Organization of intensive cardiac care units in Europe: Results of a multinational survey.

BACKGROUND: The present survey aims to describe the intensive cardiac care unit organization and admission policies in Europe. METHODS: A total of 228 hospitals (61% academic) from 27 countries participated in this survey. In addition to the organizational aspects of the intensive cardiac care units, including classification of the intensive cardiac care unit levels, data on the admission diagnoses were gathered from consecutive patients who were admitted during a two-day period. Admission policies were evaluated by comparing illness severity with the intensive cardiac care unit level. Gross national income was used to differentiate high-income countries (n=13) from middle-income countries (n=14). RESULTS: A total of 98% of the hospitals had an intensive cardiac care unit: 70% had a level 1 intensive cardiac care unit, 76% had a level 2 intensive cardiac care unit, 51% had a level 3 intensive cardiac care unit, and 60% of the hospitals had more than one intensive cardiac care unit level. High-income countries tended to have more level 3 intensive cardiac care units than middle-income countries (55% versus 41%, p=0.07). A total of 5159 admissions were scored on illness severity: 63% were low severity, 24% were intermediate severity, and 12% were high severity. Patients with low illness severity were predominantly admitted to level 1 intensive cardiac care units, whereas patients with high illness severity were predominantly admitted to level 2 and 3 intensive cardiac care units. A policy mismatch was observed in 12% of the patients; some patients with high illness severity were admitted to level 1 intensive cardiac care units, which occurred more often in middle-income countries, whereas some patients with low illness severity were admitted to level 3 intensive cardiac care units, which occurred more frequently in high-income countries. CONCLUSION: More than one-third of the admitted patients were considered intermediate or high risk. Although patients with higher illness severity were mostly admitted to high-level intensive cardiac care units, an admission policy mismatch was observed in 12% of the patients; this mismatch was partly related to insufficient logistic intensive cardiac care unit capacity.

Current concepts in the anatomy and origin of pharyngeal diverticula.

The role of this paper is to present the current concepts in anatomy and etiopathogenesis of pharyngeal diverticula. Precise anatomical considerations highly emphasizing the weak anatomic areas which predispose the pouch formation are discussed. Focus exposed in details will also be given upon the structural and functional characteristics of the upper esophageal sphincter as well as to its physiological states, architecture and dynamic functions. A brief review of historical and current perspectives regarding the origin of pharyngeal diverticula has also been given. Special attention is given to the abnormal cricopharyngeal function in patients with pharyngeal pouches in the terms of altered UES compliance, importance of gastroesophageal reflux and histopathologic changes of cricopharyngeal muscle.

Surgical experience of the national institution in the treatment of Zenker's diverticula.

AIM: To review the 8-year experience of the Department of Esophagogastric Surgery, First Surgical University Hospital in Belgrade in the surgical management of Zenker's diverticula (ZD). METHODS: Between January 2000 and January 2009, 52 patients underwent surgical procedure for the treatment of ZD. Complete preoperative workup including the symptom evaluation and large variety of structural and functional diagnostic procedures were conducted before the surgery. After the operative treatment patients underwent detailed follow-up in regular intervals up to 3 years. RESULTS: Preoperative evaluation marked higher incidence of hiatal hernia and pathologic gastroesophageal reflux (GER) among the patients with ZD then in normal population. According to the preoperative evaluation and size of diverticula, as well as due to the intraopertive findings, a variety of surgical procedures were performed, including myotomy alone (n = 2), diverticulopexy and myotomy (n = 36) and diverticulectomy and myotomy (n = 14). Regardless of the operative treatment no salivary cervical fistulas were observed. Late and early postoperative results revealed low incidence in postoperative transitory dysphagia or regurgitation. CONCLUSION: The results of this study show that the open surgical procedures are safe and effective in the treatment of ZD. Cricopharyngeal myotomy remains the essential focus of treatment, while the choice of resecting or suspending the diverticulum is brought upon its size. Complete preoperative investigation must be conducted in ZD patients, and the role of pathologic GER must be taken into account when we discuss the origin of this disorder.

Relation of matrix metalloproteinase-9 to different stages of tumors in the serum of gastric cancer.

