TLR agonists enhance responsiveness of inflammatory innate immune cells in HLA-B*57-positive HIV patients.

HLA-B*57 affects the course of HIV infection. Under antiretroviral therapy, its effects cannot be explained by outstandingly efficient T cell responses alone but may also involve cells of innate immunity. Studying in vitro stimulation with Pam3CSK4, E. coli LPS-B5 and CpG-ODN-2216, we observed greater induction of IL-6/IL-1beta double-positive CD14+CD16++ monocytes as well as IFN-gamma-positive cytotoxic CD56highCD16neg NK cells in HLA-B*57- versus HLA-B*44-positive HIV patients, while TNF-alpha induction remained unchanged. Differences were not seen in the other monocyte and NK cell subsets or in HLA-matched healthy controls. Our findings show that, in virally suppressed HIV infection, HLA-B*57 is associated with enhanced responsiveness of inflammatory innate immune cells to TLR ligands, possibly contributing to increased vulnerability in sepsis. KEY MESSAGES: • HLA-B*57 is a host factor affecting clinical outcomes of HIV infection. • HLA-B*57 modifies inflammatory subsets of NK cells and monocytes in HIV infection. • In HLA-B*57-positive HIV patients TLR agonists induce enhanced IL-6/IL-1beta in monocytes. • NK cells from HLA-B*57 HIV patients release more IFN-gamma upon TLR costimulation. • HLA-B*57 is linked to enhanced inflammatory responsiveness to TLR ligands.

Survival of HIV/HCV co-infected patients before introduction of HCV direct acting antivirals (DAA).

HIV/HCV infection is supposed to substantially reduce survival as compared to HIV mono-infection. Here, we compared longtime-survival and causes of death in a cohort of HIV- and HIV/HCV-co-infected patients on combined antiretroviral therapy (cART), before introduction of HCV direct acting antivirals (DAA). 322 Caucasian patients with HIV (n = 176) and HIV/HCV-infection (n = 146) were enrolled into this study. All patients were recruited between 2003 and 2004 and followed until 01.01.2014. We compared overall survival between the two groups by the Kaplan-Meyer method and identified independent factors associated with long-time survival by conditional Cox regression analysis. In total 46 (14.3%) patients died during the observation period (HIV infection: n = 23 (13.1%), HIV/HCV infection: n = 23 (15.8%) but overall-survival did not differ significantly between HIV/HCV-infected and HIV mono-infected patients (p = 0.619). Survival was substantially better in patients with complete suppression of HIV replication below the level of detection than in those with residual viremia (p = 0.001). Age (p = 0.008), γ-glutamyltranspeptidase (p < 0.0001) and bilirubin (p = 0.008) were significant predictors of survival irrespective from HCV co-infection. Complete repression of HIV replication on cART is the key factor determining survival both in HIV- and HIV/HCV-co-infected patients, while HCV co-infection and therapy without DAAs seem to affect survival to a lesser extent. Thus, patients with HIV/HCV co-infection require particularly intensive cART.

Characterization of a gate-defined double quantum dot in a Si/SiGe nanomembrane.

We report the fabrication and characterization of a gate-defined double quantum dot formed in a Si/SiGe nanomembrane. In the past, all gate-defined quantum dots in Si/SiGe heterostructures were formed on top of strain-graded virtual substrates. The strain grading process necessarily introduces misfit dislocations into a heterostructure, and these defects introduce lateral strain inhomogeneities, mosaic tilt, and threading dislocations. The use of a SiGe nanomembrane as the virtual substrate enables the strain relaxation to be entirely elastic, eliminating the need for misfit dislocations. However, in this approach the formation of the heterostructure is more complicated, involving two separate epitaxial growth procedures separated by a wet-transfer process that results in a buried non-epitaxial interface 625 nm from the quantum dot. We demonstrate that in spite of this buried interface in close proximity to the device, a double quantum dot can be formed that is controllable enough to enable tuning of the inter-dot tunnel coupling, the identification of spin states, and the measurement of a singlet-to-triplet transition as a function of an applied magnetic field.

