival rates were 71.4%, 71.4% and 51%, respectively. CONCLUSIONS: Circulatory support devices offer a means to maintain organ perfusion in patients who develop cardiogenic shock due to AMI. Patients can then undergo transplantation with a reasonable expectation for survival when the alternative is death. Eventually the availability of permanent support devices may obviate the need for transplant in these patients.

Ochronosis: an unusual finding at aortic valve replacement.

The condition known as ochronosis refers to the accumulation of oxidized homogentisic acid in the connective tissues of alkaptonuric patients. The diagnosis is usually made from the triad of degenerative arthritis, ochronotic connective tissue pigmentation and urine that turns dark brown or black on alkalinization. Cardiovascular disease is a less well appreciated aspect of this disorder. A patient with ochronosis of his stenotic aortic valve is reported. The role of the pigment in the genesis of the valve degeneration is discussed.

Progress with the HeartSaver Ventricular Assist Device.

BACKGROUND: Ventricular assist devices (VADs) have been shown to be effective for short- or long-term circulatory support. Devices are either being adapted or newly designed for longer term or permanent support, with the goal to provide patients with improved quality of life. Since 1990, a program has been in place to develop a totally implantable, permanent VAD. METHODS: A multidisciplinary team is developing this VAD with specific goals in mind: (1) that it have an intrathoracic position, (2) that it be a totally implantable device without any percutaneous connections, and (3) that it be possible to communicate with the device from remote locations. These goals would allow for complete patient mobility and flexibility for follow-up. RESULTS: The electrohydraulically actuated VAD combines the blood pump, volume displacement chamber, energy converter, and internal electronic module into a single compact unit. The device called the HeartSaver VAD is powered by a transcutaneous energy transfer system and can be remotely monitored and controlled. Prototypes of different versions of the device have been tested in vitro and in vivo with satisfactory performance. CONCLUSIONS: The prototypes of the HeartSaver VAD have functioned well under test conditions and fulfilled the outlined goals. Further development and testing of the design are being conducted before clinical availability.

Development of a ventricular assist device for out-of-hospital use.

BACKGROUND: Success with temporary ventricular assist devices, has prompted interest in devices developed for long term use outside of the hospital setting. METHODS: A totally implantable intrathoracic electro-hydraulic ventricular assist device has been developed. Design focused on providing the recipient with a near normal quality of life. To meet this goal the system utilizes transcutaneous energy transfer and biotelemetry to eliminate percutaneous drive-lines/cables as well as a displacement chamber capable of pressure equalization to atmospheric pressures, so as to eliminate the need for percutaneous venting. An implanted battery provides backup power to allow the recipient the ability to bathe, shower, or swim without connection to an external power source. An integrated telemedicine capability allows the device to be monitored/controlled remotely, using telephone lines. RESULTS: The system has been tested in vitro with early prototypes running for up to 5 1/2 years. The system was studied in calves (n = 25) with durations of support of up to 30 days, demonstrating the ability of the device to function as a totally implantable device without percutaneous connections. CONCLUSIONS: The various in vitro and in vivo studies have demonstrated the feasibility of the totally implantable device. Chronic in vivo experiments will follow in preparation for regulatory submissions for human use.

Are older patients with mechanical heart valves at increased risk?

BACKGROUND: Controversy exists regarding the use of mechanical valves in older patients. Many authorities believe that the use of anticoagulants in the elderly is associated with an increased risk of warfarin-related complications. Therefore, we compared the results with mechanical valves in older patients to a cohort of younger patients. METHODS: Aortic (AVR) or mitral valve replacement (MVR) with a mechanical valve was performed in 1,245 consecutive patients who were followed prospectively. They were grouped by age (group 1, < or = 65 years; group 2, > 65 years). The study groups consisted of AVR (group 1, 459 patients; group 2, 323 patients) MVR (group 1, 313 patients; group 2, 150 patients). RESULTS: The average age for the groups was: AVR (group 1, 51 years; group 2, 70 years; p = 0.03) and MVR (group 1, 53 years; group 2, 70 years; p = 0.03). For AVR the incidence of thromboembolism was 0.050 (group 1) and 0.038 (group 2) (p = 0.37) and the actuarial freedom from thromboembolism was 83.0%+/-3.0% and 86.5%+/-1.0%, respectively (p = 0.13). The incidence of bleeding after AVR was 0.021 for group 1 and 0.028 for group 2 (p = 0.49). For MVR the incidence of thromboembolism was 0.059 for group 1 and 0.051 for group 2 (p = 0.75) and the actuarial freedom from thromboembolism was 78.8%+/-3.0% and 75.4%+/-8.7%, respectively (p = 0.71). The incidence of bleeding after MVR was 0.020 for group 1 and 0.027 for group 2 (p = 0.62). CONCLUSIONS: Mechanical valves perform well in selected older patients with no increased risk of bleeding or thromboembolism.