The sera of 40 patients with gastric cancer and 11 patients as the control group were studied for the detection of matrix metalloproteinases. The malignant behavior of tumor cells mainly depends on the capability of invasion and the metastasis of cancer cells. After the components of the extracellular matrix (ECM) are degraded, tumor cells invade the surrounding tissue and the vascular or lymphatic vessels to form metastasis colonies at distant sites. Extracellular proteolytic enzymes implicate the invasion and metastasis of cancer. Proteolytic enzymes from tumors lead to the breakdown of basement membranes and the ECM, thereby, facilitating cancer cell invasion into the surrounding normal tissue. Proteinase activity is overexpressed in the serum of stage 3 and 4 tumors compared to stage 1 and 2 tumors. ProMMP-9 was detected in the serum of patients of gastric cancer by SDS polyacrylamide gel electrophoresis (SDS-PAGE) and SDS-PAGE zymography, with its molecular mass of 92 kDa. MMP-9 in serum plays an important role in the progression of gastric cancer.

Colon interposition in the treatment of esophageal caustic strictures: 40 years of experience.

The objective of this article was to analyze 40 years of experience of colon interposition in the surgical treatment of caustic esophageal strictures from the standpoints of our long-term personal experience. Colon interposition has proved to be the most suitable type of reconstruction for esophageal corrosive strictures. The choice of colon graft is based on the pattern of blood supply, while the type of anastomosis is determined by the stricture level and the part of colon used for reconstruction. In the period between 1964 and 2004, colon interposition was performed in 336 patients with a corrosively scared esophagus, using the left colon in 76.78% of the patients. In 87.5% a colon interposition was performed, while in the remaining patients an additional esophagectomy with colon interposition had to be done. Hypopharyngeal strictures were present in 24.10% of the patients. Long-term follow-up results were obtained in the period between 1 to up to 30 years. Early postoperative complications occurred in 26.48% of patients, among which anastomosic leakage was the most common. The operative mortality rate was 4.16% and late postoperative complications were present in 13.99% of the patients. A long-term follow up obtained in 84.82% of the patients found excellent functional results in 75.89% of them. We conclude that a colon graft is an excellent esophageal substitute for patients with esophageal corrosive strictures, and when used by experienced surgical teams it provides a low rate of postoperative morbidity and mortality, and long-term good and functional quality of life.

[Hiatal hernia of the esophagus and GERD as a cause of hemorrhage].

Bleeding complications arise in 1/4 of patients with hiatal hernia and GERD, and are the cause in 10% of all acute and 1/3 of chronic foregut bleedings. Most common bleeding disorders directly related to hiatal hernia and GERD are: hiatal hernia ulcers, erosive esophagitis, esophageal ulcers, peptic strictures and Barrett esophagus. The aim of this review article is to point out a significance of proper diagnosis and treatment for conditions bonded with hiatal hernia and GERD which can lead to severe esophageal bleedings. Detailed etiology, incidence, diagnostic algorithm and treatment of Cameron lesions, prolapse gastropathy, erosive esophagitis, peptic esophageal ulcers and postoperative complications related to hiatal hernia and GERD are presented in this article.

Apoptosis of cardiomyocytes in myocarditis.

Apoptosis of cardiomyocytes has been reported to be involved in the pathogenesis of heart failure of different aetiologies. The purpose of this study is to assess the role and extent of apoptosis of cardiomyocytes in active myocarditis. Endomyocardial samples from the right ventricle of 22 patients with active myocarditis were compared with 25 traffic accident victims without a history of cardiovascular disease. Twenty-two patients fulfilled the histopathologic Dallas criteria for myocarditis. The TUNEL method and immunostaining for active caspase 3 were used for the detection of apoptosis. Immunohistochemical methods were used for the evaluation of regulators of apoptosis (p53, Bcl-2) and evaluation of interstitial cells (macrophages, T and B lymphocytes). Apoptosis of cardiomyocytes (TUNEL-positive and anti-caspase 3-positive cardiomyocytes), which was not p53-dependent, was present in 0.3 to 0.4% (0.3% by TUNEL method and 0.4% by immunostaining for active caspase 3) of cardiomyocytes in active myocarditis, whereas only few apoptotic cardiomyocytes (0.0006 +/- 0.002% TUNEL-positive cardiomyocytes and 0.001 +/- 0.002% active caspase 3-positive cardiomyocytes) were found in the control group (P = 0.001). Apoptotic (TUNEL-positive and active caspase 3-positive) cardiomyocytes were found in small clusters. An increased expression of Bcl-2 was found in active myocarditis compared to the controls (P < 0.01), yet Bcl-2 failed to protect myocytes from apoptosis. We provide evidence of apoptosis of cardiomyocytes in active myocarditis, which may be involved in the development of heart failure.

