Does anterolateral ligament internal bracing improve the outcomes of anterior cruciate ligament reconstruction in patients with generalized joint hypermobility?

BACKGROUND: Generalized joint hypermobility (GJH) is a risk factor for anterior cruciate ligament (ACL) injury and ACL graft failure and is considered an indication for anterolateral ligament (ALL) reconstruction. The aim of this retrospective study was to compare functional outcomes, rupture rates, and residual instability in patients with GJH undergoing isolated ACL reconstruction or combined ACL reconstruction and ALL augmentation with internal bracing (ALL-IB). METHODS: Sixty-eight patients with GJH and unilateral ACL injury were randomly assigned to undergo either isolated ACL reconstruction (Group 1) or combined ACL reconstruction and ALL-IB (Group 2). The patients were evaluated pre- and postoperatively; their medical histories; physical examination results; anterior knee translation, as measured using the KT-1000 arthrometer; and scores of validated knee assessments were recorded. RESULTS: Groups 1 and 2 consisted of 37 and 31 patients, respectively. The mean follow-up was 30.1±4.1 and 28.1±2.9 months, respectively. In the final evaluation, the patients in Group 2 showed better rotational stability, as evaluated by the pivot-shift test (p=0.013); better anteroposterior stability, as evaluated by KT-1000 arthrometry (p=0.001); similar function (p=0.14 for the Lysholm, p=0.11 for the Cincinnati, and p=0.19 for the International Knee Documentation Committee subjective score); and failure rate (p=0.41). CONCLUSION: The functional outcomes were similar between the groups. The stability outcomes after combined ACL and ALL-IB were better than those after isolated ACL reconstruction in patients with GJH. However, the technique and its results need to be validated in larger patient series and prospective randomized controlled trials.

Analysis of the Early Results of 693 Patients Undergoing Valvular Reoperation Between 1993 and 2011.

BACKGROUND: The study aim was to identify factors affecting early mortality in valvular reoperations. METHODS: Between January 1993 and December 2011, a total of 693 patients who had undergone valvular reoperations due to problems with previously implanted mechanical and biological valves, new valve degeneration or valve failure after a reconstructive procedure was included in the study. Factors affecting early mortality were identified by the examination of preoperative and perioperative data, using multivariate analysis. RESULTS: The average age of the patients was 44.9 years. For all patients, overall hospital mortality was 15.9%, while hospital mortality rates were 12.9% and 35.3% for elective operation and urgent/emergency treatment, respectively. Factors affecting early mortality in the multivariate analysis were longer total perfusion time (>120 min, p = 0.001), emergency or urgent treatment (p = 0.001), and the presence of preoperative renal failure (p = 0.001). CONCLUSIONS: Mortality for elective patients in valvular reoperations was within an acceptable range. Total mortality was dependent on a high mortality level of emergency/urgency of the cases. The use of a well-defined protocol in valvular reoperations may decrease hospital mortality.

Posterobasal left ventricular aneurysms: surgical treatment and long-term outcomes.

This retrospective study analyzes short- and long-term outcomes in 18 patients who underwent repair of posterobasal left ventricular aneurysm from January 1993 through December 2009. As concomitant procedures, mitral reconstruction was performed in 4 patients, ventricular septal defect repair in 2 patients, and coronary artery bypass grafting in 17 patients. In regard to surgical technique, 10 patients underwent patch repair and 8 underwent closure by linear suture. The in-hospital mortality rate was 11% (2 patients). An intra-aortic balloon pump was placed postoperatively in 1 patient. One patient underwent reoperation for mediastinitis and 2 for bleeding. The 1-, 5-, and 10-year survival rates were 82%, 76%, and 52%, respectively. Posterobasal left ventricular aneurysm repair can be performed with low short-term mortality rates and good long-term outcomes. It must be judged whether a linear repair or patch repair is better, in accordance with aneurysm size and the concomitant operative procedure, if any.

Pilonidal sinus disease: risk factors for postoperative complications and recurrence.

