BACKGROUND & AIMS: OBJECTIVE:Ascending aortic atherosclerosis is a risk factor for perioperative morbidity and mortality in coronary surgery. It was the aim of our study to determine the role of atherosclerosis of the ascending aorta and other factors for the survival rate during long-term follow-up after CABG. METHODS:From 500 out of 580 CABG patients (aged 67 (33-85) years, 77% male), who underwent intraoperative epiaortic ultrasound for assessment of ascending aortic wall thickness, a complete follow up regarding long-term survival was achieved. The median follow-up time was 55 (1-78) months. RESULTS:53/500 (11%) patients died within the follow-up period, and the cumulative survival rate was 95, 90, and 84% after 1, 3, and 5 years, respectively (including hospital deaths). A significantly lower long-term survival was present in patients with: an age of 70 years or more (P<0.001), COPD (P=0.005), preoperative elevated serum creatinine of >1.2mg/dl (P=0.007), preoperative LVEF <40% (P=0.033), ascending aortic wall thickness of 4mm or more (P=0.001), carotid artery disease (P<0.001), peripheral vascular disease (P<0.001), and acute operation (P=0.009). Multivariate analysis revealed carotid artery disease, LVEF <40%, peripheral vascular disease, and advanced age to be independent risk factors. CONCLUSION:Patients with ascending aortic atherosclerosis are at risk for a decreased long-term survival after CABG. Besides, preoperative elevated serum creatinine, COPD, carotid artery disease, LVEF <40%, peripheral vascular disease, and advanced age are risk factors for a decreased long-term survival after CABG.

背景与目标： 目的：升主动脉粥样硬化是冠状动脉手术围手术期发病和死亡的危险因素。本研究的目的是确定CABG术后长期随访中升主动脉的动脉粥样硬化的作用以及其他因素对存活率的影响。
方法：在580例CABG患者（年龄67岁（33-85岁），男性77％）中，有500例接受了术中表皮超声检查以评估主动脉壁厚度的增加，从而获得了关于长期生存的完整随访。中位随访时间为55（1-78）个月。
结果：53/500（11％）患者在随访期内死亡，在1、3和5年后（包括医院死亡），累积生存率分别为95％，90％和84％。年龄在70岁或以上（P <0.001），COPD（P = 0.005），术前血清肌酐升高> 1.2mg / dl（P = 0.007）的患者的远期生存率显着降低LVEF <40％（P = 0.033），升主动脉壁厚4mm以上（P = 0.001），颈动脉疾病（P <0.001），周围血管疾病（P <0.001）和急性手术（P = 0.009） 。多因素分析显示，颈动脉疾病，LVEF <40％，周围血管疾病和高龄是独立的危险因素。
结论：升主动脉粥样硬化的患者有CABG术后长期生存降低的风险。此外，术前血清肌酐升高，COPD，颈动脉疾病，LVEF <40％，周围血管疾病和高龄是CABG术后长期生存率降低的危险因素。

BACKGROUND & AIMS: OBJECTIVE:To further elucidate the mechanism by which cytomegalovirus (CMV) may promote atherosclerosis, we studied the expression pattern of cellular inflammatory and proliferative signals in the aortic wall of CMV(+) and CMV(-) patients undergoing coronary artery bypass grafting (CABG). METHODS:Aortic biopsies and blood samples of 68 CABG patients were investigated for CMV-DNA by PCR and IN SITU hybridisation. Expression of pp65 antigen, adhesion molecules (ICAM-1, VCAM-1, E-selectin), growth factors (PDGF-AA, TGF-beta), and the cellular proliferation factor Ki-67 was studied by immunohistochemistry. Logistic regression was used to test the correlation between the presence of CMV, vascular inflammation, and traditional noninflammatory risk factors for atherosclerosis. RESULTS:CMV-DNA was detected in the aortic tissue of 52 (76%) patients, and was localised predominantly in vascular smooth muscle cells. In CMV(+) patients, the expression of adhesion molecules and growth factors in the aortic endothelium was increased compared with CMV(-) patients. A positive correlation of elevated CRP, the induction of adhesion molecules and growth factors and CMV(+) was found. Female gender, smoking, and hyperlipidaemia were identified as risk factors for CMV(+). CONCLUSIONS:CMV-DNA in smooth muscle cells induces local growth factor expression as well as endothelial activation, both of which can promote the progression of atherosclerosis. Since traditional atherogenic risk factors increase the likelihood of aortic CMV manifestation, we suggest that CMV plays a crucial role in mediating the progression of atherosclerosis.

背景与目标： 目的：为进一步阐明巨细胞病毒（CMV）促进动脉粥样硬化的机制，我们研究了在冠状动脉搭桥术（CABG）的CMV（）和CMV（-）患者主动脉壁中细胞炎性信号和增殖信号的表达模式。
方法：采用PCR和原位杂交技术对68例CABG患者的主动脉活检和血样进行CMV-DNA检测。通过免疫组织化学研究了pp65抗原，粘附分子（ICAM-1，VCAM-1，E-选择素），生长因子（PDGF-AA，TGF-beta）和细胞增殖因子Ki-67的表达。 Logistic回归用于检验CMV的存在，血管炎症与动脉粥样硬化的传统非炎症危险因素之间的相关性。
结果：CMV-DNA在52名患者（76％）的主动脉组织中被检测到，并且主要定位在血管平滑肌细胞中。与CMV（-）患者相比，在CMV（）患者中，主动脉内皮中粘附分子和生长因子的表达增加。发现CRP升高，粘附分子和生长因子的诱导与CMV（）呈正相关。女性，吸烟和高脂血症被确定为CMV（）的危险因素。
结论：平滑肌细胞中的CMV-DNA诱导了局部生长因子的表达以及内皮的激活，两者均可以促进动脉粥样硬化的发展。由于传统的动脉粥样硬化危险因素会增加主动脉CMV表现的可能性，因此我们建议CMV在介导动脉粥样硬化的进展中起关键作用。

