Beneficial effects of a program of Mindfulness by remote during COVID-19 lockdown.

OBJECTIVE: In the emergency context of COVID-19 pandemic and lockdown, mindfulness relaxation techniques can provide a safe and effective strategy to obtain in a reasonably short time some degree of relief from suffering and to guarantee a greater confidence with emotional reactions in the general population. SUBJECTS AND METHODS: The Mindfulness-Based Stress Reduction program for coping with COVID-19 emergency was designed as an 8-week program during the early phase of lockdown consisting in practice meditation exercises at least once a day guided and structured by certified instructors entered on a free online platform. At the end of the program all participants completed a survey. RESULTS: A total of 108 surveys were completed (67.6% male; 32.4% female). Despite the difficult moment of lockdown and the fear linked to the pandemic, 61.9% of interviewed subjects declared a state of general well-being from fair to good linked to the practice of mindfulness. Female subjects (p=0.001), married subjects (p=0.05) and people taking pharmacologic therapy demonstrated (p=0.009) significant improvement in daily management of emotions and practical requests during the early phase of the COVID-19 outbreak. CONCLUSIONS: Mindfulness meditation may be effective in helping people to regulate emotions and to support their mental health during this period of worry and uncertainty.

Web-mediated counseling to counteract the emotional impact of COVID-19 for women with interstitial cystitis/bladder pain syndrome.

OBJECTIVE: Interstitial Cystitis (IC) is a chronic and rare disease, more frequent in women. Symptoms of continuous pain can produce psychological disorders, such as anxiety and depression. The spread of COVID-19 pandemic added to distress experienced by patients with IC emotions, such as fear, sadness, boredom, frustration and anger. MATERIALS AND METHODS: A research on very recent literature outlines the necessity for patients facing the complexity of IC during the COVID-19 outbreak to prevent the temporary crisis, to broaden perspectives, to deal with confusion, to support in struggling with unpleasant and unexpected events. CONCLUSIONS: People affected by IC have a psychological vulnerability that needs tailored support interventions, particularly in the COVID era. A multidisciplinary approach offers a personalized treatment through a web-mediated counseling intervention for patients and their caregivers: a space for continuous discussion and reflection can favour a relationship-based process of change aimed at an improvement in quality of life.

Mental health and counseling intervention for hereditary hemorrhagic telangiectasia (HHT) during the COVID-19 pandemic: perspectives from Italy.

OBJECTIVE: Hereditary hemorrhagic telangiectasia (HHT) is an inherited disorder of fibrovascular tissue, transmitted as an autosomal dominant trait. This rare disease can involve one or more organs and clinical manifestations interest several medical specialties. MATERIALS AND METHODS: A review of recent literature and our clinical experience shows that COVID-19 pandemic greatly influences the autonomy and psychic sphere of patients with HHT, causing them further distress. RESULTS: Often patients affected by HHT experience a sense of loneliness due to the rarity of this pathology and COVID-19 pandemic adds a burden for them and their caregivers who have to face emotional experiences that interfere with personal, social and working functioning. CONCLUSIONS: Multidisciplinary approach and web-mediated counseling intervention could offer a valid and personalized support for patients affected by HHT and their caregivers during quarantine due to COVID-19 pandemic.

Neural functional correlates of emotional processing in patients with first-episode psychoses: an activation likelihood estimation (ALE) meta-analysis.

BACKGROUND: Early emotional recognition impairment characterises rst-episode psychoses (FEP) and remains stable thereafter. Patients with FEP consistently show brain activation changes during emotional processing in functional neuroimaging studies. AIM AND METHODS: To identify and compare cerebral activation correlates of FEP patients and healthy controls (HCs) during emotional task performances, we performed an Activation Likelihood Estimation (ALE) meta-analysis of peer-reviewed functional magnetic resonance imaging (fMRI) studies. RESULTS: Five studies included 71 patients with FEP and 75 HCs. Within-group analyses showed that HCs activated during emotional task performance the bilateral inferior parietal lobule (BAs 39 and 40), left inferior frontal gyrus (BAs 9 and 47), right amygdala, left middle frontal gyrus (BA 9), right cingulate gyrus (BA 32), and right middle temporal gyrus (BA 21). FEP activations correlating with emotional tasks included the right cuneus (BA 17) and right angular gyrus (BA 39). CONCLUSIONS: During emotional task performance, FEP patients fail to activate an extensive brain network comprising emotional processing-related areas, including both cortical and subcortical areas.

