Hybrid Coronary Revascularization: Perspective Current State After 25 Years of Start.

Hybrid coronary revascularization (HCR) represents a minimally invasive revascularization strategy in which the durability of the internal mammary artery to the left anterior descending artery graft is combined with percutaneous coronary intervention to treat remaining lesions. It first was introduced in the mid-1990s and aspired to bring together the "best of both worlds" - the excellent patency rates and survival benefits associated with the durable left internal mammary artery graft to the left anterior descending artery alongside the good patency rates of drug-eluting stents, which outlive saphenous vein grafts to non-left anterior descending vessels. Although in theory this is a very attractive revascularization strategy, several years later, only small randomized controlled trials comparing HCR with coronary artery bypass grafting has recently emerged in the medical literature, raising concerns regarding HCR's role. In the current review, we discuss HCR's rationale, the current evidence behind it, its limitations, and procedural challenges.

Intraaortic Balloon Pump Counterpulsation, Part I: History, Technical Aspects, Physiologic Effects, Contraindications, Medical Applications/Outcomes.

Intraaortic balloon pump counterpulsation is the most common form of mechanical circulatory support used in patients with myocardial ischemia and cardiogenic shock. The physiologic principles of counterpulsation include diastolic augmentation of aortic pressure and systolic reduction of left ventricular afterload, resulting in hemodynamic benefits through increased coronary perfusion pressure and improved myocardial oxygen balance in patients with myocardial ischemia. Major trials have failed to conclusively demonstrate improvements in morbidity and mortality with counterpulsation therapy for patients with acute myocardial infarction (MI), cardiogenic shock, and/or severe coronary artery disease undergoing revascularization therapy, and the debate over its applications continues. Part I of this review focuses on the history of the development of counterpulsation, technical considerations, and complications associated with its use, its physiologic effects, and evidence for its use in myocardial ischemia and cardiogenic shock.

Distal radial access for coronary angiography and percutaneous coronary intervention: A state-of-the-art review.

Since its introduction by Lucien Campeau three decades ago, percutaneous radial artery approach at the forearm has been shown to provide advantages over the femoral approach and has become the standard approach for coronary angiography and intervention. Though infrequent, vascular complications still remain, mainly radial artery occlusion. Therefore, a more distal radial approach at the snuffbox or at the dorsum of hand has been suggested, initially by anethesiologists for perioperative patient monitoring, and more recently by Babunashvili et al. for retrograde radial artery recanalization of radial artery occlusion and then for coronary angiography and intervention. This distal radial approach has been advocated to reduce the risk of radial artery occlusion at the forearm (which precludes reintervention through the same access site) and bleeding and vascular access site complications, as well as to improve operator and patient comfort, especially when using left radial approach. This review describes in detail the anatomy of the radial artery at the wrist and the hand, the history of distal radial access, the rationale underlying use of this technique, the results published by experienced operators, the technique, the limitations, and potential role of this approach. This journey from the very proximal to the very distal part of the radial artery was indeed initiated and conceptualized by Lucien Campeau himself.

The Success Story of LDL Cholesterol Lowering.

We can look back at >100 years of cholesterol research that has brought medicine to a stage where people at risk of severe or fatal coronary heart disease have a much better prognosis than before. This progress has not come about without resistance. Perhaps one of the most debated topics in medicine, the cholesterol controversy, could only be brought to rest through the development of new clinical research methods that were capable of taking advantage of the amazing achievements in basic and pharmacological science after the second World War. It was only after understanding the biochemistry and physiology of cholesterol synthesis, transport and clearance from the blood that medicine could take advantage of drugs and diets to reduce the risk of atherosclerotic diseases. This review points to the highlights of the history of low-density lipoprotein-cholesterol lowering, with the discovery of the low-density lipoprotein receptor and its physiology and not only the development of statins as the stellar moments but also the development of clinical trial methodology as an effective tool to provide scientifically convincing evidence.

Languages of the heart: the biomedical and the metaphorical in American fiction.

The role of heart disease in American fiction has received less attention from scholars of literature, history, and medicine than have portrayals of tuberculosis, cancer, or HIV/AIDS, despite the fact that heart disease topped mortality charts for most of the 20th century. This article surveys manifestations of coronary artery disease in popular works of 20th-century American fiction to trace how authors and their protagonists grappled with the disease while knowledge of pathophysiology and therapeutics evolved. Countering Susan Sontag's mechanistic vision of patient encounters-where disease is absent of metaphor-we pair popular fiction with concurrent historical analysis to show that the proliferation of technological narratives of cardiac therapeutics could not displace the deeply symbolic nature of characters' encounters with heart disease. Because of the limited ability of the biomedical narrative to convey the meanings of disease and treatments, doctors and patients need to communicate through the rich possibilities of metaphor.