BACKGROUND & AIMS: :With more than 800,000 coronary artery bypass grafting (CABG) operations annually worldwide and the saphenous vein being the most common conduit used, there is no question that improving saphenous vein graft patency is one of the most important tasks in CABG. This video describes the no-touch harvesting procedure of the saphenous vein on an 80-year old man with hypertension, hyperlipidemia and a previous myocardial infarction with percutaneous coronary intervention to the right coronary artery. He was complaining of exertional chest pain and was diagnosed with stable angina pectoris. The coronary angiography showed advanced three vessel disease with significant stenoses in the left anterior descending (LAD) artery, two marginal arteries (MAs) and the posterior descending artery (PDA), in addition to an occluded diagonal artery (DA). The patient received a triple sequential no-touch vein graft to the PDA and two MAs together with a double sequential no-touch vein graft to the DA and LAD. A vein graft was used to bypass the LAD due to the age of the patient and the low degree of stenosis in the LAD. The no-touch harvesting technique is described in detail in the film with complete narration. A follow-up of this patient was performed at three months both clinically and with a computed tomography angiography (CTA). No angina pectoris symptoms were reported by the patient and the wounds in the chest and lower limb were completely healed. The CTA showed patent no-touch saphenous vein grafts to all the distal anastomoses.

背景与目标： ：全球每年有超过800,000例冠状动脉旁路移植术（CABG）进行操作，并且隐静脉是最常用的导管，毫无疑问，提高隐静脉移植的通畅性是CABG中最重要的任务之一。该视频介绍了一位80岁高血压，高血脂和先前有心肌梗塞的大隐静脉的非接触式采集过程，该患者经右冠状动脉经皮冠状动脉介入治疗。他抱怨劳累性胸痛，被诊断出稳定的心绞痛。冠状动脉造影显示，除了闭塞的对角动脉（DA）外，左前降支（LAD）动脉，两个边缘动脉（MAs）和后降支动脉（PDA）均伴有明显狭窄的晚期三血管疾病。该患者接受了PDA和两个MA的三连贯非接触式静脉移植，同时还接受了DA和LAD的双连贯非接触式静脉移植。由于患者年龄大和LAD狭窄程度低，因此使用静脉移植物绕过LAD。电影中以完整的叙述详细描述了非接触式收割技术。在临床和计算机断层扫描血管造影（CTA）的三个月中对该患者进行了随访。患者未报告心绞痛症状，胸部和下肢的伤口已完全治愈。 CTA显示所有远端吻合口均采用无接触隐性大隐静脉移植。

BACKGROUND & AIMS: OBJECTIVE:To assess postoperative clinical data considering the association of preoperative fasting with carbohydrate (CHO) loading and intraoperative infusion of omega-3 polyunsaturated fatty acids (ω-3 PUFA). METHODS:57 patients undergoing coronary artery bypass grafting (CABG) were randomly assigned to receive 12.5% maltodextrin (200 mL, 2 h before anesthesia), (CHO, n=14); water (200 mL, 2 h before anesthesia), (control, n=14); 12.5% maltodextrin (200 mL, 2 h before anesthesia) plus intraoperative infusion of ω-3 PUFA (0.2 g/kg), (CHO+W3, n=15); or water (200 mL, 2 h before anesthesia) plus intraoperative infusion of ω-3 PUFA (0.2 g/kg), (W3, n=14). The need for vasoactive drugs was analyzed, in addition to postoperative inflammation and metabolic control. RESULTS:There were two deaths (3.5%). Patients in CHO groups presented a lower incidence of hospital infection (RR=0.29, 95% CI 0.09-0.94; P=0.023), needed fewer vasoactive drugs during surgery and ICU stay (P<0.05); and had better blood glucose levels in the first six hours of recovery (P=0.015), requiring less exogenous insulin (P=0.018). Incidence of postoperative atrial fibrillation (POAF) varied significantly among groups (P=0.009). Subjects who receive ω-3 PUFA groups had fewer occurrences of POAF (RR=4.83, 95% CI 1.56-15.02; P=0.001). Patients in the W3 group had lower ultrasensitive-CRP levels at 36 h postoperatively (P=0.008). Interleukin-10 levels varied among groups (P=0.013), with the highest levels observed in the postoperative of patients who received intraoperative infusion of ω-3 PUFA (P=0.049). CONCLUSION:Fasting abbreviation with carbohydrate loading and intraoperative infusion of ω-3 PUFA is safe and supports faster postoperative recovery in patients undergoing on-pump CABG.

