Background: The benefit of mitral annuloplasty for moderate ischemic mitral regurgitation remains unclear. We examined long term outcomes in patients having moderate IMR undergoing coronary bypass surgery and compared between those undergoing a restrictive annuloplasty to those having no intervention on the mitral valve. Methods: There were 231 patients: 186 underwent isolated coronary bypass, 45 underwent concomitant mitral valve annuloplasty. Univariate analysis was used to compare baseline parameters. Kaplan-Meier estimates were used to compare survival. Cox multivariate regression was used to determine predictors of late survival. Twenty year survival data is 97% complete.Results: The groups were similar with respect to age and left ventricular function. Mitral repair patients had a higher incidence of CHF at presentation (p<0.0001). Operative mortality was 7% and similar between groups (p=0.7). Ten-year survival was 55% and 52% for bypass only and mitral repair patients respectively (p=0.2). There was a slightly better improvement in functional class in the mitral group (p=0.07). Predictors of late mortality included age, CHF, LV dimensions and LV dysfunction. Neither the addition of mitral annuloplasty, type of ring implanted nor residual MR emerged as predictors of survival.Conclusions: In patients with moderate ischemic mitral regurgitation, performance of a restrictive annuloplasty does not affect operative mortality and may confer better functional improvement. The fact that patients undergoing a mitral procedure had a higher incidence of CHF preoperatively, yet attained similar survival alludes to the fact that such a procedure may be beneficial in terms of survival. The decision to repair the valve should take individual patient factors into consideration.

Introduction: Coronary artery bypass (CABG) is the preferred procedure for complete revascularization in patients with multi-vessel coronary artery disease. We analyzed evolving patient profile, early outcomes and late survival in patients undergoing CABG at our center over a 20 year period.Patients: Between 1993-2012, 4913 patients underwent CABG with or without concomitant procedures. A retrospective analysis was performed to determine early outcomes. Long-term survival was established from data from the Ministry of Interior.Results: Isolated CABG was performed in 3950 (80%). Over time, patients undergoing surgery are older (p=0.002) and the incidence of concomitant procedures increased from 20% to 61% (p<0.0001). Predicted operative mortality increased (p<0.0001) however observed mortality remained the same (p=0.5). Long-term survival was reduced in patients requiring concomitant procedures (p<0.0001) and in patients with reduced LV function (p<0.0001). Survival after isolated CABG is 86% and 70% at 5 and 10 years respectively. Late survival was affected by age and co-morbid conditions. Reduced LV function and the presence of preoperative mitral regurgitation emerged as cardiac predictors for late mortality.Conclusions: Patients undergoing CABG are older and have more extensive co-morbidity. Despite this, operative mortality has not increased. Long-term survival is affected by age, LV function and co-morbid conditions.

One-hundred and seventeen patients with aortic stenosis and moderate MR underwent aortic valve replacement: 87 underwent isolated AVR (group 1), 30 AVR with a concomitant mitral procedure (group 2- repair in 12, replacement in 18). Coronary artery disease was present in 35 (37%), all underwent concomitant CABG. Neither CABG nor the addition of a mitral procedure increased the operative risk. Patients with residual MR after surgery had reduced late survival compared to patients without MR. Predictors for late survival by Cox regression were age (p=0.02), and residual MR (p=0.01). Coronary artery disease did not have an impact on late survival in these patients. It may be beneficial in these patients to address the mitral valve at the time of aortic valve replacement.