Apollo, sudden death, and Homer's "Odyssey": a warning from the past that we may be unable to eradicate coronary artery disease.

Over recent years there has been a gratifying decrease in the incidence of recorded deaths from coronary artery disease in the Western world. The common view is that coronary artery disease is a recent phenomenon, that we have been subject to an epidemic in the mid-20th century that is now tailing off, and that with appropriate risk modification we may eradicate this disease or make it very rare. However, this article examines the cases of sudden, nontraumatic death described in Homer's Odyssey, which dates from c. 800 BCE. The results suggest that a high incidence of death from coronary artery disease may not be a recent phenomenon. Together with other described evidence, this study casts doubt on the view that coronary artery disease is a modern epidemic that can be eradicated.

Concept of vulnerable/unstable plaque.

Today's concept of vulnerable plaque has evolved primarily from the early pioneering work uncovering the pivotal role of plaque rupture and coronary thrombosis as the major cause of acute myocardial infarction and sudden cardiac death. Since the first historical description of plaque rupture in 1844, several key studies by leading researchers and clinicians have lead to the current accepted views on lesion instability. Important to the complex paradigm of plaque destabilization and thrombosis are many discoveries beginning with the earliest descriptions of advanced plaques, reminiscent of abscesses encapsulated by fibrous tissue capable of rupture. It was not until the late 1980s that studies of remodeling provided keen insight into the growth of advanced plaques, beyond the simple accumulation of lipid. The emphasis in the next decade, however, was on a focused shift toward the mechanisms of lesion vulnerability based on the contribution of tissue proteolysis by matrix metalloproteinases as an essential factor responsible for thinning and rupture of the fibrous cap. In an attempt to unify the understanding of what constitutes a vulnerable plaque, morphological studies, mostly from autopsy, suggest the importance of necrotic core size, inflammation, and fibrous cap thickness. Definitive proof of the vulnerable plaque, however, remains elusive because animal or human data supporting a cause-and-effect relationship are lacking. Although emerging imagining technologies involving optical coherence tomography, high-resolution MRI, molecular biomarkers, and other techniques have far surpassed the limits of the early days of angiography, advancing the field will require establishing relevant translational animal models that produce vulnerable plaques at risk for rupture and further testing of these modalities in large prospective clinical trials.

Myocardial Revascularization Surgery: JACC Historical Breakthroughs in Perspective.

Coronary artery bypass grafting (CABG) was introduced in the 1960s as the first procedure for direct coronary artery revascularization and rapidly became one of the most common surgical procedures worldwide, with an overall total of more than 20 million operations performed. CABG continues to be the most common cardiac surgical procedure performed and has been one of the most carefully studied therapies. Best CABG techniques, optimal bypass conduits, and appropriate patient selection have been rigorously tested in landmark clinical trials, some of which have resolved controversy and most of which have stoked further debate and trials. The evolution of CABG cannot be properly portrayed without presenting it in the context of the parallel development of percutaneous coronary intervention. In this Historical Perspective, we a provide a broad overview of the history of coronary revascularization with a focus on the foundations, evolution, best evidence, and future directions of CABG.

Percutaneous Coronary Revascularization: JACC Historical Breakthroughs in Perspective.

Over the last 4 decades, percutaneous coronary intervention has evolved dramatically and is now an acceptable treatment option for patients with advanced coronary artery disease. However, trialists have struggled to establish the respective roles for percutaneous coronary intervention and coronary artery bypass graft surgery, especially in patients with multivessel disease and unprotected left-main stem coronary artery disease. Several pivotal trials and meta-analyses comparing these 2 revascularization strategies have enabled the relative merits of each technique to be established with regard to the type of ischemic syndrome, the coronary anatomy, and the patient's overall comorbidity. Precision medicine with individualized prognosis is emerging as an important method of selecting treatment. However, the never-ending advancement of technology, in conjunction with the emergence of novel pharmacological agents, will in the future continue to force us to reconsider the evolving question: "Which treatment strategy is better and for which patient?"