Successful surgical endarterectomy of a stented coronary artery.

An occlusion in this 61-year-old male's distal right coronary artery was initially successfully opened with balloon angioplasty and three "half" Palmaz-Schatz stents (Johnson and Johnson International Systems, Warren, NJ). Subsequent occlusion of the RCA occurred and prompted bypass grafting 2 years later. An extensive manual surgical endarterectomy removed the stents, demonstrating the technical feasibility of surgically removing failed stents in accessible coronary arteries.

Heart transplantation in perspective.

Heart disease remains one of the leading causes of death in the western world. In the 35 years since the first human heart transplants, cardiac transplantation has become established as the therapeutic option of choice in the management of terminal cardiac failure. Since 1981, the introduction of cyclosporin for immunosuppression has dramatically increased cardiac transplantation. However, several obstacles limit further utilization, including limited availability of donor hearts, limited ischemic time tolerated by donor hearts, and chronic rejection. Research is underway into donor heart preservation and new immunosuppressant drugs in an effort to increase donor organ availability. Due to these constraints, alternative therapies are under development. More than 2,000 circulatory assist devices have been implanted with >25% used as a bridge to heart transplantation. The University of Ottawa Heart Institute began the first Canadian implantation of circulatory assist devices in 1986 and has implanted 23 total artificial hearts and 23 ventricular assist devices. The Heart Institute is also developing a totally implantable electrohydraulic ventricular assist device (EVAD) for long-term mechanical support outside the hospital. Another alternative being evaluated for clinical use is xenotransplantation. The major obstacle for widespread use of clinical xenotransplantation remains graft rejection, and fundamental research is ongoing to address hyperacute and delayed xenograft rejection. While cardiac transplantation is the most effective treatment of terminal heart failure, limited donor hearts compel us to rely on alternatives. In the future, the research underway on xenotransplantation and mechanical circulatory assist devices will provide new options for the clinical treatment of terminal cardiac failure.

The Ottawa telehealth project.

OBJECTIVE: To examine the telehealth system as a means of improving access to cardiac consultations and specialized health services in remote areas of Ontario. METHODS: The University of Ottawa Heart Institute has set up a telehealth test program, Healthcare and Education Access for Remote Residents by Telecommunications (HEARRT), in collaboration with industry and the provincial and federal government, as well as several remote clinical test sites. The program makes off-site cardiology consultations possible. History taking and physical examinations are conducted by video and electronic stethoscope. Laboratory results and echocardiograms are transmitted by document camera and VCR. The technology is being tested in both stable outpatient and emergency situations. Various telecommunications bandwidths and encoding systems are being evaluated, including satellite and terrestrial-based asynchronous transfer-mode circuits. Patient satisfaction and cost-effectiveness are also being assessed. RESULTS: Bandwidths from as low as 384 kbps using H.320 encoders to 40 Mbps using digital transport of NTSC video signals have been evaluated. Although lower bandwidths are sufficient for sending echocardiographic and electrocardiogram data, bandwidths with transport speeds of 4 to 6 Mbps appear necessary to capture the nuances of the cardiac physical examination. A preliminary satisfaction survey of 19 patients noted that all felt that they could communicate effectively with the cardiologist by video, and each had confidence in the advice offered. None reported that he or she would rather have traveled to the doctor in person. Initial and projected examination of the costs suggested that telehealth will effectively reduce overall health care spending while decreasing travel expenses for rural patients. CONCLUSION: Telehealth technology is sufficiently sophisticated to allow off-site cardiology assessments. Preliminary results suggest there is a sound business case for the implementation of telehealth technology to meet the needs of remote residents in northern Ontario. Working closely with government and industry, we will develop a marketing and commercialization plan to support the use of this technology throughout Ontario and expand application to patient education and continuing medical education.

Left anterior descending endarterectomy and internal thoracic artery bypass for diffuse coronary disease.