Introduction There is considerable uncertainty about the reproducibility of the various instruments used to measure dyspnea, their ability to reflect changes in symptoms, whether they accurately reflect the patient's experience and if its evolution is similar between acute heart failure syndrome patients and nonacute heart failure syndrome patients.URGENT was a prospective multicenter trial designed to address these issues.Methods Patients were interviewed within 1 hour of first physician evaluation, in the emergency department or acute care setting, with dyspnea assessed by the patient using both a five-point Likert scale and a 10-point visual analog scale (VAS) in the sitting (60º) and then supine (20º) position if dyspnea had not been considered severe or very severe by the sitting versus decubitus dyspnea measurement.Results Very good agreements were found between the five-point Likert and VAS at baseline (0.891, P <0.0001) and between changes (from baseline to hour 6) in the five-point Likert and in VAS (0.800, P <0.0001) in acute heart failure (AHF) patients.Lower agreements were found when changes from baseline to H6 measured by Likert or VAS were compared with the seven-point comparative Likert (0.512 and 0.500 respectively) in AHF patients.The worse the dyspnea at admission, the greater the amplitude of improvement in the first 6 hours; this relationship is stronger when dyspnea is measured with VAS (Spearman's rho coefficient = 0.672) than with the five-point Likert (0.272) (both P <0.0001) in AHF patients.By the five-point Likert, only nine patients (3% (1% to 5%)) reported an improvement in their dyspnea, 177 (51% (46% to 57%)) had no change, and 159 (46% (41% to 52%)) reported worse dyspnea supine compared with sitting up in AHF patients.The PDA test with VAS was markedly different between AHF and non-AHF patients.Conclusions Both clinical tools five-point Likert and VAS showed very good agreement at baseline and between changes from baseline to tests performed 6 hours later in AHF patients.The PDA test with VAS was markedly different between AHF and non-AHF patients.Dyspnea is improved within 6 hours in more than threequarters of the patients regardless of the tool used to measure the change in dyspnea.The greater the dyspnea at admission, the greater the amplitude of improvement in the first 6 hours. P2

Background. Accumulating clinical experience with ozone administration for conditions associated with ischemia has been encouraging. The aim of our study was to determine the effect of ozone on reperfusion injury in an isolated rat heart model. Methods: Isolated rat hearts were perfused with modified Krebs-Henseleit buffer solution via ascending aorta cannulation. After 15 minutes, perfusion was stopped and global ischemia was maintained for 30 minutes, following which perfusion was restarted, and continued for 40 minutes. Baseline hemodynamic measurements (heart rate, left ventricular developed pressure (LVDP), dP/dt, and coronary flow) were taken prior to ischemia, and every 10 minutes after reperfusion was started. Eleven hearts were treated with ozone during reperfusion and eight hearts served as controls. In the treatment group, after 5 minutes of reperfusion, ozone was administered in distilled water via a side arm for 5 minutes. Results: Preischemic baseline hemodynamic measurements and coronary flow were similar in the two groups. Hearts treated with ozone during reperfusion exhibited better recovery than did controls. Mean ( SE) percent recovery for treatment and control groups, respectively, was: LVDP 69 2% vs 51 6% (p = 0.04); dP/dt 68.9 +/- 13.3% vs 53.7 +/- 20.4% (p = 0.05); and LVDPxHR 61.4 +/- 3.3% vs 44.4 +/- 3.5% (p = 0.02). Conclusion: In the isolated rat heart model, treatment with ozone during reperfusion enables better recovery than in controls. Although the mechanism by which ozone exerts its beneficial effect is not identified, it is possibly due to reduction in reperfusion injury.

OBJECTIVE:Since cardiac surgery is now performed on patients with high risk for cerebrovascular disease, we studied the clinical findings and medium term outcome of patients with acute stroke/transient ischemic attack (TIA) after cardiac surgery.METHODS:All consecutive patients with acute stroke/TIA after cardiac surgery were prospectively observed during a 19 month period. Follow-up was between 3 months and 21 months. Risk factors, type of stroke, anatomic localization, initial neurological deficit and followup outcome were evaluated, using standard assessment scores.RESULTS:Among 406 patients operated (mean age 64.3 +/- 12.7 years, 284 males), 18 developed stroke and 2 TIAs (mean age 65.7 years, 13 males). There were no cases of intracerebral hemorrhage. Most of the strokes happened shortly after valve surgery (mean 1.3 days post operatively) and were right hemispheric (right = 11, left = 3; p = 0.034). Vertebrobasilar stroke appearance was delayed (mean: 8.25 days post operatively); they were attributed mostly to cardiac arrhythmias. Stroke/TIA patients did not have a higher preoperative risk than those without, but their cardiac functional score was worse (p = 0.01), and the average cardiopulmonary bypass time during surgery was longer (p = 0.009). Two patients died in hospital, both with vertebrobasilar stroke. Most of the hemispheric stroke patients became functionally independent (mean modified Rankin Scale < 2), even those with initial severe deficit.CONCLUSION:Strokes after cardiac surgery are mostly right hemispheric and exclusively ischemic. Outcome is relatively fair. We suggest an embolic injury to the right hemisphere, procedure related, as a possible mechanism.