The aim of this study is to analyze the risk factors for complications and recurrence in pilonidal sinus disease. The prospective study consisted of 144 patients with pilonidal sinus disease who were operated on at Dicle University Medical Faculty, Department of General Surgery, between February 2008 and December 2010. Patients receiving the Limberg flap totaled 106 (73.6%), while 38 (26.4%) had primary closure. Postoperative complications developed in 42 subjects (29.2%), and recurrence occurred in 19 (13.2%). The Limberg flap method was statistically considered as a risk factor for postoperative complications (P  =  0.039). Regarding recurrence, family tendency (P  =  0.011), sinus number (P  =  0.005), cavity diameter (P  =  0.002), and primary closure (P  =  0.001) were found to be risk factors. Postoperative complication rate is higher in the Limberg flap method than primary closure method. The risk of recurrence is related to family tendency, sinus number, cavity diameter and anesthesia type and is also higher in primary closure.

In vitro isoflavonoid production and analysis in natural tetraploid Trifolium pratense (red clover) calluses

Isoflavones are polyphenolic phytoestrogens, predominantly found in leguminous plants. Trifolium pratense L., Fabaceae (red clover), is rich in isoflavones that possess estrogenic activity due to their similar molecular structure and effectiveness in preventing health conditions such as menopause, osteoporosis, cardiovascular disease, hypertension and hormone-dependent cancers. In this study, presence and amount of various phytoestrogens in the tetraploid plant and in the calluses derived from the plants were investigated. Calluses were generated from explants obtained from natural tetraploid T. pratense seedlings. The best callus formation was obtained from hypocotyl explants cultured in Phillips Collins and Gamborg B5 media containing different plant growth regulators. Flowers of plants and calluses were analysed for formononetin, biochanin A, genistein and daidzein contents using HPLC. In HPLC analysis, high levels of formononetin (0.249 µg/mg) were determined in natural tetraploid T. pratense flowers in addition to genistein and biochanin A. In calluses, highest isoflavone content (1.15 µg/mg formononetin) was observed in modified Gamborg B5 medium. Biochanin A content of calluses and the plant were found to be nearly the same. But formononetin and genistein contents of the calluses in this medium were found to be respectively 4.62 and 21.39 folds higher than the tetraploid plant.

Does the surgical technique used in the orthotopic heart transplant affect the results regarding the rhythm?

OBJECTIVE: The aim of this study was to compare the requirement for temporary and permanent pacemaker insertion and the incidence of the problems regarding the rhythm following heart transplantation with the bicaval or biatrial technique in the early postoperative period. METHODS: Sixty-one patients underwent orthotopic heart transplantation between the dates of September 1989 and December 2008 in our clinics were included to the study. The study was designed as retrospective analysis, and all data were collected from hospital records. The transplantation was performed by using standard biatrial method in 28 of the patients, by using bicaval anastomosis method in 33 of the patients. Statistical analyses were performed using Chi-square, Fischer's exact and Mann-Whitney U tests. Predictors of temporary and permanent pacemaker insertion were analyzed using logistic regression analysis. RESULTS: In the biatrial group, the temporary pacemaker requirement (p<0.05), left bundle branch block (LBBB) (p<0.01) and atrioventricular block (AV block) (p<0.05) were observed statistically significantly more than in bicaval anastomosis group. In addition, in the biatrial group, one patient needed implantation of permanent pacemaker and one patient-implantable cardioverter defibrillator. On the postoperative echocardiographic evaluation, in the patients operated with the bicaval technique, the tricuspid (p<0.01) and mitral insufficiency (p<0.01) were observed significantly less. In the logistic regression analysis, hypertension (OR: 1.053, 95% CI: 1.019-1.176, p<0.05), donor age (OR: 1.016, 95% CI: 1.023-1.038, p<0.05) and application of the operation with the biatrial technique (OR: 10.287, 95% CI: 1.298-91.278, p<0.01) were determined as the risk factors requiring the temporary pacemaker usage. In the bicaval group, arrhythmia (ventricular and atrial premature beats) and atrioventricular valve insufficiency were observed less, the rhythm returned to normal in an earlier period. CONCLUSION: Biatrial surgical technique, donor age and hypertension were determined as significant predictors of temporary pacemaker insertion in the orthotopic heart transplantation. Atrioventricular block, left bundle branch block, and arrhythmia frequency was significantly less in the bicaval group. In terms of factors affecting morbidity, the bicaval technical results were found superior than biatrial technique.

Hybrid coronary revascularization for the treatment of left main coronary artery disease in high-risk patients.