背景与目标： 目的：评估术前禁食与碳水化合物（CHO）负荷和术中输注omega-3多不饱和脂肪酸（ω-3PUFA）的关联，以评估术后临床数据。
方法：57例接受冠状动脉搭桥术（CABG）的患者被随机分配接受12.5％的麦芽糊精（麻醉前2 h，200 mL），（CHO，n = 14）；水（200 mL，麻醉前2 h）（对照，n = 14）； 12.5％麦芽糊精（200 mL，麻醉前2小时）加上术中ω-3PUFA输注（0.2 g / kg），（CHO W3，n = 15）;或用水（麻醉前2 h，200 mL）加术中输注ω-3PUFA（0.2 g / kg），（W3，n = 14）。除了术后炎症和代谢控制外，还分析了对血管活性药物的需求。
结果：有两人死亡（3.5％）。 CHO组患者的医院感染发生率较低（RR = 0.29，95％CI 0.09-0.94； P = 0.023），在手术和ICU停留期间需要较少的血管活性药物（P <0.05）；并且在恢复的前六个小时血糖水平更高（P = 0.015），所需的外源胰岛素较少（P = 0.018）。各组术后房颤的发生率差异显着（P = 0.009）。接受ω-3PUFA组的受试者发生POAF的次数较少（RR = 4.83，95％CI 1.56-15.02； P = 0.001）。 W3组患者术后36 h的超敏CRP水平较低（P = 0.008）。白细胞介素10水平在各组之间不同（P = 0.013），在术中输注ω-3PUFA的患者术后观察到最高水平（P = 0.049）。
结论：快速补充碳水化合物负荷量和术中输注ω-3PUFA是安全的，并支持接受泵上CABG的患者术后恢复更快。

BACKGROUND & AIMS: BACKGROUND:Gastrointestinal perforation after coronary artery bypass graft (CABG) surgery is often difficult to diagnose and is associated with high morbidity and mortality rates. The aim of this study was to determine risk factors for this complication in the studied population to further improve prophylaxis and diagnosis in the region of study. METHODS:Of 8,975 consecutive patients undergoing CABG during 10 years (1995-2005), 15 (0.16%) developed gastrointestinal perforation requiring laparatomy. Data from patients who experienced gastrointestinal perforation were analyzed using univariate tests in a controlled retrospective design. RESULTS:Prolonged bypass time and preoperative heparin administration were found to be significant (P<0.05) risk factors. CONCLUSION:Low splanchnic blood flow and vasoconstriction might be underlying factors associated with both predictors. With current findings, however, clear inference about preoperative and postoperative predictors and their relation is not possible. With more information, the next step would be to build a prediction model in recognition of gastrointestinal perforation after CABG on the basis of the predisposing factors.

背景与目标： 背景：冠状动脉搭桥术（CABG）术后的胃肠道穿孔通常难以诊断，并与高发病率和高死亡率相关。这项研究的目的是确定所研究人群中这种并发症的危险因素，以进一步改善研究区域的预防和诊断。
方法：在10年间（1995-2005年）的8,975例连续接受CABG的患者中，有15例（0.16％）发生了需要开腹手术的胃肠道穿孔。在受控的回顾性设计中，使用单变量检验对经历了胃肠道穿孔的患者的数据进行了分析。
结果：延长旁路时间和术前给予肝素是重要的危险因素（P <0.05）。
结论：低内脏血流量和血管收缩可能是与这两个预测因素相关的潜在因素。然而，根据目前的发现，不可能明确推断出术前和术后的预测因素及其关系。有了更多的信息，下一步将是基于诱发因素建立CABG后识别胃肠道穿孔的预测模型。

BACKGROUND & AIMS: OBJECTIVE:It has earlier been suggested that postoperative thrombocytosis frequently occur after coronary artery bypass grafting (CABG) and may be linked to lipid disturbances. A prospective randomized study was undertaken to evaluate if preoperative lipid-control, using HMG-CoA-reductase inhibitor (Zocor), simvastatin, reduces the risk of postoperative thrombocytosis. METHODS:Seventy-seven patients with symptomatic coronary artery disease and hypercholesterolemia (total cholesterol > or =6.2 mmol/l), planned for CABG where randomly assigned to; undergo CABG without preoperation lipid control (group I, n = 37) or undergo simvastatin-treatment (20 mg daily) to control their lipids (4 weeks) prior to CABG (group II, n = 40). RESULTS:Patient characteristics and operation data did not differ between the groups. Serum-cholesterol, cholesterol/HDL-cholesterol, LDL-cholesterol, Apolipoprotein A1 and Plasminogen were all significantly higher in group I patients compared with group II just prior to surgery. Other laboratory parameters did not differ. RESULTS:In group II, total cholesterol and cholesterol/HDL-cholesterol quota were significantly lowered by simvaststin (-2 and -29%, respectively). Postoperative thrombocytosis (platelet counts > or =400000/microl) occurred significantly more frequently in group I 81% (30/37) compared with 3% (1/40) in group II, P<0.0001. Myocardial infarction after the 7th postoperative day was more often diagnosed in group I, 14 vs. 0% in group II. Postoperative transient renal failure occurred also more frequently in group I, 24% compared with 8% in group II. Other postoperative complications and laboratory data did not differ. CONCLUSIONS:This study once again underlines the importance of lipid control using HMG-CoA-reductase inhibitors (e.g. Zocor) in patients with established coronary artery disease. For the first time it is shown that lipid-control with simvastatin prior to CABG reduces the risk of postoperative thrombocytosis, thus lowers the risk for thrombotic complications.