Molecular detection of QTLs for agronomic and quality traits in a doubled haploid population derived from two Canadian wheats (Triticum aestivum L.).

Development of high-yielding wheat varieties with good end-use quality has always been a major concern for wheat breeders. To genetically dissect quantitative trait loci (QTLs) for yield-related traits such as grain yield, plant height, maturity, lodging, test weight and thousand-grain weight, and for quality traits such as grain and flour protein content, gluten strength as evaluated by mixograph and SDS sedimentation volume, an F1-derived doubled haploid (DH) population of 185 individuals was developed from a cross between a Canadian wheat variety "AC Karma" and a breeding line 87E03-S2B1. A genetic map was constructed based on 167 marker loci, consisting of 160 microsatellite loci, three HMW glutenin subunit loci: Glu-A1, Glu-B1 and Glu-D1, and four STS-PCR markers. Data for investigated traits were collected from three to four environments in Manitoba, Canada. QTL analyses were performed using composite interval mapping. A total of 50 QTLs were detected, 24 for agronomic traits and 26 for quality-related traits. Many QTLs for correlated traits were mapped in the same genomic regions forming QTL clusters. The largest QTL clusters, consisting of up to nine QTLs, were found on chromosomes 1D and 4D. HMW glutenin subunits at Glu-1 loci had the largest effect on breadmaking quality; however, other genomic regions also contributed genetically to breadmaking quality. QTLs detected in the present study are compared with other QTL analyses in wheat.

Isolated choroidal metastasis from primary adenocarcinoma of the distal esophagus: a case report.

We present a case of a 41-year-old male patient who, 1 year after transhiatal esophagectomy and transmediastinal gastroplasty for an adenocarcinoma of the distal esophagus, presented with an isolated metastasis in the choroids of the left eye. Because of pains caused by secondary glaucoma, enucleation of the left eyeball had to be performed as the treatment of choice. At 1 year after surgery of the eye, the secondaries in both adrenal glands were revealed. Despite the applied chemotherapy, the patient died with signs of generalized disease 3 years after the initial surgery.

[History of the evolution of surgical treatment of gastroesophageal reflux disease]. / Istorijska evolucija hirurskog lecenja gastroezofagealne refluksne bolesti.

The GERD has probably existed since the beginning of mankind but it took several millennia since any perception or knowledge of this disease started to evolve. Homo est quod est--the man is what he eats is an old Latin proverb and heartburn has been one of the most common documented symptoms in humans in the last two centuries. The term peptic esophagitis has been introduced in 1935, but the evolution of knowledge of pathogenesis, incidence, complications and way of treatment of GERD has been quite slow. In the last decade several new aspects of these problem have evolved and probably explained many unanswered questions of this very common and sometimes severe disease.

[Surgical management of long-term complications after dermatojejunoplasty of corrosive esophageal strictures]. / Hirursko lecenje kasnih komplikacija dermato-jejuno plastika kod korozivnih stenoza jednjaka.

Authors present their experience in treatment of the long term complications after Lexer-Judin and Lexer-Judin-Papo operations. They discuss the advantages and disadvantages of these procedures. In the period from 1977 to 2003 in the Institute for digestive diseases 16 patients had to be operated because of the stenosis in the region of dermato-jejunal anastomosis or because of the bad esthetic results of this operations. They suggest that the extirpation of dermal tube, mobilisation of the jejunum and new pharyngo-jejunal anastomosis is the operation of choice.

Changes in left ventricular morphology and function in end-stage dilated cardiomyopathy after reductive annuloplasty of double mitral and tricuspid orifices.

BACKGROUND AND AIM: The aim of this study is to show the changes in left ventricular morphology and function after reductive annuloplasty of double mitral and tricuspid orifices (RADO) in ischemic dilated cardiomyopathy (IDCM) and primary dilated cardiomyopathy (PDCM) analyzed by intraoperative transesophageal echocardiography (TEE). METHODS: There were 274 patients, mean age 50.1 years, 188 operated due to IDCM with ejection fraction under 30%, and 86 patients due to PDCM. Mitral annuloplasty according to A. Carpentier and our own procedure was done in 49 and 225 patients, respectively. In 265 cases (97%) our modified De Vega's tricuspid annuloplasty was performed. CONCLUSION: RADO significantly changes left ventricular morphology, reverses remodeling of the heart, decreases sphericity of the left heart, improves hemodynamic function of both ventricles, and slows down progression of cardiac failure. We recommend RADO in the early stage of PDCM, immediately after the first decompensation, and as an important associated procedure in IDCM.