OBJECTIVE: Hybrid coronary revascularization is an alternative for treatment for high-risk patients with coronary artery disease. We evaluated the efficacy of staged hybrid coronary revascularization for the treatment of unprotected left main coronary artery disease in high-risk patients. METHODS: Patients with left main or proximal left anterior descending coronary artery stenosis who are not good candidates for percutaneous coronary intervention and who had suitable lesions in the right coronary and circumflex arteries were considered for staged hybrid therapy if they had poor left ventricular functions (ejection fraction <0.40) and comorbid illnesses. From January 2008 through December 2010, 11 patients (8 men, 3 women; mean age: 66.1 ± 9.1 years) were treated with off-pump coronary artery bypass grafting combined with staged percutaneous coronary intervention. Nine patients had left main coronary artery stenosis together with circumflex or right coronary artery stenosis, and 2 patients had proximal left anterior descending artery stenosis and right coronary artery stenosis. RESULTS: After off-pump coronary artery bypass grafting, procedure-related complications did not occur, and there was no in-hospital death. Coronary re-angiography after a median of 16 days revealed patent and functioning left internal mammarian artery grafts in all patients. Applying subsequent percutaneous transluminal coronary angioplasty and occasional stenting (n = 14), a total of 14 lesions were treated successfully. Procedure related complications did not occur. All patients remained angina-free, and no stress electrocardiographic changes were recorded. CONCLUSION: Our preliminary results indicate that a "staged hybrid" approach to the treatment of left main coronary artery disease in high-risk patients is safe and effective. Hybrid coronary revascularization enables complete revascularization and may be an alternative method of treating left main coronary artery disease in selected high-risk patients.

Anatomical investigations on root, stem, and leaf of Gentiana olivieri Griseb.

BACKGROUND: Gentiana olivieri Griseb. (Afat) (Gentianaceae), which has many bioactive compounds is used as antidiabetic, hepatoprotective, digestive aid, antidepressant, and antianemic in traditional medicine. MATERIALS AND METHODS: Root, stem, and leaf sections of G. olivieri were taken free hand or by sliding microtome and examined on light microscope. RESULTS: Anatomical characters of the species were observed to be similar to the usual features of Gentianaceae anatomy. CONCLUSION: Intraxylary phloem, which was primarily the distinguishing feature between Gentianoideae and Menyanthoideae sub-families was observed in G. olivieri roots.

Postoperative revision surgery for bleeding in a tertiary heart center.

We analyzed cases of re-exploration for bleeding after 19,680 open heart operations performed between January 1995 and January 2009 to determine the risk factors for mortality and morbidity. Half of the 282 patients reexplored had nonsurgical causes of bleeding. The patients were grouped according to the timing of reoperation, early re-exploration being on the day of the operation. Mortality, total morbidity, and the need for transfusion of any blood product were compared between the early and late re-exploration groups. Most patients (77.7%) were reexplored early. Overall mortality was 8.5% (24 patients). Mortality, total morbidity, renal, gastrointestinal, neurologic and infectious complications, and low cardiac output differed significantly between the 2 groups. Significant predictors of mortality were old age, female sex, left ventricular dysfunction, noncoronary operations, and delayed reoperation. Predictors of morbidity were old age, preoperative dialysis, tobacco use, chronic lung disease, and delayed reoperation. No factors were found to be associated with the need for transfusion.

Aortic valve replacement in isolated severe aortic stenosis with left ventricular dysfunction: long-term survival and ventricular recovery.