Early clinical predictors and correlates of long-term morbidity in bipolar disorder.

OBJECTIVES: Identifying factors predictive of long-term morbidity should improve clinical planning limiting disability and mortality associated with bipolar disorder (BD). METHODS: We analyzed factors associated with total, depressive and mania-related long-term morbidity and their ratio D/M, as %-time ill between a first-lifetime major affective episode and last follow-up of 207 BD subjects. Bivariate comparisons were followed by multivariable linear regression modeling. RESULTS: Total % of months ill during follow-up was greater in 96 BD-II (40.2%) than 111 BD-I subjects (28.4%; P=0.001). Time in depression averaged 26.1% in BD-II and 14.3% in BD-I, whereas mania-related morbidity was similar in both, averaging 13.9%. Their ratio D/M was 3.7-fold greater in BD-II than BD-I (5.74 vs. 1.96; P<0.0001). Predictive factors independently associated with total %-time ill were: [a] BD-II diagnosis, [b] longer prodrome from antecedents to first affective episode, and [c] any psychiatric comorbidity. Associated with %-time depressed were: [a] BD-II diagnosis, [b] any antecedent psychiatric syndrome, [c] psychiatric comorbidity, and [d] agitated/psychotic depressive first affective episode. Associated with %-time in mania-like illness were: [a] fewer years ill and [b] (hypo)manic first affective episode. The long-term D/M morbidity ratio was associated with: [a] anxious temperament, [b] depressive first episode, and [c] BD-II diagnosis. CONCLUSIONS: Long-term depressive greatly exceeded mania-like morbidity in BD patients. BD-II subjects spent 42% more time ill overall, with a 3.7-times greater D/M morbidity ratio, than BD-I. More time depressed was predicted by agitated/psychotic initial depressive episodes, psychiatric comorbidity, and BD-II diagnosis. Longer prodrome and any antecedent psychiatric syndrome were respectively associated with total and depressive morbidity.

First Evidence of Cardiac Stem Cells From the Left Ventricular Apical Tip in Patients With Left Ventricular Assist Device Implantation.

BACKGROUND: Recent studies have challenged the dogma that the adult heart is a postmitotic organ and raise the possibility of the existence of resident cardiac stem cells (CSCs). Our study aimed to explore if these CSCs are present in the "ventricular tip" obtained during left ventricular assist device (LVAD) implantation from patients with end-stage heart failure (HF) and the relationship with LV dysfunctional area extent. METHODS: Four consecutive patients with ischemic cardiomyopathy and end-stage HF submitted to LVAD implantation were studied. The explanted "ventricular tip" was used as a sample of apical myocardial tissue for the pathological examination. Patients underwent clinical and echocardiographic examination, both standard transthoracic echocardiography (TTE) and speckle tracking echocardiography (STE), before LVAD implantation. RESULTS: All patients presented severe apical dysfunction, with apical akinesis/diskinesis and very low levels of apical longitudinal strain (-3.5 ± 2.9%). Despite this, the presence of CSCs was demonstrated in pathological myocardial samples of "ventricular tip" in all 4 of the patients. It was found to be a mean of 6 c-kit cells in 10 fields magnification 40×. CONCLUSIONS: Cardiac stem cells can be identified in the LV apical segment of patients who have undergone LVAD implantation despite LV apical fibrosis.

Comparison of psychotic bipolar disorder, schizoaffective disorder, and schizophrenia: an international, multisite study.

OBJECTIVE: Nosological distinctions among schizoaffective disorder (SA), bipolar I disorder with psychotic features (BDp), and schizophrenia (SZ) remain unresolved. METHOD: We compared 2269 subjects with psychotic features in DSM-IV-TR diagnoses (1435 BDp, 463 SZ, 371 SA) from 8 collaborating international sites, by 12 sociodemographic and clinical measures, all between diagnostic pairs. RESULTS: In bivariate comparisons, SA was consistently intermediate between BDp and SZ for 11/12 features (except onset stressors), and SZ vs. BDp differed in all 12 factors. SA differed from both BDp and SZ in 9/12 factors: SA and BDp were similar in education and suicidal ideation or acts; SA and SZ were similar in education, onset stressors, and substance abuse. Meta-analytic comparisons of diagnostic pairs for 10 categorical factors indicated similar differences of SA from both SZ and BDp. Multivariate modeling indicated significantly independent differences between BDp and SZ (8 factors), SA vs. SZ (5), and BDp vs. SA (3). Measurement variance was similar for all diagnoses. CONCLUSION: SA was consistently intermediate between BDp and SZ. The three diagnostic groups ranked: BDp > SA > SZ related to lesser morbidity or disability. The findings are not consistent with a dyadic Kraepelinian categorization, although the considerable overlap among the three DSM-IV diagnostic groups indicates uncertain boundaries if they represent distinct disorders.