Association of Myianoetus muscarum (Acari: Histiostomatidae) With Synthesiomyia nudiseta (Wulp) (Diptera: Muscidae) on Human Remains.

Synthesiomyia nudiseta (Wulp) (Diptera: Muscidae) was identified during the course of three indoor medicolegal forensic entomology investigations in the state of Texas, one in 2011 from Hayes County, TX, and two in 2015 from Harris County, TX. In all cases, mites were found in association with the sample and subsequently identified as Myianoetus muscarum (L., 1758) (Acariformes: Histiostomatidae). This report represents the first records of a mite associated with S. nudiseta in the continental United States. In particular, this association is believed to be of potential future value in forensic investigations, as it lends new insight into the community structure of colonizers on human remains in indoor environments.

Two-axis control of a singlet-triplet qubit with an integrated micromagnet.

The qubit is the fundamental building block of a quantum computer. We fabricate a qubit in a silicon double-quantum dot with an integrated micromagnet in which the qubit basis states are the singlet state and the spin-zero triplet state of two electrons. Because of the micromagnet, the magnetic field difference ΔB between the two sides of the double dot is large enough to enable the achievement of coherent rotation of the qubit's Bloch vector around two different axes of the Bloch sphere. By measuring the decay of the quantum oscillations, the inhomogeneous spin coherence time T2* is determined. By measuring T2* at many different values of the exchange coupling J and at two different values of ΔB, we provide evidence that the micromagnet does not limit decoherence, with the dominant limits on T2* arising from charge noise and from coupling to nuclear spins.

A roadmap for bridging basic and applied research in forensic entomology.

The National Research Council issued a report in 2009 that heavily criticized the forensic sciences. The report made several recommendations that if addressed would allow the forensic sciences to develop a stronger scientific foundation. We suggest a roadmap for decomposition ecology and forensic entomology hinging on a framework built on basic research concepts in ecology, evolution, and genetics. Unifying both basic and applied research fields under a common umbrella of terminology and structure would facilitate communication in the field and the production of scientific results. It would also help to identify novel research areas leading to a better understanding of principal underpinnings governing ecosystem structure, function, and evolution while increasing the accuracy of and ability to interpret entomological evidence collected from crime scenes. By following the proposed roadmap, a bridge can be built between basic and applied decomposition ecology research, culminating in science that could withstand the rigors of emerging legal and cultural expectations.

Routine use of bilateral skeletonized internal thoracic artery grafting: long-term results.

BACKGROUND: Skeletonized harvesting of the internal thoracic artery (ITA) decreases the severity of sternal devascularization, thus reducing the risk of postoperative sternal complications in patients undergoing bilateral ITA grafting. METHODS AND RESULTS: Between 1996 and 2001, 1515 consecutive patients underwent skeletonized bilateral ITA grafting. Of the 1179 male and 336 female patients, 641 (42.3%) were >70 years of age, and 519 (34.2%) had diabetes mellitus. Operative mortality was 2.8%. Early postoperative morbidity included sternal infection (1.6%), cerebrovascular accident (3%), and perioperative myocardial infarction (1%). Multiple regression analysis showed chronic obstructive pulmonary disease (odds ratio, 11.3; 95% confidence interval [CI], 4.45 to 28.55), repeat operation (odds ratio, 12.7; 95% CI, 3.25 to 49.56), and diabetes mellitus (non-insulin dependent: odds ratio, 4.64; 95% CI, 1.85 to 11.59; insulin dependent: odds ratio, 6.9; 95% CI, 1.35 to 35.27) to be associated with increased risk of sternal infection. Follow-up (between 5 and 12 years) revealed 305 late deaths. Kaplan-Meier 10-year survival rates for patients <65, 65 to 74, and >75 years of age were 87%, 75%, and 52%, respectively. Cox regression analysis revealed increased overall mortality (early and late) in patients with peripheral vascular disease (hazard ratio [HR], 1.8; 95% CI, 1.39 to 2.33), patients >75 years of age (HR, 7.23; 95% CI, 4.16 to 12.55), those undergoing repeat operations (HR, 2.22; 95% CI, 1.27 to 3.89), patients with preoperative congestive heart failure (HR, 1.64; 95% CI, 1.29 to 3.75), and those with chronic renal failure (HR, 1.52; 95% CI, 1.11 to 2.01). Operations performed without cardiopulmonary bypass were associated with better postoperative survival (HR, 0.66; 95% CI, 0.49 to 0.87). CONCLUSIONS: Bilateral ITA grafting is associated with low morbidity and good long-term results. Use of skeletonized bilateral ITA is appropriate for the elderly and most patients with diabetes; however, it is not recommended for repeat operations or for patients with chronic obstructive pulmonary disease.