Background: Ischemic mitral regurgitation is associated with reduced survival after coronary artery bypass surgery.Objectives: To compare long-term survival among patients undergoing coronary surgery for reduced left ventricular function and severe ischemic MR in whom the valve was repaired, replaced, or no intervention was performed.Methods: Eighty patients with severe left ventricular dysfunction and severe MR underwent coronary bypass surgery. The mean age of the patients was 65 years (range 42-82), and 63 (79%) were male. Sixty-three (79%) were in preoperative NYHA functional class III-IV (mean NYHA 3.3), and 26 (32%) were operated on an urgent/emergent basis. Coronary artery bypass surgery was performed in all patients. The mitral valve was repaired in 38 and replaced in 14, and in 28 there was no intervention. The clinical profile was similar in the three groups, although patients undergoing repair were slightly younger.Results: Operative mortality was 15% (8%, 14%, and 25% for the repair, replacement and no intervention respectively; not significant). Long-term follow up was 100% complete, for a mean of 38 months (range 2-92). Twenty-nine patients (57%) were in NYHA I-II (mean NYHA 2.3). Among the surgery survivors, late survival was improved in the repair group compared to the other groups (P < 0.05). Predictors for late mortality were non-repair of the mitral valve, residual MR, and stroke (P = 0.005).Conclusions: Patients with severe ischemic cardiomyopathy and severe MR undergoing coronary bypass surgery should have a mitral procedure at the time of surgery. Mitral valve repair offers a survival advantage as compared to replacement or no intervention on the valve. Patients with residual MR had the worst results.

One hundred and twenty two patients with ischemic mitral regurgitation grade 3-4 underwent surgery for mitral valve repair with annuloplasty ring. Patient age was 65 +/- 10 and 89 (73%) were male. Eighty-six (70%) were in NYHA class III-IV, 77 (63%) had reduced LV function, and mean MR grade (+/- SD) was 3.8 +/- 0.4. One hundred and thirteen operative survivors were followed for a mean of 33 months. Overall MR grade improved and was 1.6 +/- 1. Twenty-eight patients (25%) remained with MR grade 3-4. Survival was 70% at 5 years. Predictors for late mortality were LV function, NYHA class IV, and older age. Residual MR did not emerge as a predictor for late mortality.