Evaluation of Right Ventricular Function in the Management of Patients Referred for Left Ventricular Assist Device Therapy.

BACKGROUND: Speckle tracking echocardiography analysis (STE) has recently allowed an in-depth analysis of right ventricular (RV) performance. The aim of the study was to observe RV function by STE in patients with advanced heart failure before and after left ventricular assist device (LVAD) implantation. METHODS: A transthoracic echocardiogram was performed in 19 patients referred for LVAD implant at baseline and with serial echocardiograms after LVAD implantation (Jarvik 2000). All echocardiographic images were analyzed off line by an independent operator to calculate with STE the RV free wall longitudinal strain (RVLS). RESULTS: All the patients, except 4, showed a progressive increase of RVLS after LVAD implant. However, 4 patients, who presented the lowest RVLS values at baseline, presented a further RV failure in the postoperative. The value of -11% represented the empirical preoperative cutoff able to identify patients at greater risk of postimplant RV failure. CONCLUSIONS: RV myocardial deformation may have important clinical implications for the selection and management of LVAD patients. It can be used to evaluate RV function before LVAD implantation, to drive decisional strategy regarding the management of this type of patients, and after LVAD implant for the follow-up.

DSM-5 criteria for depression with mixed features: a farewell to mixed depression.

OBJECTIVE: To review the DSM-5 proposed criteria for mixed depression in light of robust and consistent historical and scientific evidence. METHOD: An extensive historical search, a systematic review of the papers used by DSM-5 as reference papers, and a PubMed search were performed. RESULTS: As Hippocrates, depressive mixed states have been described as conditions of intense psychic suffering, consisting of depressed mood, inner tension, restlessness, and aimless psychomotor agitation. In DSM-5, new criteria are proposed for a mixed features specifier, as part of depression either in major depressive disorder (MDD) or bipolar disorder. Those criteria require, as diagnostically specific, manic/hypomanic symptoms that are the least common kinds of symptoms that actually arise in depressive mixed states. The DSM-5 proposal is based, almost entirely, on a speculative wish to avoid 'overlapping' manic and depressive symptoms. Mixed states are, in fact, nothing but overlapping manic and depressive symptoms. CONCLUSION: In this article, we review the psychopathology and research on mixed depressive states, and try to demonstrate that the DSM-5 proposal has weak scientific basis and does not identify a large number of mixed depressive states. This may be harmful because of the different treatment required by these conditions.

Weighing the stigma of weight: An fMRI study of neural reactivity to the pain of obese individuals.

Explicit negative attitudes and blameful beliefs (e.g. poor diet, laziness) towards obese individuals are well documented and are pervasive even among health professionals. Here we sought to determine whether obesity stigma is reflected in a fundamental feature of intersubjectivity namely the automatic neural resonance with others' affective experiences. During fMRI, normal-weight female participants observed short clips depicting normal-weight (NW) and obese (Ob) models experiencing pain. Importantly, participants believed that half of the Ob were overweight due to a hormonal disorder (HormOb) and ignored the cause of obesity of the remaining models (Unknown obese models; UnkOb). Analyses of hemodynamic responses showed reduced activity to the pain of Ob compared to that of NW in areas associated with pain processing and early visual processing. The comparison between the two Ob conditions revealed a further decrease of activity to HormOb's pain compared to UnkOb's (and NW) pain in the right inferior frontal gyrus, an area associated with emotional resonance. Our study demonstrates that stigma for obese individuals can be observed at implicit levels, and that it is modulated by knowledge concerning the etiology of obesity, with the seemingly surprising result that obesity due to disease may result in greater stigmatization. Moreover, the perceived similarity with the models and the ambivalent emotion of pity may index biased brain responses to obese individuals' pain. The study highlights a possibly important neural link between resonance with the pain of others and obesity stigma.

Ethical questions in human clinical psychopharmacology: should the focus be on placebo administration?