Initiation of shape-memory effect by inductive heating of magnetic nanoparticles in thermoplastic polymers.

In shape-memory polymers, changes in shape are mostly induced by heating, and exceeding a specific switching temperature, T(switch). If polymers cannot be warmed up by heat transfer using a hot liquid or gaseous medium, noncontact triggering will be required. In this article, the magnetically induced shape-memory effect of composites from magnetic nanoparticles and thermoplastic shape-memory polymers is introduced. A polyetherurethane (TFX) and a biodegradable multiblock copolymer (PDC) with poly(p-dioxanone) as hard segment and poly(epsilon-caprolactone) as soft segment were investigated as matrix component. Nanoparticles consisting of an iron(III)oxide core in a silica matrix could be processed into both polymers. A homogeneous particle distribution in TFX could be shown. Compounds have suitable elastic and thermal properties for the shape-memory functionalization. Temporary shapes of TFX compounds were obtained by elongating at increased temperature and subsequent cooling under constant stress. Cold-drawing of PDC compounds at 25 degrees C resulted in temporary fixation of the mechanical deformation by 50-60%. The shape-memory effect of both composite systems could be induced by inductive heating in an alternating magnetic field (f = 258 kHz; H = 30 kA x m(-1)). The maximum temperatures achievable by inductive heating in a specific magnetic field depend on sample geometry and nanoparticle content. Shape recovery rates of composites resulting from magnetic triggering are comparable to those obtained by increasing the environmental temperature.

Revision total knee arthroplasty with modular components inserted with metaphyseal cement and stems without cement.

The clinical and radiographic outcomes of 50 consecutive revision total knee arthroplasties in 47 patients, placed with metaphyseal cemented femoral and tibial components with press-fit cementless stems, were reviewed at 36-month average follow-up. Revision was performed for aseptic loosening (11/50), infection (17/50), periprosthetic fracture (8/50), component failure (6/50), instability (6/50), and malalignment (2/50). The press-fit cementless stems were 80 to 160 mm in length and tightly contacted the endosteum of the metadiaphyseal areas. Four (9%) knees were re-revised for infection, zero for aseptic loosening. The average modified Hospital for Special Surgery knee score improved from 49 to 87. One patient (2%) reported thigh pain, and 1 reported leg pain. Metaphyseal cemented revision total knee components with press-fit cementless femoral and tibial stems were not associated with significant thigh and leg pain.

Gait analysis of stapling for genu valgum.

Many authors have advocated stapling or epiphysiodesis of the distal medial femur as a means of correcting genu valgum. However, in the literature, aside from clinical improvement (appearance, pain, function), objective evidence of kinetic and kinematic improvement is lacking. Therefore, the authors undertook a prospective gait analysis evaluation of a series of patients treated for genu valgum, comparing pre- and postsurgical measurements to document the benefits of normalizing the mechanical axis. These results indicate that after surgery knee and hip angles and knee moments were returned to within the normal range for a similarly aged control group.

Anterior thoracolumbar instrumentation: stiffness and load sharing characteristics of plate and rod systems.