In this month's edition of IMAJ, Lev-Ran and colleagues report the results of off-pump coronary artery bypass grafting with 1,000 consecutive patients [1]. It is an important article demonstrating new trends in coronary bypass surgery. Historically, cardiopulmonary bypass and cardioplegic arrest of the heart brought relative technical ease to cardiac surgery by providing a bloodless still surgical field while performing coronary anastomosis. This is indeed an important adjunct in guaranteeing safe and stable hemodynamics. There is no question that coronary bypass surgery during the last three decades of the 20th century demonstrated phenomenal success with outstanding early and late results in alleviating cardiac symptoms as well as prolonging life. It is estimated that in recent years approximately 1,000,000 CABG procedures are performed annually in the western world [2]. However, the use of cardiopulmonary bypass entails a host of accompanying problems. It induces a whole-body inflammatory response that is capable of causing significant morbidity [3]. Implicit in the technique of CPB is a non-pulsatile flow state that may also contribute to end-organ dysfunction. Employing CPB requires aortic cannulation and cross-clamping, which may lead to atheromatous embolization and organ damage, especially cerebral stroke and cognitive dysfunction. In view of the above-mentioned potential complications of CPB, it is no surprise that during the early 1990s techniques of coronary bypass surgery without CPB, which were originally described at the inception of coronary bypass surgery, were revitalized and received tremendous momentum. The development of effective stabilizers and intracoronary shunts accelerated the popularity of off-pump coronary bypass surgery. It is currently estimated that 25% of all procedures in the United States and Europe are performed offpump [4]. The goals set by off-pump coronary bypass surgery protagonists are to achieve: a) good early results (mortality, perioperative myocardial infarction) and late results (long-term graft patency, cardiac event-free survival rate, life expectancy) comparable to those of conventional CABG surgery; and b) better outcomes in high risk patients due to the inherent morbidities attributed to the use of CPB. Today, after more than 10 years of accumulated experience with off-pump CABG surgery, what lessons can be learned from reviewing the literature? . Although off-pump CABG is more demanding, early results are comparable to those of standard CABG (mortality, perioperative myocardial infarction) [5±7]. . Long-term results are not yet fully established. However, early patency rates of grafts seem to be matching those of standard surgery. These issues have yet to be clarified [8]. . The high expectations of improved outcome by avoiding CPB complications failed to materialize. Most importantly is the severe problem of perioperative stroke. To date, randomized studies have failed to demonstrate an advantage of off-pump surgery [5,6]. However, a retrospective STS database analysis including 118,440 patients did demonstrate a stroke benefit for off-pump CABG compared with on-pump (1.25% vs. 1.99%, P < 0.001) [7]. While the question of cognitive dysfunction is still hotly debated, there is no conclusive evidence that off-pump CABG surgery is beneficial [5,6]. Nonetheless, some clear advantages should be mentioned. One is blood utilization, with most series showing significantly reduced utilization of blood products [9,10]; another is shorter extubation time and reduced hospital stay [6,9,11,12]. In the new era of evidence-based medicine, we need solid evidence proving the advantage of off-pump CABG surgery in order to convert all CABG surgery into this modality. This might explain why off-pump CABG surgery has not gained universal acceptance and has not become the standard of practicing CABG surgery. It is hoped that future publications will settle this much debated issue. Nevertheless, it can be stated unequivocally that in clinical scenarios such as elderly patients with severe calcified aorta, or patients with significant chronic renal failure, off-pump CABG is the modality of choice. The current article by Lev-Ran and colleagues [1] is an important contribution to the documented experience concerning off-pump surgery. It is the largest experience in Israel. However, this study could have elucidated the subject and increased our knowledge considerably more had they employed a better methodology. It is CABG = coronary artery bypass grafting CPB = cardiopulmonary bypass

Background: The Arterial Revascularization Therapies Study was a multicenter, randomized trial designed to compare percutaneous coronary intervention with stenting versus coronary artery bypass graft surgery in 1,205 patients with multivessel coronary artery disease. The most appropriate type of treatment for these patients is still a matter of considerable debate.Objectives: To evaluate the clinical characteristics of patients enrolled in the ARTS trial in Israel in comparison to those worldwide, and to assess the I year outcome in these patients.Methods.. Between April 1997 and June 1998, a total of 1,205 patients with multivessel coronary artery disease, who were considered to be equally treatable with both modalities, were randomized to either stenting (n = 600) or CABG (n = 605) at 67 centers around the world. In Israel, 53 patients at four participating medical centers were randomized to either PCI with stents (n = 27) or CABG (n = 26).Results: Clinical and angiographic characteristics were similar in the two groups, except fora significantly higher incidence of diabetic patients in Israel who were randomized to CABG, compared to those worldwide (35% vs. 16%, P = 0.01). Also, there were more patients with unstable angina in Israel (63 vs. 37%, P = 0.006). At 1 year follow-up, overall mortality and cerebrovascular accident rates were similar between the two groups and equivalent to results obtained around the world. There was a significantly higher incidence of myocardial infarction rates in patients randomized to stenting in Israel compared to patients worldwide (7.4 vs. 5.3%, P = 0.01) or to patients randomized to CABG in Israel (7.4 vs. 0%, P = 0.006). Similar to the overall ARTS results, there was a higher incidence of repeat revascularization procedures in patients assigned to the PCI with stenting arm (22.2 vs. 3.8%, P = 0.004) compared to those randomized to CABG, respectively.Conclusions: The results of this analysis of the Israeli ARTS population indicate that coronary stenting and bypass surgery yield similar findings with regard to mortality and stroke and are comparable to those obtained in the whole study group. Likewise, coronary stenting was associated with an increased incidence of repeat revascularization procedures as compared to CABG. However, patients in Israel randomized to stenting had a higher rate of myocardial infarction as compared to the overall results and,to patients who underwent CABG in Israel. The present analysis provides important data for the-safety and efficacy of either stenting or bypass surgery in treating, patients with multivessel disease in Israel.