Myocytes' apoptosis and proliferation in endomyocardial biopsy as prognostic factors in terminal heart failure.

The aim of the preliminary study was to evaluate the role of apoptosis and proliferation of myocytes in order to predict the prognosis and optimal treatment of patients with end-stage dilated cardiomyopathy. Endomyocardial biopsy was performed during open-heart surgery (reductive annuloplasty of double orifice) in 19 patients with end-stage dilated cardiomyopathy. The terminal deoxynucleotidyl transferase d-UTP-biotin nick-end labelling (TUNEL) method was used for the detection of apoptosis, and immunohistochemical methods were used for the evaluation of inhibitor of apoptosis such as proto-oncogene Bcl-2 (B-cell lymphoma gene), and proliferative markers such as proliferation cell nuclear antigen (PCNA) and Ki-67 proliferative antigen. The increased percentage of apoptotic myocytes and decreased expression of bcl-2 is associated with earlier death after surgery. Increased expression of proliferation markers of myocytes in patients who survived seven years after surgery compared to those who died within three years suggest that adult cardiomyocytes are not terminally differentiated and this might represent potential growth reserve of the diseased heart. Based on our preliminary study we may conclude that myocytes' apoptosis and proliferative activity might help us to predict the prognosis and optimal treatment of patients with end-stage dilated cardiomyopathy.

[Correction of failed primary surgical interventions in benign lesions of the esophagus]. / Korekcija neuspelih primarnih hirurskih intervencija kod benignih lezija jednjaka.

In an retrospective analysis of documentation and printed paper in period between 1964-1998 168 patients required reoperations in benign esophageal lesions. Failed initial interventions were found in 66 (39.28%) pts. operated in our clinic and 102 (60.71%) pts operated in other institutions in our country. The corrective procedure was possible in 140 (83.33%) pts and impossible in 11 (6.54%). Post-operative mortality was 7.73% so the definitive failed corrections were 14.27%. The main cause of failure were: Defective operative technique, wrong preoperative diagnosis and indications including inadequate initial procedure. Among the 168 pts undergoing corrective surgery, more than a half of pts had obstructive lesions requiring resections and reconstructions. Dilatation of the stricture was possible in 16% followed by total diversion, particularly in previous gastric surgery. Malignant degeneration of benign lesions were found in 10.71%. Only 4 pts (2.3%) refused suggested operations. Satisfactory long-term results especially in patients undergoing esophageal corrective reconstructions for benign diseases were good to excellent in regular yearly postoperative routine control examination.

[A retroperitoneal bronchogenic cyst]. / Bronhogena cista u retroperitoneumu.

Bronchogenic cyst is a rare congenital (developmental) anomaly. It is usually asymptomatic but its enlargement and localization may cause serious symptoms. Exact preoperative diagnosis is rarely established. As a rule, it is established during histological examination of the resected specimen. We present a patient with a subdiaphragmatic retroperitoneal bronchogenic cyst in whom exact diagnosis was documented by histological examination of excised cyst. To our knowledge this is the third such case ever reported.

[Subcutaneous pseudoaneurysm of the left ventricle--a rare complication of ischemic dilated cardiomyopathy]. / Supkutana pseudoaneurizma leve komore--retka komplikacija ishemijske dilatativne kardiomiopatije.

INTRODUCTION: Pseudoaneurysm of the heart is extremely rare in cardiology and cardiac surgery. It can be presented as a complication of myocardial infarction, cardiac trauma or surgical intervention. CASE PRESENTATION: 9 years after by-pass surgery combined with left ventricle aneurysmectomy a 69-year-old patient was admitted in hospital after full cardiologic examination. On admission, during routine chest examination 9 years after by-pass surgery combined with left ventricle aneurysmectomy, a great pulsatile mass was found in the region of left mammilla++. A left ventricle aneurysm (aneurysm per magna) was confirmed by all noninvasive and invasive tests, and new surgical aneurysmectomy was indicated. The existence of pseudoaneurysm was suspected by intraoperative transesophageal echocardiography and during the operation a false aneurysm was finally confirmed. DISCUSSION: False aneurysm develops after acute rupture of an infarcted left ventricle area. It is usually fatal, but if the adhesion or pericardial fibrosis exists and is adherent to epicardium it can create a saccular cavity (hemopericardium). Persistent communication between the left ventricle and hemopericardium can create false aneurysm of different size and shape. In more than 50% of patients false aneurysm is found accidentally. In most cases the pseudoaneurysm is asymptomatic and the treatment is surgical. CONCLUSION: False aneurysms as case presentations are very rare. Sometimes they are difficult to confirm prior to surgery; even if full diagnostic screening was arranged (including 2-D transthoracic echocardiography, transesophageal echocardiography and complete hemodynamic investigation).

