Background-Coronary artery bypass graft surgery with cardiopulmonary bypass is a safe, routine procedure. Nevertheless, significant morbidity remains, mostly because of the body's response to the nonphysiological nature of cardiopulmonary bypass. Few data are available on the effects of off-pump coronary artery bypass graft surgery (OPCAB) on cardiac events and long-term clinical outcomes. Methods and Results-In a single-center randomized trial, 308 patients undergoing coronary artery bypass graft surgery were randomly assigned: 155 to OPCAB and 153 to on-pump CAB (ONCAB). Primary composite end points were death, myocardial infarction, further revascularization (surgery or angioplasty), or stroke. After 5-year follow-up, the primary composite end point was not different between groups (hazard ratio 0.

Objective To evaluate the impact of IVUS guidance on the final volume of contrast agent utilized in patients undergoing PCI. Background To date, few approaches have been described to reduce the final dose of contrast agent in percutaneous coronary interventions (PCI). We hypothesized that intravascular ultrasound (IVUS) might serve as an alternative imaging tool to angiography in many steps during PCI, thereby reducing the use of iodine contrast. Methods A total of 83 patients were randomized to I) angiography-guided PCI or II) IVUS-guided PCI, both groups treated according to a pre-defined meticulous procedural strategy. The primary endpoint was the total volume contrast agent used during PCI. Patients were followed clinically for an average of 4 months. Results The median total volume of contrast was 64.5 ml (interquartile range [IQR] 42.8 – 97.0 ml; minimum 19 ml; maximum 170 ml) in angiography-guided group vs. 20.0 ml (IQR 12.5 – 30.0 ml; minimum 3 ml; maximum 54 ml) in IVUS-guided group (p<0.001). Similarly, the median volume of contrast / creatinine clearance ratio was significantly lower among patients treated with IVUS-guided PCI (1.0 [IQR 0.6 – 1.9] vs. 0.4 [IQR 0.2 – 0.6] respectively; p<0.001). In-hospital and 4-month outcomes were not different between patients randomized to angiography-guided and IVUS-guided PCI. Conclusions Thoughtful and extensive utilization of IVUS as the primary imaging tool to guide PCI is safe, and markedly reduces the volume of iodine contrast, compared to angiography-alone guidance. The use of IVUS should be considered for patients at high risk for contrast-induced acute kidney injury or volume overload undergoing coronary angioplasty.

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Background-Although coronary angioplasty and myocardial bypass surgery are routinely used, there is no conclusive evidence that these interventional methods offer greater benefit than medical therapy alone. This study is intended to evaluate, in a prospective, randomized, and comparative analysis, the benefit of the 3 current therapeutic strategies for patients with stable angina and single proximal left anterior descending coronary artery stenosis. Methods and Results-In a single institution, 214 patients with stable angina, normal ventricular function, and severe proximal stenosis (Ͼ80%) on the left anterior descending artery were selected for the study. After random assignment, 70 patients were referred to surgical treatment, 72 to angioplasty, and 72 to medical treatment. The primary end points were the occurrence of acute myocardial infarction or death and presence of refractory angina. After a 5-year follow-up, these combined events were reported in only 6 patients referred to surgery as compared with 29 patients treated with angioplasty and 17 patients who only received medical treatment (Pϭ0.001). However, no differences were noted in relation to the occurrence of cardiac-related death in the 3 treatment groups (Pϭ0.622). No patient assigned to surgery needed repeat operation, whereas 8 patients assigned to angioplasty and 8 patients assigned to medical treatment required surgical bypass after the initial random assignment. Surgery and angioplasty reduced anginal symptoms and stress-induced ischemia considerably. However, all 3 treatments effectively improved limiting angina. Conclusions-Bypass surgery for single-vessel coronary artery disease is associated with a lower incidence of medium-term and long-term events as well as fewer anginal symptoms than that found in the patients who underwent angioplasty or medical therapy. In this study, coronary angioplasty was only superior to medical strategies in relation to the anginal status. However, the 3 treatment regimens yielded a similar incidence of acute myocardial infarction and death. Such information should be useful when choosing the best therapeutic option for similar patients. (Circulation. 1999;100[suppl II]:II-107-II-113.)