Human long-lasting PerAF is characterized by heterogeneous and unstable patterns of activation including wavefronts, transient rotational circuits, and disorganized activity.
The international experts recommend various benefits of sutureless and rapid deployment technology, which may represent a helpful tool in aortic valve replacement for patients requiring a biological valve. However, further evidence will be needed to reaffirm the benefit of sutureless and rapid deployment valves.
Long-term patency of a bypass graft is an important determinant in reducing morbidity and increasing survival after coronary bypass surgery. The purpose of this review is to analyse factors contributing to improved outcomes of commonly used conduits. Progress has been limited by the lack of uniform definitions of graft failure and development of appropriate statistical models. Evolving techniques for assessing patency at more frequent intervals has provided insight into the time and sites of early disease. The explosion of scientific knowledge of graft physiology has added to improving harvest, storage and early protection procedures thereby reducing early morbidity. Similarly, the understanding and management of risk factors have contributed to graft durability and possibly survival. Conduits have different characteristics and applications, which are patient dependent. Competitive flow remains a problem especially with arterial conduits; functional studies as opposed to anatomy of the target artery may improve understanding of the contribution of the collateral circulation. Selected patency data provide comparison between grafts. The role of the second internal thoracic artery graft is the subject of the Arterial Revascularisation Trial. Off-pump bypass procedures and patient characteristics affect conduit selection. Stroke is a major complication, which can be minimised by avoiding the aorta especially during off-pump surgery. There are few randomised controlled trials on the late outcomes comparing different bypass grafts and between bypass grafting and current percutaneous intervention methods. Accurate reporting of outcomes of graft patency will improve the scientific content and emphasise the importance of surgery in the management of coronary disease.
Background: An internal thoracic artery graft to the left anterior descending artery is standard in coronary bypass surgery, but controversy exists on the best second conduit. The RAPCO trials (Radial Artery Patency and Clinical Outcomes) were designed to compare the long-term patency of the radial artery (RA) with that of the right internal thoracic artery (RITA) and the saphenous vein (SV). Methods: In RAPCO-RITA (the RITA versus RA arm of the RAPCO trial), 394 patients <70 years of age (or <60 years of age if they had diabetes mellitus) were randomized to receive RA or free RITA graft on the second most important coronary target. In RAPCO-SV (the SV versus RA arm of the RAPCO trial), 225 patients ≥70 years of age (or ≥60 years of age if they had diabetes mellitus) were randomized to receive RA or SV graft. The primary outcome was 10-year graft failure. Long-term mortality was a nonpowered coprimary end point. The main analysis was by intention to treat. Results: In the RA versus RITA comparison, the estimated 10-year patency was 89% for RA versus 80% for free RITA (hazard ratio for graft failure, 0.45 [95% CI, 0.23–0.88]). Ten-year patient survival estimate was 90.9% in the RA arm versus 83.7% in the RITA arm (hazard ratio for mortality, 0.53 [95% CI, 0.30–0.95]). In the RA versus SV comparison, the estimated 10-year patency was 85% for the RA versus 71% for the SV (hazard ratio for graft failure, 0.40 [95% CI, 0.15–1.00]), and 10-year patient survival estimate was 72.6% for the RA group versus 65.2% for the SV group (hazard ratio for mortality, 0.76 [95% CI, 0.47–1.22]). Conclusions: The 10-year patency rate of the RA is significantly higher than that of the free RITA and better than that of the SV. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT00475488.
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