BACKGROUND:Aortic valve replacement (AVR) in the presence of a calcified aorta or patent grafts may preclude clamping of the ascending aorta. We employed deep hypothermic circulatory arrest in order to circumvent this problem.METHODS:Between January 1993 and December 2000, 415 patients underwent AVR in our department. Eight of these were operated using deep hypothermic circulatory arrest. There were 5 males, and mean age was 72 years (range 56-81). Indications for using circulatory arrest were reoperation with patent grafts and/or severe calcification of the ascending aorta. In six patients, cardiopulmonary bypass was achieved via femoro-femoral bypass, and in two via aortic-right atrial cannulation. Retrograde cerebral perfusion was employed in five. Mean bypass time was 155 minutes (range 122-187), and mean circulatory arrest time was 38 minutes (range 31-49).RESULTS:There was no operative mortality, and no patient suffered any neurologic sequelae. Echocardiography showed all valves to be functioning well.CONCLUSIONS:AVR under deep hypothermic circulatory arrest can be accomplished with an acceptable degree of safety. It should be considered as an alternative in patients in whom aortic clamping is prohibitive, and might otherwise be considered inoperable. The ability to connect the patient to bypass and the presence of a "window" to allow aortotomy are prerequisites for employing this method.

Myxomatous mitral valve disease is now the most common cause of mitral regurgitation in the western world. Repair of the leaking valve has become standard surgical procedure during the past 2 decades. Between 1993-1999 we performed 113 repairs of the mitral valve. In 25 patients the etiology was myxomatous degeneration (no mortality). Long-term clinical results depend on patients' functional class at surgery. Based on this fact, and the good surgical results, it is recommended to refer such patients even with severe mitral incompetence for surgery at an early stage, even if symptoms are minimal.

BACKGROUND:Patients with ischemic mitral valve insufficiency (MR) and poor left ventricular (LV) function present a high operative risk. Whether to repair or replace these valves is controversial, while some suggest that heart transplant offers a better solution. We investigated our early and late results in this difficult subset of patients. METHODS:Between 1993-1999,115 patients underwent mitral valve repair (MVR) in our department. Twenty-one patients had severe LV dysfunction with ejection fraction < 25%. Mean age was 60 years (range 45-81). Nineteen (90%) were in New York Heart Association (NYHA) Class IV, 7 (33%) underwent emergency surgery, 3 (14%) were in cardiogenic shock, and 2 (10%) were taken to the operating room under cardiopulmonary resuscitation. All underwent coronary artery bypass grafting (CABG) in addition to MVR, with a mean number of grafts 2.9 per patient. RESULTS:There were no early operative deaths. The average stay in intensive care was 5.9 days (range 1-52). There were three late deaths (14%). Follow-up evaluation up to 3 years showed marked improvement in clinical status. Twelve (67%) patients are in NYHA Class I-II, and three (17%) in Class III. Echocardiography revealed good function of the mitral valve in all, although overall LV function did not change significantly. CONCLUSION:(1) MVR in patients with severe ischemic cardiomyopathy can be accomplished with excellent results. (2) There is marked symptomatic improvement in these patients, even though LV function did not seem to be improved. (3) Long-term survival still needs to be defined.

The radial artery has been used as an access for transcatheter procedures as well as a source for arterial conduit during coronary bypass surgery. It has been reported that 5Eth 13% of radial arteries may be damaged during transradial catheterization. The damage can be irreversible, and may therefore prohibit the radial arteryOs subsequent utilization as a coronary conduit.

Patients with ischemic mitral insufficiency and poor left ventricular function are high operative risks. We present 101 patients who had mitral valve repair in our department: 21 had severely reduced left ventricular function, 19 were in NYHA functional Class IV, and 2 in Class III. All had concomitant coronary artery bypass. There was no early operative mortality, but there were 2 late deaths (9.6%). At follow-up (3-36 months) all valves were functioning normally, 9 patients (43%) were in NYHA functional Class I, and 4 (19%) in Class II. Our experience shows that repair of ischemic mitral insufficiency in the presence of severe left ventricular dysfunction can be performed with good results, and is preferable to mitral valve replacement. Late follow-up showed significant symptomatic improvement.