背景与目标： 目的：早期曾有人提出冠状动脉搭桥术（CABG）后常发生术后血小板增多症，并可能与脂质紊乱有关。进行了一项前瞻性随机研究，以评估术前使用HMG-CoA-还原酶抑制剂（Zocor）辛伐他汀进行脂质控制是否能降低术后血小板增多症的风险。
方法：77例有症状的冠状动脉疾病和高胆固醇血症（总胆固醇>或= 6.2 mmol / l）的患者计划随机分配至CABG；在未进行术前血脂控制的情况下进行CABG治疗（I组，n = 37）或在进行CABG治疗前（4周）进行辛伐他汀治疗（每天20 mg）以控制血脂（II组，n = 40）。
结果：两组之间的患者特征和手术数据没有差异。 I组患者的血清胆固醇，胆固醇/ HDL胆固醇，LDL胆固醇，载脂蛋白A1和纤溶酶原均显着高于手术前的II组。其他实验室参数没有差异。
结果：在第二组中，辛伐他汀显着降低了总胆固醇和胆固醇/高密度脂蛋白胆固醇（分别为-2％和-29％）。 I组术后血小板增多症（血小板计数>或= 400000 /μl）的发生率明显高于II组3％（1/40）的81％（30/37），P <0.0001。术后第7天心肌梗死在I组中被更频繁地诊断出，14组比II组中的0％更容易被诊断出。 I组术后短暂性肾功能衰竭的发生率也更高，为24％，而II组为8％。其他术后并发症和实验室数据无差异。
结论：这项研究再次强调了使用HMG-CoA-还原酶抑制剂（例如Zocor）控制血脂对已确诊的冠心病患者的重要性。首次显示在CABG之前用辛伐他汀进行脂质控制可降低术后血小板增多症的风险，从而降低血栓并发症的风险。

BACKGROUND & AIMS: BACKGROUND:The incidence of patients with previous history of coronary artery bypass grafting (CABG) presenting for aortic valvular replacement has been consistently on the rise. Repeat sternotomy for surgical aortic valve replacement (SAVR) carries an inherent risk of morbidity and mortality when compared to Transcatheter aortic valve replacement (TAVR). METHODS:The Nationwide inpatient sample (NIS) from 2012 to 2014 was queried using the International Classification of Diseases-Ninth edition, Clinical Modification (ICD-9-CM) codes to identify all patients ≥ 18 years with prior CABG who underwent TAVR (35.05 and 35.06) or SAVR (35.21 and 35.22). Propensity score matching (1:1) was performed and in-hospital outcomes were compared between matched cohorts. RESULTS:From 2012 to 2014, there was progressive increase in the annual number of TAVR procedures from 1485 to 4020, with a decrease in patients undergoing SAVR from 2330 to 1955 (Ptrend  < 0.0001) in the above population. There was no significant difference in in-hospital mortality rates. Compared to SAVR, TAVR was associated with lower risk of stroke (1.2% vs. 3.3%, P = 0.009), AKI (12.9% vs. 21.3%, P < 0.0001), myocardial infarction (0.9% vs. 2.7%, P = 0.01) and major bleeding (9.1% vs. 25.1%, P < 0.0001). TAVR was associated with higher risk of pacemaker implants (9.6% vs. 4.9%, P = 0.001) and trend toward lower risk of vascular complications (2.3% vs. 4.1%, P = 0.05). CONCLUSION:In this large cohort of patients with previous CABG, there is no significant difference in in-hospital mortality between TAVR and SAVR. TAVR was associated with lower risk of in-hospital outcomes.

背景与目标： 背景：具有主动脉瓣置换术的冠状动脉旁路移植术（CABG）既往史的患者的发病率一直在上升。与经导管主动脉瓣置换术（TAVR）相比，重复进行胸骨切开术进行外科主动脉瓣置换术（SAVR）具有固有的发病和死亡风险。
方法：使用国际疾病分类-第九版临床修改（ICD-9-CM）代码查询2012年至2014年的全国住院患者样本（NIS），以识别所有接受过TAVR且先前CABG≥18岁的患者（35.05和35.06）或SAVR（35.21和35.22）。进行倾向得分匹配（1：1），并比较匹配队列之间的院内结局。
结果：从2012年到2014年，TAVR每年的手术数量从1485例增加到4020例，而上述人群中接受SAVR的患者从2330例下降到1955年（趋势tr <0.0001）。住院死亡率无显着差异。与SAVR相比，TAVR与中风的风险较低（1.2％比3.3％，P = 0.009），AKI（12.9％比21.3％，P <0.0001），心肌梗塞（0.9％比2.7％，P = 0.01）和大出血（9.1％对25.1％，P <0.0001）。 TAVR与起搏器植入物的较高风险（9.6％vs. 4.9％，P = 0.001）和血管并发症风险降低的趋势（2.3％vs. 4.1％，P = 0.05）相关。
结论：在这一大群既往患有CABG的患者中，TAVR和SAVR之间的院内死亡率无显着差异。 TAVR与院内预后降低相关。

BACKGROUND & AIMS: OBJECTIVE:The aim of this study was to investigate the impact of perioperative administration of N-acetylcysteine, selenium and vitamin C on the incidence and outcomes of acute kidney injury after off-pump coronary bypass graft surgery. METHODS:291 patients requiring elective off-pump coronary bypass graft surgery were randomized to receive either N-acetylcysteine, vitamin C and selenium 600 mg, 1500 mg, 0.5 mg, and nothing orally twice a day, respectively, from the day before to 2 days after surgery. They were assessed for the development of acute kidney injury using Acute Kidney Injury Network criteria, time of onset, its severity and duration, duration of mechanical ventilation, intensive care unit and hospital length of stay, and in-hospital mortality. RESULTS:272 patients completed the study. The total incidence of acute kidney injury was 22.1% (n=60) with 14 (20.9%), 15 (22.1%), 21 (31.8%), and 10 (14.1%) patients in the vitamin C, NAC, selenium, and control groups, respectively (P=0.096). We did not register significant differences in the incidence, the time of occurrence, the severity and the duration of acute kidney injury, as well as the duration of mechanical ventilation, the intensive care unit and hospital length of stay, and the in-hospital mortality among the four groups. CONCLUSION:We found that perioperative administration of N-acetylcysteine, vitamin C and selenium were not effective in preventing acute kidney injury and associated morbidity and mortality after off-pump coronary bypass graft surgery.