STUDY DESIGN: An in vitro biomechanical study using a thoracolumbar corpectomy model to compare load sharing capabilities and stiffnesses of six different anterior instrumentation systems (three rod styles and three plate styles) for stabilizing the thoracic and lumbar spine. OBJECTIVES: To evaluate the axial load sharing capabilities of the instrumentation in a thoracolumbar corpectomy model and to measure the bending stiffness of the anterior instrumentation systems for the axes of flexion-extension, lateral bending, and axial rotation with and without an anterior column graft in place. SUMMARY OF BACKGROUND DATA: Prior publications have analyzed biomechanical characteristics of many spinal instrumentation systems. These reports have compared anterior instrumentation systems with posterior instrumentation systems, in situ fusion techniques, intervertebral spacers, structural allograft and instrumentation, and combined anterior and posterior instrumentation. Other reports have published data on the biomechanical characteristics of typical anterior and posterior spinal instrumentation systems. However, there are no published reports that specifically compare the characteristics of anterior plate-style with anterior rod-style systems, or examining load sharing capabilities. METHODS: Six constructs of each of six instrumentation systems were mounted on simulated vertebral bodies. A custom four-axis spine simulator was used to apply independent flexion-extension, lateral bending, and axial rotation moments as well as axial compressive loads. Axial load sharing was measured through a range of applied axial loads from 50 N to 500 N with rotational moments maintained at 0 Nm. The bending stiffness of each construct was calculated in response to +/-5.0 Nm moments about each axis of rotation with a 50 N compressive axial load with a full-length corpectomy graft in place, simulating reconstruction of the anterior column, and with no graft in place, simulating catastrophic graft failure. Statistical significance was determined using an analysis of variance and Fisher PLSD post hoc test with an alpha

Comparison of vasoactive response of left and right internal thoracic arteries to isosorbide-dinitrate and nitroglycerin: an in vitro study.

OBJECTIVE: The internal thoracic artery (ITA) is the most important graft in coronary artery bypass grafting. Its distal region is, however, prone to vasospasm. We studied the effects of nitroglycerin (NTG) and isosorbide-dinitrate (DSDN) on distal segments of left versus right ITA. METHODS: Rings of distal segments (6 to 9 mm proximal to bifurcation) of the human left and right ITA were studied. After baseline contraction of the rings, achieved using 60 mmol/L of KCl, they were exposed to increasing doses of ISDN and NTG (10 to 100 microg/ml), and dose-response curves were recorded. RESULTS: The contractile response of left ITA rings to KCl were significantly lower than those of right ITA rings (1.87 +/- 0.25 g versus 3.5 +/- 0.61 g, p < 0.005). Both nitrates inhibited the contractile response in a concentration-dependent manner, with relaxing effects of ISDN higher than those of NTG (p < 0.01) in both left and right ITA rings. CONCLUSIONS: The distal segment of the left ITA is less prone to vasospasm than that of the right. ISDN has a considerably higher relaxant effect on this segment than NTG. We therefore recommend favoring high doses of ISDN over NTG as an antispastic measure.

Rotational stability of a modified step-cut for use in intercalary allografts.