OBJECTIVE: The aim of this study was to assess the effects of aortic valve replacement (AVR) on the recovery of left ventricular function and the predictors for long-term survival in patients suffering from isolated severe aortic stenosis (AS) with a significant left ventricular dysfunction (LVD). METHODS: This retrospective study was conducted on 46 patients with isolated severe AS and LVD [left ventricular ejection fraction (LVEF) = or < 40%] who underwent AVR in our clinic between January 1993 and March 2006. Patients with coronary artery disease, with more than moderate aortic regurgitation (>2), with previous valve replacement or repair, and with other valve pathologies were excluded. The mean aortic valve area was 0.7+/- 0.09 cm2. The following fourteen variables were analyzed: etiology, age (= or >70 years), sex, preoperative New York Heart Association (NYHA) functional class, chronic obstructive pulmonary disease, hypertension, diabetes, peripheral arterial disease, chronic renal insufficiency, need for concomitant procedures for the ascending aorta, cardiopulmonary bypass time = or >120 min, aortic cross-clamp time = or >90 min, intraaortic balloon pump support and inotropic support. Statistical analysis for comparison of pre- and postoperative changes in clinical and functional variables was performed using Wilcoxon rank test. The predictors of early mortality after AVR were analyzed using logistic regression analysis and late survival was studied using Cox proportional regression and Kaplan Meier survival analyses. RESULTS: Operative mortality was 8.6% with four patients. As the result of univariate logistic regression analysis, preoperative NYHA functional class = or >3 was found to be predictive of early mortality. Patients with NYHA class = or >3 had 12.6 times (OR: 12.6; 95%CI: 1.2-131.3; p=0.035) higher probability of early mortality than those with a lower NYHA class. However, multivariate logistic regression analysis demonstrated no predictor for early mortality. A positive change was observed in the LVEF in 79.3% of survivors and the mean LVEF increased from 34.5+/- 3.9% to 44.7+/- 10.4% (p<0.001). There were eight (19%) late deaths. Actuarial survival was 83. +/- 5.9% at 5 years and 59.6% +/- 10.9% at 10 years. Cox proportional hazards regression analysis demonstrated diabetes mellitus (HR: 6.6; 95% CI: 1.19-36.9, p=0.031) and intraaortic balloon pump use (HR: 10.7; 95% CI: 2.9-39.7, p<0.001) as significant predictors for late mortality. CONCLUSION: Left ventricular ejection fraction and symptoms improve after AVR in patients with isolated severe AS and LVD with an acceptable operative mortality and satisfactory long-term survival.

Second and third cardiac valve reoperations: factors influencing death and long-term survival.

We retrospectively investigated preoperative and postoperative characteristics in order to determine factors that affected hospital death in patients who underwent 3 or 4 separate cardiac valvular surgeries. The hospital records of 53 such patients who were operated upon from 1985 through 2006 were obtained. The patients were divided into 2 groups according to whether their initial operation was a closed mitral commissurotomy (group C, n = 33) or open-heart surgery with cardiopulmonary bypass (group O, n = 20). In group C, all patients who had initially undergone 1 or 2 closed mitral commissurotomy procedures underwent subsequent reoperations that entailed median sternotomy and cardiopulmonary bypass. Sternotomy and cardiopulmonary bypass had been used in valvular operations of all group O patients. The total early mortality rate was 11.3% (6 of 53 patients). Multivariate analysis revealed that longer aortic cross-clamp times and double valve replacement at last operation significantly increased the risk of death. Herein, we discuss our conclusion that 3rd or 4th cardiac valvular operations incurred acceptable early postoperative mortality rates.

Surgical treatment of post-infarction left ventricular pseudoaneurysm: a two-decade experience.

Herein, we present a retrospective analysis of our experience with acquired pseudoaneurysms of the left ventricle over a 20-year period.From February 1985 through September 2004, 14 patients underwent operation for left ventricular pseudoaneurysm in our clinic. All pseudoaneurysms (12 chronic, 2 acute) were caused by myocardial infarction. The mean interval between myocardial infarction and diagnosis of pseudoaneurysm was 7 months (range, 1-11 mo). The pseudoaneurysm was located in the inferior or posterolateral wall in 11 of 14 patients (78.6%). In all patients, the pseudoaneurysm was resected and the ventricular wall defect was closed with direct suture (6 patients) or a patch (8 patients). Most patients had 3-vessel coronary artery disease. Coronary artery bypass grafting was performed in all patients. Five patients died (postoperative mortality rate, 35.7%) after repair of a pseudoaneurysm (post-infarction, 2 patients; chronic, 3 patients). Two patients died during follow-up (median, 42 mo), due to cancer in 1 patient and sudden death in the other. Although repair of left ventricular pseudoaneurysm is still a surgical challenge, it can be performed with acceptable results in most patients. Surgical repair is warranted particularly in cases of large or expanding pseudoaneurysms because of the propensity for fatal rupture.

Surgical management of coronary malperfusion due to type a aortic dissection.

