Towards a Saphenous Vein Graft Moratorium.

Atherosclerosis develops and rapidly progresses in saphenous veins grafts after coronary bypass surgery. In contrast to native coronary artery, percutaneous revascularization does not impede the progression of saphenous vein atherosclerosis and saphenous vein graft failure commonly ensues. The protracted patency of arterial grafts is likely to account for most of the long-term superiority of coronary artery bypass surgery over percutaneous revascularization in patients with complex coronary artery disease. Long-lasting, complete coronary revascularization may be best achieved by combining surgical arterial grafting of diseased coronary arteries to percutaneous revascularization with drug-eluting stents than by the continued use of saphenous vein grafts.

A Practical Approach to Hybrid Coronary Revascularization.

Combined surgical and percutaneous coronary revascularization, ie, hybrid coronary revascularization (HCR) consists of surgical left internal mammary artery (LIMA) bypass to the left anterior descending artery (LAD) and percutaneous revascularization of other diseased coronary arteries. Developed as a 1-stage procedure, HCR has not been widely adopted by the cardiovascular community. The recommended minimally invasive approach through a small left thoracotomy incision is technically demanding, and same-day percutaneous revascularization requires a hybrid operating room that is not available in most hospitals. In this review, we consider present HCR protocols, barriers to widespread adoption of HCR, and we give special attention to the surgical approach for the LIMA graft to the LAD and the timing of percutaneous revascularization. We conclude that grafting the LIMA to the LAD through a median sternotomy approach and delaying the percutaneous revascularization may facilitate the widespread use of HCR in patients with multivessel coronary artery disease and a low to intermediate Synergy between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery score.

Precardiogenic Shock: A New Clinical Entity.

The pathogenesis of cardiogenic shock (CS) has evolved from an acute event due to a large myocardial infarction to a semiacute event due to rapid hemodynamic deterioration on a background of preexisting left ventricular systolic dysfunction. Pre-CS refers to the period of rapid hemodynamic deterioration that precedes overt CS with hypotension, inflammatory response, and end-organ failure. Mortality remains extremely high in CS and has not improved over the past decades. Pre-CS offers a unique opportunity to initiate early treatment that may result in better clinical outcomes. The present review addresses the definition, recognition, and management of pre-CS with the pharmacologic or mechanical support of the failing left ventricle.

Obesity and Pulmonary Hypertension.

PURPOSE OF REVIEW: Whether the present obesity epidemic will increase the prevalence of pulmonary hypertension over the next decades is unclear. We review the obesity-related mechanisms that may further the development and progression of pulmonary hypertension. RECENT FINDINGS: Systemic and local inflammation, insulin resistance and oxidative stress contribute to the pathobiology of obesity and pulmonary arterial hypertension. Preliminary data suggest that expansion of adipose tissue surrounding the pulmonary artery may hasten the progression of pulmonary arterial hypertension in obese persons. Further, obesity-associated cardiac and pulmonary conditions may increase the prevalence of groups 2 and 3 pulmonary hypertension. The obesity epidemic is likely to increase the prevalence of pulmonary arterial hypertension by enabling vascular remodeling. Obesity-associated cardiac and pulmonary conditions will increase pulmonary hypertension prevalence.