背景与目标： 目的：本研究旨在探讨围手术期使用N-乙酰半胱氨酸，硒和维生素C对非体外循环冠状动脉搭桥手术后急性肾损伤的发生率和结局的影响。
方法：291名需要进行选择性非体外循环冠状动脉搭桥手术的患者从前一天到第二天随机两次分别接受N-乙酰半胱氨酸，维生素C和硒600 mg，1500 mg，0.5 mg口服，每天两次不口服。手术后的几天。使用急性肾损伤网络标准，发病时间，严重程度和持续时间，机械通气时间，重症监护病房和住院时间以及住院死亡率对他们进行了急性肾脏损伤的评估。
结果：272例患者完成了研究。维生素C，NAC，硒，和对照组（P = 0.096）。在发病率，发生时间，急性肾损伤的严重程度和持续时间，机械通气时间，重症监护病房和住院时间以及住院死亡率方面，我们没有发现显着差异。在四个组中。
结论：我们发现围手术期服用N-乙酰半胱氨酸，维生素C和硒不能有效地预防非体外循环冠状动脉搭桥手术后的急性肾脏损伤以及相关的发病率和死亡率。

BACKGROUND & AIMS: :Little is known about the quality of care that veterans obtain in the private sector. To explore this issue, we identified the hospital in which 4,008 veterans enrolled in the Veterans Administration (VA) obtained coronary artery bypass graft (CABG) surgery in the New York private sector between 1997 and 2000. We used published risk-adjusted mortality rates to assign New York CABG centers to performance quintiles. VA patients with the lowest incomes were 2.4 times more likely than those in the highest incomes to use the highest-mortality hospitals (95 percent CI: 2.0-3.0). Compared with white patients, black (OR 1.8; 95 percent CI: 1.2-2.8) and Hispanic VA patients (OR 1.6; 95 percent CI: 0.9-2.8) were more likely to use the highest-mortality hospitals. About one third of patients using the highest-mortality hospitals lived closer to low-mortality hospitals. Efforts to direct VA patients' care to high-performance hospitals could improve outcomes and reduce racial and ethnic disparities in care.

背景与目标： ：关于退伍军人在私营部门获得的护理质量知之甚少。为了探讨这个问题，我们确定了1997年至2000年之间，退伍军人管理局（VA）招募的4,008名退伍军人在纽约的私营部门进行了冠状动脉搭桥术（CABG）手术的医院。将纽约CABG中心分配给绩效五分位数。收入最低的VA患者使用死亡率最高的医院的可能性是收入最高的VA患者的2.4倍（95％CI：2.0-3.0）。与白人患者相比，黑人（OR 1.8； 95％CI：1.2-2.8）和西班牙裔VA患者（OR 1.6； 95％CI：0.9-2.8）更倾向于使用死亡率最高的医院。使用死亡率最高的医院的患者中，约有三分之一居住在死亡率较低的医院附近。将VA患者的护理直接转移到高性能医院的努力可以改善治疗效果，并减少种族和种族之间的护理差距。

BACKGROUND & AIMS: BACKGROUND:Hierarchical modelling represents a statistical method used to analyze nested data, as those concerning patients afferent to different hospitals. Aim of this paper is to build a hierarchical regression model using data from the "Italian CABG outcome study" in order to evaluate the amount of differences in adjusted mortality rates attributable to differences between centres. METHODS:The study population consists of all adult patients undergoing an isolated CABG between 2002-2004 in the 64 participating cardiac surgery centres.A risk adjustment model was developed using a classical single-level regression. In the multilevel approach, the variable "clinical-centre" was employed as a group-level identifier. The intraclass correlation coefficient was used to estimate the proportion of variability in mortality between groups. Group-level residuals were adopted to evaluate the effect of clinical centre on mortality and to compare hospitals performance. Spearman correlation coefficient of ranks (rho) was used to compare results from classical and hierarchical model. RESULTS:The study population was made of 34,310 subjects (mortality rate = 2.61%; range 0.33-7.63). The multilevel model estimated that 10.1% of total variability in mortality was explained by differences between centres. The analysis of group-level residuals highlighted 3 centres (VS 8 in the classical methodology) with estimated mortality rates lower than the mean and 11 centres (VS 7) with rates significantly higher. Results from the two methodologies were comparable (rho = 0.99). CONCLUSION:Despite known individual risk-factors were accounted for in the single-level model, the high variability explained by the variable "clinical-centre" states its importance in predicting 30-day mortality after CABG.