BACKGROUND: Acute aortic dissection coexisting with coronary malperfusion is a relatively rare but fatal condition. Surgical treatment of these patients is to perform early coronary revascularization concomitant with aortic repair. We review our surgical results of a selected group of 14 patients with type A acute aortic dissection and coronary artery dissection. METHODS: Between January 1993 and March 2005, 14 patients (10.2%) from a total of 136 consecutive patients with acute type A aortic dissection concomitant coronary dissection were treated by performing aortic repair and coronary artery bypass grafting. There were 11 men and 3 women (mean age, 56.7 +/- 8.4 years). The right coronary artery was involved in eight patients, the left in two patients, and both coronary arteries in four patients. At admission, nine patients had Q waves (64.2%), inferior in seven (50%) and anterior or lateral in two (14.2%). RESULTS: Hospital mortality rate was 21.4% (3 of 14 patients). Of these, two patients could not be weaned from cardiopulmonary bypass, and one patient died of multiorgan failure in the intensive care unit. CONCLUSIONS: Since acute type A aortic dissection with coronary involvement is associated with high mortality rate, immediate coronary artery bypass grafting and aortic repair is a safe and reliable approach to these challenging group of patients.

[Developmental aspects in expert testimony for juvenile court]. / Entwicklungsaspekte in der Strafrechtsbegutachtung.

The history of German legislation resulting in the developmental orientation of juvenile court law (JCL) led to setting the minimum age of criminal responsibility at the age of 14, which places Germany within the average range compared to other EU countries, even though most skills regarding the discernment of right- or wrong-doing are developed in earlier stages of life. The requirement put by section sign 3 JCL that legal discernment be emotionally grounded and the necessity to explore context factors (family or group, specific situation) make psychiatric evaluation of adolescents in court a delicate task. It is indispensable that new findings in neurobiology be considered upon making an assessment of the individual neuro-developmental status. In contrast, an assessment according to section sign 105 JCL considers the overall development irrespective of the crime(s). Developmental issues regarding legal prognosis are discussed for some types of offences (homicide, sexual offences, arson).

Does aortic root enlargement impair the outcome of patients with small aortic root?

BACKGROUND: Posterior root enlargement procedures provide the implantation of suitable-sized prosthetic valves in patients with a small aortic root to prevent a high postoperative transvalvular gradient. The aim of this study was to evaluate long-term results of the posterior root enlargement. METHODS: Between 1985 and 2002, 124 patients underwent aortic valve replacement with a posterior root enlargement. The main indication was a small aortic valve orifice area to patient body surface area (indexed valve area < 0.85 cm2/m2). Fifty-four (44%) patients were male, and 70 (56%) were female with a mean age 39.1 +/- 14.3 years. Indications for operation were severe calcified aortic valve stenosis (37.1%), severe aortic insufficiency (25.8%), or combination (37.1%). Seventy-five (60%) patients received double-valve replacement. A pericardial patch was used in 100 patients (80.6%) and a Dacron patch was used in 24 patients. RESULTS: Operative mortality was 6.4% (8 patients). The causes of hospital mortality were low cardiac output syndrome (LCOS) (in 6 patients), cerebrovascular events (in 1 patient) and multiple organ failure (in 1 patient). Multivariate analysis demonstrated concomitant coronary revascularization to be a significant (p = 0.03) predictor for early mortality. There were six (5.4%) late deaths. Cox proportional hazards regression analysis demonstrated LCOS (p = 0.013) and infective endocarditis (p = 0.003) to be significant predictors for late mortality. Atrioventricular block required a permanent pacemaker was observed in 4 patients (3.2%). CONCLUSIONS: Posterior aortic root enlargement techniques can be easily applied without additional risks. Long-term survival and freedoms from valve-related complications are satisfactory.

Pedicled right internal mammary artery for reoperative off-pump revascularization of left anterior descending coronary artery.

In situ right internal mammary artery is the graft of choice in reoperative off-pump coronary artery bypass grafting, as well as in primary on-pump coronary artery bypass grafting, unless the vessel has been used previously. However, there are not enough data about postoperative angiographic findings of the in situ right internal mammary artery in reoperative coronary artery bypass grafting with the off-pump technique. From September 1993 through January 2004, we reviewed the postoperative course and the graft patency of 12 selected patients who underwent off-pump coronary artery bypass grafting reoperation only for revascularization of the left anterior descending artery, by means of a pedicled right internal mammary artery graft. All patients were evaluated clinically and by postoperative coronary angiography. There were no early or late deaths during the mean follow-up period of 33.08 +/- 30.05 months (range, 1-77 months). The mean interval from the 1st operation to the 2nd operation was 74.1 +/- 57.01 months (range, 4.5-171 months). Postoperative coronary angiograms of all patients showed a 100% patency rate for both in situ grafts and composite grafts. We suggest that use of the in situ right internal mammary artery in off-pump coronary artery bypass grafting is a safe and reliable option for revascularizing the left anterior descending artery, especially in reoperation.

