[Current evidence-based situation in coronary revascularization--CABG vs. PCI and diabetes?]

A variety of randomized, controlled trials comparing percutaneous coronary intervention (PCI) with coronary artery bypass grafting (CABG) found similar results in mortality but significant differences in number of reinterventions in favor of CABG. This work gives an overview about the relevance and limitations of these studies in line with newly published large scale observational studies, which reveal significantly lower mortality-rates in CABG patients. Emphasis is placed on the special situation in the diabetic patient.

Protecting the Endothelial Integrity of Internal Thoracic Arteries

BACKGROUND

Previous functional studies on human internal thoracic arteries, comparing the effect of the traditional harvesting method (occlusion with a clip) with a method leaving the artery perfused, revealed considerably impaired endothelial function associated with enhanced contractility after clipping. We have now investigated whether these observations could be correlated (1) with plasma markers of endothelial dysfunction, and (2) with structural changes in the endothelial layer.

METHODS

32 patients were randomly distributed into groups of clipped and perfused arteries. Arterial blood samples were obtained from both the artery and extracorporeal circulation to determine sP-selectin, sE-selectin, sL-selectin, and thrombomodulin using enzyme-linked immunosorbent assay. Arteries from three patients were examined by scanning electron microscopy.

RESULTS

Concentrations of sP-selectin and thrombomodulin were significantly higher in plasma from clipped arteries compared to perfused arteries, whereas sE-selectin and sL-selectin concentrations were similar within the groups. Scanning electron microscopy revealed significant structural changes and loss of endothelial cells in clipped arteries.

CONCLUSION

Biochemical and structural results support our findings that leaving the internal thoracic artery perfused preserves endothelial function in the arterial graft.

[Ambulatory long-term management of a left ventricular assist device. Current modality in terminal heart failure]

We report about the first use and successful outpatient therapy with an implantable pulsatile left ventricular assist device (LVAD, Novacor) in a patient with a combined dilative and ischemic cardiomyopathy in Switzerland. The patient, a 51 year old man (112 kg, 191 cm, blood type A) developed end-stage heart failure (New York Heart Association class (NYHA) IV) while he was awaiting orthotopic heart transplantation. Due to his profession as an independent graphic-designer the patient was afraid of a long-term temporary disablement with consecutive bankruptcy. Therefore we decided and performed the implantation of a Novacor-LVAD as a bridge to transplantation with the possibility to outpatient therapy in a favourable course. The patient was supported by the device for more than five months. His cardiac functional status returned to NYHA class I, and the patient was discharged 5 weeks after implantation. He returned into his normal life and started working at 100% again. Furthermore the LVAD enabled the patient to participate in almost all activities. Five months (151 days) after implantation a donor organ became available and the patient underwent orthotopic heart transplantation. The use and successful outpatient therapy with an implantable pulsatile left ventricular assist device in our patient has proved to be save, reliable, life-saving, quality of life improving and could be an important alternative for the economic burden in heart failure therapy.