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Poor long-term patency of saphenous vein grafts limits the long-term success of the coronary artery bypass operation. If this is to be improved, either measures that increase the patency of saphenous vein grafts or alternative conduits are required. The benefits of using the left internal mammary artery as a pedicled graft to the left anterior descending coronary artery have prompted increasing use of arterial grafts to further improve outcome. Concurrently advances in the understanding of the pathological processes underlying saphenous vein graft occlusion raise the possibility of improving vein graft patency. In this paper we review the problem of vein graft occlusion and possible solutions, the theoretical benefits of arterial grafts and the clinical results associated with their use.

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When investigating complex congenital heart disease, determination of atrial situs is essential. Pathological studies have demonstrated that the best predictor of atrial situs is thoracic situs. To assess thoracic situs, bronchial tomography was performed in 92 patients with congenital heart disease. Sixty-four of these, without abnormalities of situs or cardiac position, formed 'normal' controls. The lengths of the left and right main bronchi were measured. When these were related to age, and the results analyzed statistically, linear discriminant equations resulted giving a chance of only 0.09% of misclassifying a bronchus of unknown morphology. The lowest ratio between bronchial lengths (BLR) in any individual was 1.71:1. These results were then used to assess thoracic situs in 17 patients with abnormal situs or CARDIAC POSITION. In 7 (2 with situs inversus), abdominal and thoracic situs agreed. Of 6 patients with bilateral left lung, 3 had an interrupted inferior vena cava. Of 4 patients with presumptive asplenia, 2 had bilateral right lung, but two had thoracic lateralization, one solitus and one inversus. The highest BLR in thoracic isomerism was 1.4:1. This emphasizes the complex interrelation of splenic status, thoracic, and abdominal situs, but demonstrates the value of bronchial measurement particularly in apparent situs indeterminatus.

suMMARY A controlled trial was undertaken to examine the efficacy of physical training in patients recovering from the replacement of a single heart valve.Patients A regression line of submaximal heart rate on oxygen consumption was calculated from the data of each exercise test in each patient. Alterations in this line were used as an "index" of changes in "cardiorespiratory fitness".The individual results showed a consistent improvement in "cardiorespiratory fitness" over the first 12 weeks in both groups. Only patients in the test group continued to improve between 12 and 24 weeks. Thus the exercise programme modified the recovery of "cardiorespiratory fitness" after operation.Results in patients who developed clinical complications, and were excluded from the trial, predicted a deteriorating clinical condition.This finding suggested that sequential exercise tests are of value after cardiac surgery.