Of all ethical issues in clinical trial designs, only placebo use is dealt with acrimony and unwarranted, rhetoric emphasis. Many misconceptions are biased and may hamper research in the mechanisms of healing and recovery if placebo is banned from clinical trials, as some influential ethicists propose. Current treatments in psychiatry are by no means optimal and may vary in their effect across studies, rendering difficult to find the best available therapeutic method with which to compare new drugs. Because drugs possess specific mechanisms, it is not possible to compare drugs with different mechanisms as to their relevance in the pathophysiology of a given disorder. Placebo acts through non-specific mechanisms and is the ideal control for any disorder whose pathophysiology is relatively unknown and its treatment is still suboptimal. Sticking to short-term patient benefit in a trial reflects an individualistically oriented thinking in contemporary ethics and is likely to limit further research and efforts to better understand the mechanisms of disease and drug action, but also those related to general body reactance and self-healing, which are enhanced by placebo administration. Because in history ethics are swinging between two opposed views, it is possible that in the near future, the balance will move towards communitarianism, which is more likely to better serve long-term patient needs. Ethicists should also consider some other aspects of human experimentation, such as the consistency of research lines and the trend to substitute older drugs with their metabolites or enantiomers.

Melancholia agitata and mixed depression.

OBJECTIVE: The diagnostic entity of major depressive episode includes both simple and agitated or mixed depression. Mixed depression is characterized by a full depressive episode with several symptoms of excitatory nature. Mixed depressions worsen if treated with antidepressants. METHOD: We have reviewed the clinical charts of the 2141 patients treated at the Centro Lucio Bini of Rome from January 1999 to June 2006. These patients were diagnosed according to DSM-IV criteria. Research diagnostic criteria were applied for agitated depression with motor agitation and Author's diagnostic criteria for agitated depression without motor agitation. RESULTS: One thousand and twenty-six patients had a depressive episode as index episode. Three hundred and forty six (33%) were mixed depressive states. One hundred and thirty eight (44%) of them were spontaneous; in 173 cases, the onset of the mixed depression was associated with antidepressants. CONCLUSION: Psychic and motor agitation are considered equally important for the definition of agitated depression. Treating agitated depression with antidepressants worsens the clinical picture. The use of Electroconvulsive Therapy (ECT), neuroleptics and anticonvulsants are recommended. The term Melancholia Agitata is proposed for agitated (mixed) depression.

Early and late outcome of skeletonised bilateral internal mammary arteries anastomosed to the left coronary system.

OBJECTIVES: To investigate in a retrospective study the technical aspects of using the in situ bilateral internal mammary arteries (IMAs), with the right IMA (RIMA) used for revascularisation of the circumflex system, and to evaluate early and late outcome. MATERIALS AND METHODS: Between January 1997 and July 2003, 552 consecutive patients underwent grafting of the circumflex artery system with an in situ skeletonised RIMA routed through the transverse sinus (eventually retrocaval). Mean (SD) age was 63.8 (11) years. 331 (60%) patients underwent total arterial myocardial revascularisation. Mean follow up was 26 (9) months. RESULTS: The success rate of skeletonised RIMA grafting to the circumflex branch was 100%. There were 19 (3.4%) in-hospital deaths. Perioperative myocardial infarction occurred in 12 (2.2%) patients. In 155 patients undergoing postoperative angiography, two had an occluded RIMA and a string-like phenomenon was seen in three RIMA and one left IMA (LIMA). Three RIMA and three LIMA had stenotic lesions. The patency rates of RIMA and LIMA were 94% and 97.4%, respectively. Strong predictors of non-functional IMA grafts were a recipient coronary artery diameter of < 1.5 mm (p = 0.022), < 60% stenosis of the recipient coronary artery (p = 0.015), diffuse stenotic lesions of the recipient coronary artery (p = 0.018), and a small IMA calibre (p = 0.0001). Cumulative actuarial survival at three years was 96.4% and event-free cumulative survival was 93.8%. CONCLUSIONS: Use of the bilateral IMAs offers the possibility of constructing various configurations, making total arterial myocardial revascularisation possible with a minimum number of arterial conduits. Use of the skeletonised RIMA through the transverse sinus and eventually retrocavally can reach most branches of the circumflex system and is associated with an excellent patency rate. Patients who received bilateral IMA grafts for left coronary system revascularisation had improved early and late outcomes and decreased risk of death, reoperation, and angioplasty.

Duration and stability of the rapid-cycling course: a long-term personal follow-up of 109 patients.