背景与目标： 背景：分层建模代表了一种统计方法，用于分析嵌套数据，例如那些涉及到不同医院的患者的数据。本文的目的是使用“意大利CABG结果研究”中的数据构建层次回归模型，以评估归因于中心之间差异的调整后死亡率的差异量。
方法：研究人群包括2002年至2004年间在64个参与的心脏外科手术中心接受隔离CABG的所有成年患者，并使用经典的单水平回归建立了风险调整模型。在多级方法中，变量“临床中心”被用作组级标识符。组内相关系数用于估计各组之间死亡率差异的比例。采用组水平残差来评估临床中心对死亡率的影响并比较医院的绩效。使用Spearman等级相关系数（rho）来比较经典模型和分层模型的结果。
结果：研究人群为34,310名受试者（死亡率为2.61％；范围为0.33-7.63）。多级模型估计，死亡率的总变异性的10.1％由中心之间的差异解释。对组水平残差的分析突出显示了3个中心（经典方法中为VS 8），其估计死亡率低于平均水平；而11个中心（VS 7），其死亡率显着高于平均水平。两种方法的结果可比（rho = 0.99）。
结论：尽管在单级模型中考虑了已知的个体危险因素，但变量“临床中心”解释的高变异性说明了其在预测CABG后30天死亡率中的重要性。

BACKGROUND & AIMS: BACKGROUND:Many patients demonstrate psychological distress and reduced physical activity before coronary artery bypass graft surgery (CABG). Here we evaluated the addition of a brief, cognitive-behavioural intervention (the HeartOp Programme) to routine nurse counselling for people waiting for CABG surgery. METHODS:Randomised controlled trial comparing nurse counselling with the HeartOp programme to routine nurse counselling in 204 patients awaiting first time elective CABG. Primary outcome measures were: anxiety and length of hospital stay; secondary outcome measures were: depression, physical functioning, cardiac misconceptions and cost utility. Measures were collected prior to randomisation and after 8 weeks of their intervention prior to surgery, excepting length of hospital stay which was collected after discharge following surgery. RESULTS:100 patients were randomised to intervention, 104 to control. At follow-up there were no differences in anxiety or length of hospital stay. There were significant differences in depression (difference=7.79, p=0.008, 95% CI=2.04-13.54), physical functioning (difference=0.82, p=0.001, 95%CI=0.34-1.3) and cardiac misconceptions (difference=2.56, p<0.001, 95%CI=1.64-3.48) in favour of the HeartOp Programme. The only difference to be maintained following surgery was in cardiac misconceptions. The HeartOp Programme was found to have an Incremental Cost Effectiveness Ratio (ICER) of pound 288.83 per Quality-Adjusted Life Year. CONCLUSIONS:Nurse counselling with the HeartOp Programme reduces depression and cardiac misconceptions and improves physical functioning before bypass surgery significantly more than nurse counselling alone and meets the accepted criteria for cost efficacy.

背景与目标： 背景：许多患者在进行冠状动脉搭桥手术（CABG）之前表现出心理困扰和身体活动减少。在这里，我们评估了常规护士咨询中为等待CABG手术的人提供的简短的认知行为干预（HeartOp计划）。
方法：随机对照试验比较了204名初次选择CABG的患者中采用HeartOp计划进行的护士咨询与常规护士咨询的比较。主要结局指标为：焦虑和住院时间长短；次要结果指标是：抑郁，身体机能，心脏误解和费用效用。措施在随机分组之前和手术干预的8周后进行收集，但住院时间的长短是在手术后出院后收集的。
结果：100例患者被随机分为干预组，104例为对照组。随访时，焦虑或住院时间无差异。抑郁症（差异= 7.79，p = 0.008，95％CI = 2.04-13.54），身体功能（差异= 0.82，p = 0.001，95％CI = 0.34-1.3）和心脏误解（差异= 2.56）存在显着差异。 ，p <0.001，95％CI = 1.64-3.48）以支持HeartOp计划。手术后唯一要维持的区别是心脏误解。发现HeartOp计划每质量调整生命年的成本效益比（ICER）为288.83英镑。
结论：HeartOp计划的护士咨询比单独的护士咨询更能减少抑郁症和心脏误解，并改善旁路手术前的身体机能，并符合成本效益的公认标准。

BACKGROUND & AIMS: OBJECTIVE:Closed circuit extracorporeal circulation (CCECC) has been developed to reduce deleterious effects of standard cardiopulmonary bypass (CPB). This study compares the effects of CCECC (CORx system), CPB, and off-pump coronary artery bypass grafting (OPCAB) on red blood cell damage, coagulation activation, fibrinolysis and cytokine expression. METHODS:Thirty patients underwent coronary artery bypass grafting (CABG). Twenty of them were randomized into two groups: CCECC (n = 10), CPB (n = 10). While not randomized, OPCAB (n = 10) served as a separate reference group. CCECC and CPB patients received cardioplegic arrest. Interleukin 6 (IL-6), free hemoglobin (fHb), von Willebrand factor activity (vWf), thrombin-antithrombin-III-complex (TATc), prothrombin fragment 1.2 (F 1+2) and plasmin-antiplasmin complex (PAPc) were assessed preoperatively, perioperatively and 24 h postoperatively. RESULTS:CCECC showed significantly lower red blood cell damage than CPB (fHb: CCECC, 7.1+/- 5.7 micromol/l; CPB, 16.8+/-11.4 micromol/l; P = 0.025; OPCAB, 3.4+/-1.1 micromol/l). Perioperatively, CCECC exhibited significantly lower activation of coagulation and fibrinolysis than CPB, but did not differ from OPCAB (vWf: CCECC, 133+/-52%; CPB, 241+/-128%; P = 0.052; OPCAB, 153+/-58%; TATc: CCECC, 4.7+/-0.9 ng/ml; CPB, 31.1+/-15.8 ng/ml; P < 0.001; OPCAB, 2.4+/-0.6 ng/ml; PAPc: CCECC, 214+/-30 ng/ml; CPB, 897+/-367 ng/ml; P < 0.001; OPCAB, 253+/-98 ng/ml). In contrast, fibrinolysis markers and IL-6 were markedly increased in CCECC postoperatively (PAPc: CCECC, 458+/-98 ng/ml; CPB, 159+/-128 ng/ml; P < 0.001; OPCAB, 262+/-174 ng/ml; IL-6: CCECC, 123.4+/-49.8 pg/dl; CPB, 18.8+/-13.1 pg/dl; P < 0.001; OPCAB, 31.6+/-26.2 pg/dl). CONCLUSIONS:CCECC for CABG is associated with a significant reduction of red blood cell damage and activation of coagulation cascades similar to OPCAB when compared with conventional CPB while a delayed fibrinolytic and inflammatory activity was observed. These findings require further investigation to verify the promising concept of CCECC.