BACKGROUND: Intercalary allografts are used for the reconstruction of major skeletal defects. Step-cuts help to provide rotational stability when intramedullary fixation is used. A modified step-cut is proposed to reduce rotation at the interface. This study compares the rotational stability of conventional and modified step-cuts. METHODS: In Phase I, seven pairs of human cadaveric femora were divided into a conventional step-cut group (left femora) and a modified step-cut group (right femora). All femora were cut transversely at the mid-diaphysis. In the conventional group, a 1-cm step-cut was created in the exact midsagittal plane in both the proximal and distal segments. In the modified group, a 1-cm step-cut was created in the parasagittal plane, leaving 2 mm of additional bone on both the proximal and the distal fragment. Phase II was identical except that in the modified step-cut group only 1 mm of additional bone was left. Smooth femoral nails were then placed after standard reaming. Specimens were tested by fixing the proximal segment and applying +/-2 N-m (17.7 in-lb) of torque to the distal segments with ten oscillation cycles. Maximum rotation was measured. The data were analyzed with the paired Student t test. RESULTS: The average rotation in Phase I was 23.3 degrees for the conventional step-cut group and 3.0 degrees for the 2-mm modified step-cut group; the difference was significant (p < 0.001). Four femora sustained an incomplete fracture during nail insertion. The average rotation in Phase II was 20.6 degrees for the conventional step-cut group and 0.5 degrees for the 1-mm modified step-cut group without any fractures; the difference was significant (p < 0.001). CONCLUSIONS: Step-cut modification that leaves more bone in the sagittal plane provides rigid fixation and significantly more stability than the conventional step-cut technique.

Tibial component fixation with cement: full- versus surface-cementation techniques.

Despite excellent outcomes with cemented tibial components in total knee arthroplasty, it still is debated whether the tibial stem should be cemented and what the optimal tibial stem design should be. Proponents of full cementation of the tibial stem and component state that better short-term and long-term component fixation is achieved when full cementation is used. Advocates for surface cementation contend that sufficient implant stability is achieved without the increased bone loss that occurs at revision and the stress shielding thought to be linked with cemented stems. This biomechanical cadaver study compared initial fixation and cement penetration depth in fully cemented versus surface cemented tibial trays with two different stem geometries (cruciate and I-beam) and compared two stem designs (cruciate and I-beam) fixed with surface cementation. Under an eccentric load, simulating three times body weight for 6000 cycles, there seems to be no difference in the micromotion of either tibial component implanted with surface or full cementation. Additionally, no difference in the average depth of cement penetration was detected between fixation techniques or stem types. The initial fixation stability of the surface cement technique seems correlated to the depth of cement penetration into proximal tibial surface. The current data support other studies which indicate that stability of surface-cemented tibial components may be related to the depth of cement penetration.

Technical aspects of harvesting the radial artery with the harmonic scalpel.

BACKGROUND: Harvesting the radial artery (RA) with ultrasonic dissection with the Harmonic Scalpel reduces spasm induced by surgical handling. Topical exposure to phentolamine methanesulphonate (Regitine) exerts an additional effect of vasodilatation. METHODS: Between January and December 2002, the RA was harvested as a pediculated vessel with the Harmonic Scalpel in 145 consecutive patients undergoing myocardial revascularization. A fasciotomy of the pedicle was performed after harvest ing. A composite graft with the reverse free RA on the in situ left internal thoracic artery (ITA) was prepared before the construction of distal coronary anastomoses. The RA was then placed in a syringe filled with Regitine (0.07 microg/mL) for 10 minutes. \par RESULTS: The mean number of grafts/patient was 3.0. The mean number of RA anastomoses was 2.0/patient. Left ITA free flow was 105 +/- 34 mL/min. Regitine increased the RA free flow from 60 +/- 35 mL/min to 82 +/- 30 mL/min (P <.05). Fourteen patients underwent postoperative coronary angiography. All RA anastomoses were patent. CONCLUSION: The compound effect of RA harvesting with the Harmonic Scalpel and topical treatment with the alpha- blocking agent Regitine increases the RA free flow and significantly decreases intraoperative spasticity.

Midterm results of routine bilateral internal thoracic artery grafting.