[Comparison of preoperative and postoperative hemodynamic parameters in replacement or reconstruction of the mitral valve in ischemic dilated cardiomyopathy]. / Uporedivanje preoperativnih i postoperativnih vrednosti hemodinamickih parametara kod zamene i rekonstrukcije mitralnog zaliska u ishemicnoj dilatativnoj kardiomiopatiji.

INTRODUCTION: Ischemic mitral insufficiency is a clinical syndrome described as a consequence of the coronary artery disease where the basic problem is blood regurgitation between the left ventricle and left atrium following mitral annulus dilatation. Mitral regurgitation occurs in different degrees during the natural evolution of the ischemic heart disease. The main reason for the existence of mitral regurgitation is global deterioration in the left ventricle geometry as a consequence of myocardial infarction or/and left ventricle dilatation. Surgical correction of this problem is possible by simultaneous correction of mitral insufficiency (repair or replacement) and complete myocardial revascularisation. MATERIAL AND METHODS: Complete hemodynamic monitoring was followed by Swan-Ganz catheter including: central venous pressure, mean pulmonary artery pressure, pulmonary capillary wedge pressure, cardiac output, cardiac index and pulmonary vascular resistance. All surgical procedures were performed in extracorporeal circulation (ECC) with membrane oxygenator using moderate systemic hypothermia and transseptal surgical approach to mitral valve. Hemodynamic parameters were followed before and after ECC, immediately after surgery and during the first 48 hours after operation in the intensive care unit. In 88 patients posterior semicircular annuloplasty by N. Radovanovic was performed whereas in 13 patients mitral valve replacement was done. RESULTS: There is a great, statistically significant hemodynamic improvement after the surgical procedure and during the continuous 48 hours monitoring in the intensive care unit no matter if mitral repair or replacement was done. No statistically significant difference was recorded between these two groups considering that the hemodynamic improvement is very similar. DISCUSSION: Simultaneous surgical procedures, including myocardial revascularization, mitral and usually consecutive tricuspid insufficiency correction, are a very common surgical problem with higher operative risk than isolated coronary bypass procedures. In 88 cases where mitral reconstruction was possible, posterior semicircular reductive annuloplasty was performed. Thus mitral annulus area reduction is achieved preserving its physiologic shape and avoiding rigidity. Mitral valve replacement includes implantation of the latest generation of bileaflet valve prosthesis and operative technique that preserves subvalvular apparatus to maintain myocardial contractility as much as possible. This policy and also good immediate postoperative care, improve the hemodynamic status in both groups. CONCLUSION: All hemodynamic parameters followed by ECC and 48 hours in the intensive care unit were significantly improved no matter whether mitral reconstruction or replacement was done. There is no statistically significant difference in hemodynamic parameters and clinical improvement between these two groups. Carefully chosen operative tactic and techniques as well as good preoperative and postoperative care may explain these very good results.

Myocardial revascularization with skeletonized left mammary artery.

Graft selection has a direct influence on overall morbidity and mortality in patients selected for coronary artery bypass grafting (CABG) procedures. In the last decade internal mammary artery has been established as a conduit of choice for myocardial revascularization. However, there is still no official policy which operative technique has advantage in harvesting of the internal mammary artery (IMA). Current dilemma is whether pedicle or skeletonized grafts are better in immediate and long term results. Method of skeletonization of IMA increases surgeon's technical demands, but on the other hand has many advantages. Precise operative technique and selective preparation of IMA without concomitant elements reduces trauma to the chest wall, enables elongation and ideal graft positioning, and reduces graft compression by hyperinflated lungs. Complete graft visualization allows inspection of internal mammary artery in entire length, which excludes possibility to implant dissected or hypoplastic graft. From June 1996 we started using the method of skeletonization of IMA, and until February 1st 1999 skeletonized IMA was used as a conduit in 1001 patients. In our hands myocardial revascularization with IMA is a procedure with minimal morbidity and mortality. Precise operative technique during the harvesting of IMA is advantage especially in diabetics, old patients and patients with chronic obstructive pulmonary disease (COPD), that were considered as limiting factors for IMA use in the past. Our initial results with the quality of this conduit encourage us to extend the indication for using IMA as a dominant graft in multiple myocardial revascularization.