背景与目标： 目的：已经开发出闭路体外循环系统（CCECC），以减少标准体外循环（CPB）的有害作用。这项研究比较了CCECC（CORx系统），CPB和非体外循环冠状动脉搭桥术（OPCAB）对红细胞损伤，凝血激活，纤维蛋白溶解和细胞因子表达的影响。
方法：30例患者接受了冠状动脉搭桥术（CABG）。其中的20个被随机分为两组：CCECC（n = 10），CPB（n = 10）。虽然未随机分组，但OPCAB（n = 10）作为一个单独的参考组。 CCECC和CPB患者接受了心脏停搏。白细胞介素6（IL-6），游离血红蛋白（fHb），血管性血友病因子活性（vWf），凝血酶-抗凝血酶III复合物（TATc），凝血酶原片段1.2（F 1 2）和纤溶酶-抗纤溶酶复合物（PAPc）分别为在术前，围手术期和术后24小时进行评估。
结果：CCECC显示的红细胞损伤明显低于CPB（fHb：CCECC，7.1 /-5.7 micromol / l; CPB，16.8 /-11.4 micromol / l; P = 0.025; OPCAB，3.4 /-1.1 micromol / l）。围手术期，CCECC的凝血和纤溶活性明显低于CPB，但与OPCAB并无差异（vWf：CCECC，133 / -52％; CPB，241 / -128％; P = 0.052; OPCAB，153 / -58％ ; TATc：CCECC，4.7 /-0.9 ng / ml; CPB，31.1 /-15.8 ng / ml; P <0.001; OPCAB，2.4 /-0.6 ng / ml; PAPc：CCECC，214 / -30 ng / ml; CPB ，897 / -367ng / ml； P ＜0.001； OPCAB，253 / -98ng / ml）。相比之下，术后CCECC中的纤溶蛋白标记物和IL-6显着增加（PAPc：CCECC，458 / -98 ng / ml; CPB，159 / -128 ng / ml; P <0.001; OPCAB，262 / -174 ng / ml毫升； IL-6：CCECC，123.4 /-49.8 pg / dl； CPB，18.8 /-13.1 pg / dl； P <0.001； OPCAB，31.6 /-26.2 pg / dl）。
结论：与常规CPB相比，CAECC的CCECC与红细胞损伤的显着减少和类似于OPCAB的凝血级联的激活有关，同时观察到纤溶和炎症活性的延迟。这些发现需要进一步调查以验证CCECC的前景广阔。

BACKGROUND & AIMS: :The efficacy of physiotherapy techniques used for patients following uncomplicated coronary artery bypass surgery (CABG) is well documented. Previous research showed that some of this evidence was not rapidly adopted into practice by cardiothoracic physiotherapists; however, there has been no recent evaluation of the uptake of evidence. Our aim was to identify current physiotherapy interventions in use for patients following uncomplicated CABG surgery. A survey was sent to senior cardiothoracic physiotherapists from all Australian and New Zealand hospitals that perform CABG surgery. Fifty-four surveys were returned (response rate 88%). The most common treatments used were mobilisation (94% of hospitals), range of motion exercises (79%), deep breathing and/or cough (77%), cardiovascular exercise (42%), and incentive spirometry (40%). Respondents with a bachelor or diploma in physiotherapy were more likely to implement deep breathing exercises or coughing than those who obtained a postgraduate degree (p = 0.045). Respondents perceived personal experience as the most influential factor on postoperative treatment choices. Physiotherapists treating patients following uncomplicated CABG surgery continue to use interventions such as deep breathing exercises that are not supported by best available evidence. Standardised guidelines may be required to better match clinical practice with current literature.

背景与目标： ：对于无并发症冠状动脉搭桥手术（CABG）后的患者，理疗技术的功效已得到充分证明。先前的研究表明，某些证据并未被心胸物理治疗师迅速采用。但是，最近没有证据的评估。我们的目标是确定简单CABG手术后患者当前正在使用的理疗干预措施。来自澳大利亚和新西兰所有进行CABG手术的医院的高级心胸物理治疗师进行了调查。返回了五十四份调查问卷（答复率为88％）。最常用的治疗方法是动员（94％的医院），运动范围（79％），深呼吸和/或咳嗽（77％），心血管运动（42％）和肺活量测定（40％）。拥有物理治疗学士学位或文凭的受访者比获得研究生学位的受访者更有可能进行深呼吸练习或咳嗽（p = 0.045）。受访者认为个人经历是影响术后治疗选择的最重要因素。在简单的CABG手术后治疗患者的物理治疗师继续使用诸如深呼吸练习之类的干预措施，但没有最好的现有证据支持。可能需要标准化的指南才能更好地将临床实践与当前文献相匹配。