BACKGROUND: Skeletonized dissection of the internal thoracic artery (ITA) decreases the occurrence of sternal devascularization, thus decreasing the risk of postoperative sternal complications in patients undergoing bilateral ITA grafting. METHODS: From April 1996 to July 1999, 1000 consecutive patients underwent bilateral skeletonized ITA grafting. Of the 770 male and 230 female patients, 420 were older than 70 years, and 312 had diabetes. RESULTS: Operative mortality was 3.3%. Follow-up (40-78 months) revealed 79 late deaths, and the Kaplan-Meier 6-year survival rate was 88%. Cox regression analysis revealed increased overall mortality (early and late) in patients with preoperative congestive heart failure (risk ratio [RR], 2.13; 95% confidence interval [CI], 1.31-3.45), in patients with peripheral vascular disease (RR, 5.52; 95% CI, 3.31-9.19), and in patients older than 70 years (RR, 2.18; 95% CI, 1.37-3.47). Early postoperative morbidity included sternal infection (2.2%), cerebrovascular accident (1.6%), and perioperative myocardial infarction (1%). Multiple regression analysis showed repeat operation (odds ratio [OR], 7.5; 95% CI, 1.77-31.6) and chronic obstructive pulmonary disease (OR, 3.6; 95% CI, 1.27-10.75) to be independent predictors of sternal infection. During follow-up, angina returned in 95 patients, 24 of whom required reintervention (20 cases of percutaneous balloon angioplasty and 4 reoperations). Postoperative coronary angiography performed in 87 patients revealed an ITA patency rate of 91%. CONCLUSIONS: Bilateral skeletonized ITA grafting is associated with satisfactory early and midterm results. We do not recommend the use of this surgical technique in patients with chronic obstructive pulmonary disease.

Pretreatment with alpha-adrenergic blockers for prevention of radial artery spasm.

BACKGROUND: Radial artery (RA) conduits are prone to early vasospasm. Current intraoperative treatment with papaverine fails to inhibit postoperative RA constriction. Pretreatment with topical a-antagonist solutions can inhibit RA vasoconstriction and cause dilatation for a longer period than achieved with papaverine. METHODS: In 10 patients undergoing myocardial revascularization, the radial artery was harvested as a skeletonized vessel. A composite graft with reverse free RA on an in situ left internal thoracic artery was prepared before construction of distal coronary anastomoses. The RA pedicle was then put in a small syringe filled with Regitine (phentolamine methansulphonic, 0.07 mg/mL) ("Jacuzzi") and warmed by immersing the container in a warm saline bath for 8 to 15 minutes. The RA free flow was measured before and after topical treatment with Regitine. RESULTS: The mean number of grafts per patient was 2.9 (range 2 to 4). The mean number of radial anastomoses was 1.8 per patient. Left internal thoracic artery free flow was 110 +/- 29 mL/min. Regitine increased radial free flow from 49 +/- 35 to 77 +/- 30 mL/min (p < 0.01). Five patients underwent postoperative coronary angiography. All radial anastomoses were patent. CONCLUSIONS: Topical treatment of RA with Regitine increases RA free flow and is an effective intraoperative means of decreasing RA spasticity.

Protamine-induced cardiotoxicity is prevented by anti-TNF-alpha antibodies and heparin.

BACKGROUND: We investigated the role of tumor necrosis factor alpha (TNF-alpha) in protamine-induced cardiotoxicity and the possibility of preventing or decreasing this effect by anti TNF-alpha antibodies and heparin. METHODS: Isolated rat hearts were perfused for 60 min with Krebs-Henseleit solution (KH). The control group was perfused with KH alone, the KH > protamine > KH group was treated from the 20th to the 40th minute with protamine, and the KH + anti-TNF > protamine + anti-TNF > KH + anti-TNF group was treated the same as the KH > protamine > KH group but with anti-TNF-alpha antibodies added throughout perfusion. The KH + heparin > protamine + heparin > KH + heparin group was treated the same as the KH > protamine > KH group but with heparin added to KH throughout perfusion. The KH > protamine > KH + heparin was perfused the same as the KH> protamine > KH group but with heparin added to KH for the last 20 min. Left ventricular (LV) function and coronary flow were measured every 10 min. TNF-alpha was measured in the coronary sinus effluent. Left ventricular TNF messenger RNA was determined in the control and KH > protamine > KH groups at baseline and after the 40-min perfusion. RESULTS: Protamine caused a significant decrease of peak systolic pressure and dP/dt (to 25% of baseline). Significant amounts of TNF-alpha in the effluent in the KH > protamine > KH group (102.3 +/- 15.5 pg/min) and TNF messenger RNA expression in left ventricular samples were detected. TNF-alpha was below detectable concentrations in the control, KH + anti-TNF > protamine + anti-TNF > KH + anti-TNF, and KH + heparin > protamine + heparin > KH + heparin groups. TNF-alpha concentrations correlated with depression of LV peak systolic pressure (r = 0.984; P = 0.01) and first derivate of the increase of LV pressure (r = 0.976; P = 0.001). Heparin improved LV recovery and decreased protamine-induced TNF-alpha release (KH > protamine > KH + heparin group). CONCLUSIONS: Anti-TNF-alpha antibodies and heparin prevent protamine-induced TNF-alpha release and depression of LV function. Heparin improves protamine-induced depression of cardiac function.