Multivariate analysis for operative mortality in obstructive prosthetic valve dysfunction due to pannus and thrombus formation.

The objective of the present study was to investigate the risk factors for early hospital mortality in reoperations performed for obstructive prosthetic valve dysfunction. Between January 1994 and April 2005, 63 patients underwent reoperation for obstructive prosthetic valve dysfunction. The mean age of the patients was 40.3 +/- 12.8 years. The mitral valve was replaced in 47 (74.6%) patients, the aortic valve in 6 (9.5%) patients, and both valves in 10 (15.9%) patients. Forty-three (68.2%) patients underwent emergency reoperations. Early hospital mortality occurred in 13 (20.6%) patients. The ethiology of the valve dysfunction was pannus formation in 45 (71.4%) patients and thrombus formation in 18 (28.6%). Pannus and thrombus were localized at the atrial side of the prosthetic valve in 15 (23.9%) patients, at the ventricular side in 13 (20.6%), and at both sides in 35 (55.5%). Inadequate anticoagulation was diagnosed in 28 of 63 (44.4%) patients. The mean INR level in these 28 patients was 1.43 +/- 0.24. In multivariate analysis, the only risk factor for early hospital mortality was left ventricular ejection fraction (P = 0.015; Odds: 0.000, 95% CI: 0.000-0.043). It is concluded reoperations for prosthetic valve dysfunction have a high mortality rate. This study revealed that left ventricular dysfunction is the major determinant of surgical mortality in patients requiring reoperation for valve dysfunction due to pannus or thrombus.

Combined approach to a peripheral congenital arteriovenous malformation: surgery and embolization.

A 28-year-old woman with a complex peripheral congenital arteriovenous malformation in the left shoulder and left upper arm was treated by a combination of surgery and embolization. In the consecutive four operations, the major feeding arteries of the arteriovenous malformation were ligated, but as her complaints increased, transcatheter embolization was planned for releaving the symptoms in the first aspect. A total of eight embolization sessions were performed with Onyx during the 3-year period. The arteriovenous communications were occluded by embolization, with approximately more than an 80% decrease in the lesion size angiographically. After these interventions, the patient's symptoms improved clinically and dyspnea was lessened. Peripheral congenital arteriovenous malformation is a rare and therapeutically challenging condition in which a combination of surgery and embolization would be necessary to obtain a good result.

Using the bilateral internal mammary artery in the left or right coronary artery system: 5-year comparison of operation techniques and angiographic results.

OBJECTIVE: Using the bilateral internal mammary artery (IMA) in coronary artery bypass grafting (CABG) surgery has prolonged survival, improved functional capacity, and reduced the rate of reintervention without increasing postoperative early morbidity and mortality. METHODS: Between January 1996 and December 1997, 94 CABG operations were performed using the bilateral IMA. In Group A (n = 45), the right IMA was anastomosed to the left coronary artery system; in Group B (n = 49), the right IMA was anastomosed to the right coronary artery system. The left IMA was always anastomosed to the left coronary artery system in both groups. RESULTS: There was 1 death (Group A) (1.06%), and 1 late death (Group B) (1.07%). One patient in Group A underwent balloon angioplasty, and 1 patient in Group B underwent reoperation after the follow-up. Pre- and postoperative data were similar between both groups, except for off-pump CABG, which was higher in Group B (2.2% versus 36.7%; P <.001). Twenty-three randomized patients in each group underwent control angiography until May 2002. Angiographic results showed that the patency of the right IMA to the right or left coronary artery system was similar (78.26% versus 82.6%; P = .7). But the left IMA had a better patency rate than the right IMA (95.65% versus 80.43%; P = .02). The patency rates of the left and right IMA anastomosis on the beating heart in Group B were not significantly different (92.3% versus 76.9%; P = .27). The patency of right IMA anastomosis with or without off-pump technique in Group B was similar (76.9% versus 80%; P = .84). CONCLUSIONS: Bilateral IMA can be used with low morbidity and mortality. The angiographic and clinical results of off-pump CABG show that bilateral IMA can also be used in off-pump surgery with similar results.