BACKGROUND & AIMS: OBJECTIVES:To identify factors that influence graft disease and native coronary arteries progression disease and prognostic implication of this process. BACKGROUND:Unsolved problem in CABG patients is progression of the disease in bypass grafts and native coronary arteries. METHODS:Data from 102 patients with CABG, who underwent re-coronarography, were analyzed: - Pre and post-operative variables: risk factors, clinical status, functional capacity, left ventricular parameters and angiographic status (before and after CABG). Proportional hazard regression model, was used, p<0.05 was considered statistically significant. RESULTS:Cardiac death, myocardial infarction and heart failure were more frequent in patients with graft occlusion, non-stable angina pectoris in non-occlusive graft disease, which together with acute myocardial infarction was more often in patients with native coronary arteries progression disease. PCI was significantly more often performed on native coronary arteries. CONCLUSION:Graft disease and native coronary artery progression disease is a continuous process which can be slowed by aggressive risk factors reduction, medications, and PCI procedures. In contrary, it leads to unfavorable clinical outcome (Tab. 8, Fig. 6, Ref 19).

背景与目标： 目的：确定影响移植物疾病和天然冠状动脉进展性疾病的因素以及该过程的预后意义。
背景：CABG患者尚未解决的问题是旁路移植和天然冠状动脉疾病的进展。
方法：对102名接受冠状动脉造影的CABG患者的数据进行了分析：-术前和术后变量：危险因素，临床状况，功能能力，左心室参数和血管造影状况（CABG前后）。使用比例风险回归模型，p <0.05被认为具有统计学意义。
结果：在非闭塞性移植疾病中，移植物闭塞，不稳定型心绞痛患者的心源性死亡，心肌梗塞和心力衰竭的发生频率更高，而伴有天然冠状动脉进展性疾病的患者中，急性心肌梗死的发生率更高。在原生冠状动脉上进行PCI的频率明显更高。
结论：移植物疾病和天然冠状动脉疾病是一个连续的过程，可以通过降低积极的危险因素，药物和PCI程序来减缓。相反，它导致不良的临床结果（表8，图6，参考文献19）。

BACKGROUND & AIMS: BACKGROUND:Blood conservation remains an important element for patients undergoing cardiac operations with cardiopulmonary bypass. Preoperative platelet-rich plasma (PRP) harvest is an autologous blood conservation method. The efficacy of preoperative PRP harvest and post-cardiopulmonary bypass reinfusion on postoperative bleeding and need for postoperative blood transfusion was evaluated in patients undergoing redo coronary artery bypass grafting in a prospective, randomized manner. METHODS:All adult patients admitted for redo coronary artery bypass grafting entered into the study. The PRP harvest aim was 20% or more of the total estimated circulating platelets. Immediately preoperatively three sequestration cycles were performed. The PRP was reinfused after weaning from cardiopulmonary bypass. One hundred seven parameters/patient were recorded. There were 20 patients in the RPR group and 20 controls (without PRP harvest). RESULTS:Patient characteristics, operative data, and preoperative hematologic parameters did not differ between the groups. In the PRP group, the mean platelet count in the PRP was 864 +/- 139 x 10(3)/microL, and the platelet yield was 27% +/- 5% (range, 20% to 37%). The average total chest tube blood loss was 423 mL (PRP) compared with 1,462 mL (controls; p < 0.001). Fourteen patients in the control group required blood transfusions postoperatively compared with only 1 patient in the PRP group (p < 0.001). Postoperative fluid requirements were also significantly greater in the control group (p < 0.001). Postextubation gas exchange was significantly better in the PRP group compared with controls (p < 0.01). Postoperative ventilation time and intensive care stay were significantly shorter in patients in the PRP group. CONCLUSIONS:A preoperative PRP harvest of 20% or more of the total platelets and reinfusion of the PRP after cardiopulmonary bypass resulted in significantly less postoperative blood loss and decreased fluid and blood transfusion requirements compared with controls. Postextubation gas exchange, ventilation time, and time required in the intensive care unit were also better, and the method was found cost-effective.

背景与目标： 背景：血液保持仍然是接受心脏体外循环心脏手术患者的重要因素。术前富血小板血浆（PRP）收获是一种自体血液保存方法。以前瞻性，随机方式评估了接受重做冠状动脉搭桥术的患者的术前PRP收集和体外循环后再输注对术后出血和术后输血的需要的疗效。
方法：所有接受重做冠状动脉旁路移植术的成年患者均进入研究。 PRP的收获目标是估计的总循环血小板的20％或更多。术前立即进行了三个隔离周期。断奶后从心肺转流术中重新注入PRP。记录了一百七十七个参数/患者。 RPR组有20例患者，而对照组则有20例（未收获PRP）。
结果：两组患者的特征，手术数据和术前血液学参数无差异。在PRP组中，PRP中的平均血小板计数为864 /-139 x 10（3）/ microL，血小板产率为27％/-5％（范围为20％至37％）。平均总胸管失血量为423 mL（PRP），而同期为1,462 mL（对照； p <0.001）。对照组中有14名患者术后需要输血，而PRP组中只有1名患者（p <0.001）。对照组的术后液体需求量也显着更高（p <0.001）。与对照组相比，PRP组拔管后的气体交换明显更好（p <0.01）。 PRP组患者的术后通气时间和重症监护时间明显缩短。
结论：与对照组相比，术前PRP采集占总血小板的20％或更多，并在体外循环后再输注PRP导致术后失血量明显减少，输液量和输血量减少。拔管后的气体交换，换气时间和重症监护室所需的时间也更好，该方法具有成本效益。