BACKGROUND: The risk and efficacy of using an arterial conduit to bypass an endarterectomized coronary artery remain incompletely defined. To address this question we analyzed retrospectively 74 patients from 1989 to 1994 in whom bypass grafting using the left internal thoracic artery to an endarterectomized left anterior descending artery was performed. METHODS: There were 60 men and 14 women with a mean age of 60.1 +/- 8.6 years. Of this cohort, 55 patients (74.3%) had a previous infarction, 18 (24.3%) were diabetic, and 5 (6.7%) had reoperations; 25 patients (34%) had a totally occluded left anterior descending artery and the average ejection fraction was 45%. Each patient had 2.95 +/- 0.52 grafts with 48 patients (65%) requiring multiple endarterectomies. The average length of the endarterectomized segment was 3.1 +/- 1.6 cm. Average anoxia time was 49 +/- 13 minutes. Postoperatively 19 patients (25.6%) required intraaortic balloon and 18 (24.3%) required inotropic support. Perioperative infarction in the left anterior descending artery distribution occurred in 5 patients (6.7%). RESULTS: There were 3 (4.0%) early and 4 (5.4%) late deaths at a mean follow-up of 36 +/- 16 months. Recurrent angina was present in 9 patients (14.7%). Actuarial 5-year survival was 84.5%. Angiographic follow-up obtained in 23 patients (37.4%) demonstrated 74% anastomotic patency, with good distal run-off in 13 (65%). The anterior segmental wall motion was preserved. CONCLUSIONS: The use of the left internal thoracic artery bypass and adjunctive left anterior descending artery endarterectomy to expand the scope of myocardial revascularization in carefully selected circumstances appears to be beneficial.

Cardiac operations in the elderly: who is at risk?

BACKGROUND: With the growing number of elderly patients presenting for cardiac operations we analyzed their early survival data to determine whether any preoperative variables might be indicative of increased risk. METHODS: From 1990 to 1995, 436 consecutive patients who were 75 years old or older had either coronary artery bypass, valve replacement(s), or a combination of these. A total of 34 preoperative variables were assessed for their effect on hospital survival by using univariate and multivariable analysis. RESULTS: There were 266 men and 170 women, with 292 patients being 75 to 80 years old and 144 patients being older than 80 years. Coronary artery bypass was performed in 242 patients, valve replacement was performed in 93 patients, and a combination of these in 101 patients. The operation was considered elective in 202 patients, urgent in 209, and emergent in 25 patients of whom 21 were in cardiogenic shock. Overall there were 61 hospital deaths (13.9%). The most common cause of death, low cardiac output syndrome, occurred in 34 patients of whom 26 suffered a perioperative myocardial infarction. Stroke was the cause of death in eight and multiple organ failure accounted for nine deaths. In the univariate analysis, variables that influenced survival included heart failure (p = 0.004), pulmonary edema (p = 0.004), cardiomegaly (p = 0.02), elevated serum creatinine (p = 0.009), surgical priority (p = 0.002), and cardiogenic shock (p = 0.002). In the multivariable analysis there were three independent determinants of hospital survival: cardiomegaly (odds ratio, 1.8:1) serum creatinine level higher than 150 micromol/L (odds ratio, 5.5:1) and emergency procedure (odds ratio, 2.5:1). CONCLUSIONS: Although cardiac operations can be performed safely in many elderly patients, we identified several factors that might help both in case selection and in perioperative decisions.

Minimally invasive coronary artery bypass: a series with early qualitative angiographic follow-up.

BACKGROUND: Notwithstanding the advantages offered by minimally invasive coronary bypass, valid concerns have been raised about the technical accuracy of the distal anastomoses that can be fashioned on a beating heart. The main objective of our study was to undertake early and complete qualitative angiographic graft analysis in all patients undergoing this procedure. METHODS: All enrolled patients (25) from January to October 1996 who had bypass done by one surgeon via left minithoracotomy (19) or median sternotomy (6) on a beating heart underwent postoperative angiography within 4 to 6 hours. These angiograms were then reviewed for qualitative analysis and compared with a similar series done under conventional cardioplegic arrest. RESULTS: There was 97.5% graft patency (28/29) and no anastomotic occlusions. One internal thoracic artery was damaged. There was no mortality and no perioperative myocardial infarctions. All patients are alive and symptom free. The follow-up is 100% complete and ranges from 15 days to 11 months. Of the 26 anastomoses that could be assessed, 21 (81%) were grade A and 5 (19%) were grade B. In comparison, 24/25 (96%) of the anastomoses fashioned on an arrested heart by the same surgeon were grade A (p = 0.175). CONCLUSIONS: Minimally invasive coronary bypass can be carried out effectively and safely in a select group of patients, and the development of stabilizing devices and proper instrumentation should further improve results.