Chronic total occlusion--use of a 5 French guiding catheter in a 6 French guiding catheter.

We present a case of a chronic total occlusion that required the use of a 5 Fr in a 6 Fr guiding catheter. The 5 Fr in a 6 Fr guiding catheter method allows ultra-deep seating to increase backup support and assist stent delivery. This technique was paramount in this case, as there were technical challenges with failure to track drug-eluting stents due to vessel tortuosity and lack of support.

Multi-vessel off-pump coronary artery bypass grafting can be taught to trainee surgeons.

BACKGROUND: Although, Off-Pump Coronary Artery Bypass (OPCAB) surgery is being increasingly explored and practised in many cardiac units worldwide, there have been only few reports documenting the training of surgeons in this new technique. The purpose of this study was to address the reproducibility of the OPCAB in a unit where this technique is used extensively. METHODS: Registry data, notes and charts of 64 patients who were operated on by four trainee cardiac surgeons over a period of thirteen months at Harefield Hospital, were reviewed retrospectively. These trainees were part of an accredited training programme for cardiothoracic training and were trained by a single consultant trainer in a cardiac unit after it has had an established recent experience in performing non-selective OPCAB for all coming-in patients. Five (7.8%) patients (with 17 distal anastomoses) consented and underwent early postoperative angiography to check the quality of the grafts and anastomoses. RESULTS: The mean age of the study patients was 65.6 and the mean Parsonnet score was 9.4. There was a mean of 2.9 grafts per patient and circumflex territory anastomoses were performed in 48 (75%) patients. No operation required conversion to Cardiopulmonary Bypass (CPB). Angiography of the five patients revealed satisfactory seventeen (100%) distal anastomoses. CONCLUSION: With appropriate training, it is possible for trainees to learn OPCAB and perform multi-vessel revascularization in relatively high-risk patients with good results.

Does routine use of the radial artery increase complexity or morbidity of coronary bypass surgery?

BACKGROUND: Despite increasing data supporting its use, the uptake of radial artery coronary bypass grafting by most surgeons remains low. This may partly be from perceptions that it increases risk or complexity of coronary surgery. METHODS: Data on 151 patients who had radial grafts are compared with 179 concurrent nonrandomized controls that underwent conventional surgery using saphenous vein. Additionally, telephone interviews were conducted on 127 radial recipients to assess subjective outcome. RESULTS: Cardiopulmonary bypass and cross-clamp times were similar in both groups (72 versus 74 minutes and 20 versus 22 minutes). Morbidity was comparable (mortality 1% versus 2%; cerebral vascular accident 1% versus 2%; sternal infection 1% versus 2%; resternotomy 4% versus 6%). Of 127 patients contacted, 41 (32%) reported that they had experienced parasthesia, and 65 (51%) reported numbness related to radial harvest; of these, 75% reported their symptoms as resolved or resolving. Early angiography performed in 36 patients revealed a radial patency rate of 92%. CONCLUSIONS: Concerns about increased morbidity and mortality should not hinder adoption of radial artery grafting.

Late endothelial function of free and pedicled internal mammary artery grafts.

The internal mammary artery has greater long-term patency than the saphenous vein when used for coronary bypass grafting. Therefore, bilateral use of the internal mammary artery for grafting with the right internal mammary artery used as a "free" graft may result in improved graft survival. The study objectives were to compare the endothelial-dependent and -independent vasodilatory response in free and pedicled internal mammary artery grafts in patients who had previously undergone coronary surgery. Free (group 1, n = 8) and pedicled (group 2, n = 7) internal mammary artery grafts were studied by comparing the response to selective infusion of the endothelial-dependent vasodilator substance P (1.4 up to 22.4 pmol/min in doubling dose increments) followed by isosorbide dinitrate (2 mg over 2 minutes), in patients undergoing coronary angiography, 1 month to 6 years after coronary surgery. Maximal dilatory response to substance P was 8.7% +/- 1.8% in pedicled grafts compared with 8.8% +/- 2.3% in free grafts (p = not significant), with the dose response for both groups being similar. Infusion of isosorbide dinitrate produced only minimal further dilatation in both groups. No significant difference was found in endothelium-dependent and -independent vasodilatory response between free and pedicled internal mammary artery grafts, suggesting that the use of the free right internal mammary artery and other arterial grafts may enhance graft survival.

Coronary endothelial function in cardiac transplant recipients with accelerated coronary disease.

BACKGROUND: Previous studies with the endothelium-dependent vasodilator substance P have shown a preserved vasodilator response in cardiac transplant recipients with angiographically normal coronary arteries. Although endothelial dysfunction is known to occur in cardiac transplant recipients with accelerated coronary disease, the degree to which the endothelium is affected is not known precisely. The aim of the present study was to examine endothelial function in accelerated coronary disease following cardiac transplantation. METHODS: Thirteen cardiac transplant recipients with epicardial coronary disease underwent substance P infusion. The response to incremental doses of substance P was measured in smooth segments of affected coronary arteries. Substance P was infused over 2 min with a starting dose of 1.4 pmol/min and a maximum of 22.4 pmol/min, reached by doubling the dose in steps, followed by an infusion of 2 mg isosorbide dinitrate over 2 min. RESULTS: Substance P caused less vasodilation at lower concentrations, with a significantly higher dose required to achieve half maximal dilation compared with cardiac transplant recipients with no coronary disease. The mean maximal dilatation achieved with substance P was 22.98 +/- 4.62% compared to 21.95 +/- 4.9% with isosorbide dinitrate; the latter value was not significantly different from the maximal dilation achieved in cardiac transplant recipients without coronary disease. CONCLUSIONS: In cardiac transplant recipients with accelerated coronary disease the functional vasodilatory ability of the coronary endothelium is impaired in segments of apparently unaffected epicardial arteries, which may lead to an increase in the resting vasoconstrictor tone and have important functional and therapeutic implications.

Substance P for evaluation of coronary endothelial function after cardiac transplantation.

The endothelium-dependent vasodilator substance P dilates normal and diseased coronary vessels in humans in vivo and produces a maximal response similar to that seen with intracoronary isosorbide dinitrate. Twelve cardiac transplant recipients underwent intracoronary infusion of substance P after routine annual investigations. All patients were well, with no evidence of rejection and with angiographically normal coronary arteries. Substance P was infused at 2 ml/min for 2 min into the coronary artery, starting at a dose of 1.4 pmol/min and increasing by doubling increments, and followed by isosorbide dinitrate (1 mg/min) infused over 2 min. Coronary artery diameter was measured in 23 vessel segments from 12 transplant recipients. The following doses were infused: saline solution (1 ml/min), substance P (0.7 [three patients], 1.4, 2.8, 5.6, 11.2, 22.4 pmol/min) and isosorbide dinitrate (1 mg/min). The mean percent increase in diameter (+/- SEM) in response to increasing doses of substance P was as follows: 0, 6.5 +/- 2.9%, 10.9 +/- 2.9%, 12.1 +/- 2.9%, 16.5 +/- 2.6%, 19.2 +/- 3.1% and 25.8 +/- 2.2%, respectively. Half maximal dilation was produced with 1.4 to 2.8 pmol/min of substance P; the maximal response (mean percent diameter change) was 22 +/- 2.5%. This was not significantly different from that achieved with isosorbide dinitrate. It is concluded that coronary endothelial function as assessed by response to substance P is preserved in cardiac transplant recipients with angiographically normal coronary arteries. Substance P may be a suitable agent for testing endothelial function in these patients.