Primary total knee arthroplasty in the valgus knee: creating a balanced soft tissue envelope.

Lateral tissue releases in valgus total knee arthroplasty frequently produce asymmetric flexion-extension gaps and ligamentous instability. This study compared 2 lateral-release sequences and quantified the effects of sequential lateral capsular ligamentous structure release. One knee from 7 paired specimens was released according to a 4-step sequence: posterior cruciate ligament (PCL), ibiotibial tract (IT band), popliteus tendon/lateral collateral ligament (PT/LCL), and biceps femoris tendon. The contralateral knees were released according to a 5-step sequence: PCL, posterolateral capsule, IT band, PT, and LCL. After each release step, flexion and extension gaps were measured and recorded for the medial and lateral aspects. The 5-step sequence produced more symmetric flexion-extension gaps, whereas the absolute magnitudes of correction were lower than with the 4-step sequence. LCL sacrifice in both sequences produced marked lateral flexion-extension gap asymmetry.

Arterial myocardial revascularization with in situ crossover right internal thoracic artery to left anterior descending artery.

BACKGROUND: The extra length obtained by skeletonizing the internal thoracic arteries (ITAs) enables versatile use of in situ bilateral ITAs for coronary artery bypass grafting, as the longer skeletonized right ITA more easily reaches the anastomotic site on the left anterior descending coronary artery. METHODS: Between April 1996 and November 1999, 365 consecutive patients underwent revascularization with bilateral in situ ITAs (29% of 1,250 grafting procedures performed with both ITAs in our department during this period). The right ITA was routed anterior to the aorta to graft the left anterior descending coronary artery, and the in situ left ITA was used to graft circumflex branches. Right coronary artery branches were grafted with right gastroepiploic artery or saphenous vein graft. The right ITA crossed the midline above the aorta at the most cranial point to avoid damage in case of a repeat sternotomy in the future. RESULTS: The operative mortality rate was 2.2% (8 patients). Postoperative morbidity included seven strokes (1.9%), eight sternal wound infections (2.2%), and four perioperative myocardial infarctions (1.1%). Follow-up (6 to 49 months) of 97% of hospital survivors showed a return of angina in 3%. Postoperative coronary angiography (22 patients) revealed a 95% patency rate of both ITAs. One-year and 4-year survival rates (Kaplan-Meier) were 95% and 92.4%, respectively. Important predictors of an early unfavorable event were chronic obstructive pulmonary disease, old age (> or = 70 years), emergency operation, and diabetes. Chronic obstructive pulmonary disease was the only independent predictor of sternal wound infection (odds ratio, 15; 95% confidence interval, 2.8 to 80). It also predicted decreased late survival (hazard ratio, 8.3; 95% confidence interval, 3 to 21.5). CONCLUSIONS: With skeletonized dissection of ITAs, the right ITA easily reaches the left anterior descending coronary artery for left-sided arterial revascularization with in situ bilateral ITAs. This procedure is safe, but we recommend avoiding its use in patients with chronic obstructive pulmonary disease.