BACKGROUND: Recognition by the DSM-IV of rapid cyclicity as a course specifier has raised the question of the stability and long-term outcome of rapid-cycling (RC) patients. Data on this topic is sparse and often inconsistent. To our knowledge, these are the first personally followed patients over the long term, dealing directly with the issue of the duration of the RC course. METHODS: We examined the evolution of the course of 109 RC patients (68 women and 41 men) followed for a minimum of 2 years and up to 36 years, beginning with the index episode when the RC course was diagnosed by the authors (A.K., G.P.M., P.G., L.P., D.R.). Patients were included in the study if they met criteria for RC as defined by>or=4 affective episodes per year (Dunner and Fieve, 1974). The follow-up period varied from 2-5 years for 25 patients, 6-10 years for 24 patients, 11-15 years for 24 patients, 16-20 years for 19 patients, 21-25 years for 13 patients, 30-36 years for four patients. RESULTS: In 13 patients (12%), RC emerged spontaneously and in 96 patients (88%), it was associated with antidepressant and other treatments. In 19 women (28% of all women) RC course started in perimenopausal age (45-54 years). The mean duration of RC during the follow-up period was 7.86 years (range 1-32) and its total duration (including RC course prior to the follow-up period) was 11 years (range 1-40). The total duration of the affective disorder, from the first episode to the end of the follow-up, was 21.78 years (range 1-70). At the end of the follow-up, 36 patients (33%) had complete remission for at least the past year, 44 (40%) stayed rapid cycling with severe episodes (six of this group committed suicide), while 15 (14%) were rapid cycling but with attenuated episodes. The other 14 patients (13%) became long cyclers, eight with severe episodes and six with milder ones. The main distinguishing features between those who remitted from and those who persisted in the RC course were: (1). the initial cycle pattern: patients with Depression-Hypomania(mania)-Free interval cycles (53 patients) had a worse outcome: 26.4% remitted and 52.8% persisted in the RC course through to the end of the follow up period. The Mania/Hypomania-Depression-Free interval cycles (22 patients) had a significantly better outcome, with 50% remitted and 27.2% persisting RC; and (2). the occurrence of the switch process from depression to hypomania/mania and the occurrence of agitated depressions made the prognosis worse. Continuous treatment was more effective against mania/hypomania than against depression, yet in all persisting RC cases the mania/hypomania remitted only partially. LIMITATIONS: These data derive from clinics known for their expertise in mood disorders, and they may have attracted and retained patients with a more severe course. Treatment was uncontrolled and consisted more of lithium than divalproex, lamotrigene and olanzapine, recently shown to be beneficial in subgroups of patients with rapid-cycling. CONCLUSIONS: Our findings suggest that rapid cyclicity, spontaneous or induced, once established, becomes for many years a stable rhythm in a substantial proportion of patients, linked to endogenous and environmental factors. The suggestion is made to consider as rapid-cyclers, at least for research purposes, those patients who have had a rapid cycling course for at least 2 years, borrowing the duration criterion currently employed for other chronic disorders such as Dysthymia and Cyclothymia. That our patients had poorer prognosis than some other cohorts in the literature is probably due to the shorter duration of "rapid-cycling" at entry in the latter cohorts. A true understanding of the nature of rapid-cycling will require a rigorous definition of not only duration, but also pole-switching and course patterns at entry into study.

Emergency management of spontaneous coronary artery dissection.

Six cases of spontaneous coronary arteries dissection are reported. In one patient, triple vessel spontaneous coronary artery dissection was identified. Another patient presented spontaneous left main coronary artery dissection. In one case we found the spontaneous dissection of the left anterior descending artery associated with distal aortic arch dissection. These conditions are very rare and may present a surgical dilemma. Causative factors and underlying pathology are clarified. Prompt diagnosis and surgical intervention is safe and effective. Early recognition of left main coronary artery dissection or three-vessel dissection is essential because urgent coronary artery bypass grafting may be life saving.

Beating heart myocardial revascularization on extracorporeal circulation in patients with end-stage coronary artery disease.