Multiple hexose transporters of Schizosaccharomyces pombe.

We have identified a family of six hexose transporter genes (Ght1 to Ght6) in the fission yeast Schizosaccharomyces pombe. Sequence homology to Saccharomyces cerevisiae and mammalian hexose transporters (Hxtp and GLUTp, respectively) and secondary-structure predictions of 12 transmembrane domains for each of the Ght proteins place them into the sugar porter subfamily within the major facilitator superfamily. Interestingly, among this sugar porter family, the emerging S. pombe hexose transporter family clusters are separate from monosaccharide transporters of other yeasts (S. cerevisiae, Kluyveromyces lactis, and Candida albicans) and of humans, suggesting that these proteins form a distinct structural family of hexose transporters. Expression of the Ght1, Ght2, Ght5, and Ght6 genes in the S. cerevisiae mutant RE700A may functionally complement its D-glucose uptake-deficient phenotype. Northern blot analysis and reverse transcription-PCR showed that among all Ght's of S. pombe, Ght5 is the most prominently expressed hexose transporter. Ght1p, Ght2p, and Ght5p displayed significantly higher specificities for D-glucose than for D-fructose. Analysis of the previously described S. pombe D-glucose transport-deficient mutant YGS-5 revealed that this strain is defective in the Ght1, Ght5, and Ght6 genes. Based on an analysis of three S. pombe strains bearing single or double mutations in Ght3 and Ght4, we conclude that the Ght3p function is required for D-gluconate transport in S. pombe. The function of Ght4p remains to be clarified. Ght6p exhibited a slightly higher affinity to D-fructose than to D-glucose, and among the Ght's it is the transporter with the highest specificity for D-fructose.

[Late results of myocardial revascularization in patients with coronary artery endarterectomy]. / Kasni rezultati revaskularizacije miokarda kod pacijenata kod kojih je radena endarteriektomija koronarnih arterija.

INTRODUCTION: The aim of this study was to evaluate long-term results after myocardial revascularization in patients with diffuse and distal coronary disease, and to compare this procedure with the classical approach--indirect myocardial revascularization (revascularization without endarterectomy). MATERIAL AND METHODS: This retrospective study was done in the period of three years, and includes patients operated between January 1, 1985 and December 31, 1990 at the University Clinic of Cardiovascular Surgery, Novi Sad. 500 patients were included and two groups were made. The investigated group consisted of 251 patients with endarterectomy and control group of 249 patients without endarterectomy. Other parameters (age, gender, preoperative hemodynamic parameters etc.) were practically the same. RESULTS: Postoperative mortality (PM) during immediate 30 postoperative days was 4.64% in the investigated group, and 1.97% in the control group (total PM = 2.66%). The main causes of death were cardiac (3.74%), and the rest of them were respiratory, renal and cerebral. The highest postoperative mortality according to the localization of endarterectomy was left artery descendent (LAD) in the position of the first septal artery (36.36%). The follow-up study included 500 operated patients. The mean follow-up period was 9 years (0-13 years). Cumulative survival curve and postoperative myocardial infarction curve made by Wilcocxon (Gehan) and Kaplan-Meier methods showed no statistically significant difference between groups after 13 years of follow up. Lower incident of new angina was found in the investigated group (p < 0.01). Most of patients show good physical condition, well toleration of the stress test (Bruce protocol) and no significant impairment of ejection fraction. DISCUSSION: Despite its long history and development, endarterectomy of coronary arteries is one of the most controversial methods in cardiac surgery. Application of this method was very restrictive mostly because its complexity and very controversial results from one institution to another. Endarterectomy of the first septal artery has the highest operative risk, but it is the method of choice in full revascularization of this region. Despite higher operative mortality, the immediate and long term results of this study show that endarterectomy of the coronary arteries is a method with very acceptable operative risk. CONCLUSION: Endarterectomy is a good and effective method for direct myocardial revascularization in cases with diffuse coronary disease. It is the best procedure for revascularization of the septum. The number of endarterectomies and low ejection fraction are independent predictors for early and long-term mortality. Endarterectomy is also a method of choice in patients with low ejection fraction and poor coronary bed. Frequent and repeated application of angioplasty, higher incidence of diffuse and distal coronary disease and no available donors for heart transplantation will increase the application of this method. In the future we expect further improvement and complete affirmation of endartrectomy of coronary arteries.