OBJECTIVES: To evaluate in a cohort of ESCAD patients (pts) the effects of on-pump/beating-heart versus conventional CABG in terms of early and mid-term survival and morbidity and LV function improvement. METHODS: Between January 1993 and December 2000, 78 (Group I) ESCAD pts underwent on-pump/beating-heart surgery. Mean age in Group I was 66.2+/-6 (58-79), NYHA and CCS class were 3.2+/-0.6 and 3.3+/-0.4 respectively, Myocardial viability index 0.69+/-0.1 (%), LVEF (%) 24.8+/-4, LVEDP (mmHg) 28.1+/-5.8 and LVEDD(mm) 69.5+/-6. Group II consisted in 78 ESCAD patients undergoing conventional CABG selected in a randomized fashion from an age, sex, and LVEF corrected group of patients. Mean age in Group II was 65.7+/-5 (57-78), NYHA 3.1+/-0.7, CCS 3.4+/-0.8, LVEF(%) 25+/-5, LVEDP(mmHg) 27.9+/-4.4 and LVEDD(mm) 69.2+/-7.2. RESULTS: Postoperatively, 5(7.7%) patients died in Group I versus 7(11.5%) patients in Group II (P>0.1). CPB time resulted to be in Group II patients (P=0.001) and the mean distal anastomoses per patient was similar between groups (P=Ns). Perioperative AMI (P=0.039), LCOS (P=0.002), necessity for ultrafiltration (P=0.018) and bleeding>1000 ml (P=0.029) were significantly higher in Group II. None of the Group I patients underwent surgical revision for bleeding versus 8(10.3%) patients in Group II (P=0.011). At 6 months after surgery, the LV function improved significantly in Group I patients, demonstrated by an increased LVEF=27.2+/-4(%)(P=0.001), lower LVEDP=26.4+/-3(mmHg)(P=0.029) and LVEDD=67+/-4(mm) (P=0.004) instead of a lower LVEDD=66.8+/-6(mm)(P=0.032) versus the preoperative data in Group II. The actuarial survival at 1, 3 and 5 yr were 90, 82 and 71% in Group I and 89, 83 and 74% in Group II (P=Ns). CONCLUSION: In ESCAD patients who may poorly tolerate cardioplegic arrest, on-pump/beating-heart CABG may be an acceptable alternative associated with lower postoperative mortality and morbidity. Such a technique offers a better myocardial and renal protection associated with lower postoperative complications due to intraoperative hypoperfusion.

Urgent surgical revascularization of unstable angina. Influence of double mammary arteries.

OBJECTIVE: Aim of this study was to evaluate retrospectively: (1) the outcome in patients with unstable angina (UA) refractory to the medical therapy undergoing urgent-emergent CABG; (2) the influence of both IMAs employment. PATIENTS AND METHODS: Between January 1995 and July 2000, 576 (28.5%) consecutive patients with UA underwent CABG procedure. 182 (31.6%, Group I) patients, presenting unstable hemodynamic or angina pectoris refractory to the maximal medical therapy, underwent urgent/emergent CABG. 397 (68.4%, Group II) patients, after the maximal medical therapy did not present angina's episodes or ECG alterations and underwent elective CABG procedure. Preoperative data were similar in the two groups. Both IMAs were used in 68 (37.4%) patients of I and 152 (38%) of II (P>0.05) to left side revascularization. RESULTS: CAD extension was greater in Group I: 45 (24.7%) patients presented ischemia in >1 area vs 53 (13.5%) in II (P<0.001). Incidence of anteroseptal ischemia resulted significantly higher in I (P=0.017); left main coronary artery stenosis was present in 68 (37%) patients in I vs 108 (27%) in II (P=0.01). LV function resulted significantly depressed in I, demonstrated by a significantly lower LVEF (P<0.001), higher NYHA class (P<0.001) and preoperative incidence of IABP (P<0.001). Intraoperative data analysis did not reveal any difference between groups. Hospital mortality was 13 (7%) and 21 (5.3%) patients in I and II respectively (P=ns). Multivariate analysis of all preoperative and intraoperative variables revealed the age >65 years (P=0.01), congestive heart failure (P<0.001), LVEF<35% (P=0.03), >1 ischemic area (P=0.02) as strong predictors for poor overall survival, and LIMA (P=0.006) and both IMAs (P=0.001) as strong predictors for good overall survival. Actuarial survival at 1, 3 and 5 years resulted to be 98.5, 96.5 and 90% in I and 99, 96 and 92% in II (P=ns). CONCLUSION: CABG has been associated with acceptable outcome in patients with UA which should be applied soonest possible in patients refractory to medical treatment. Total coronary revascularization and employment of both IMAs for left myocardial side are associated with low operative risk and incidence of complications, permit to have acceptable short and long-term outcome in this pool of patients.