Biosensors, Aarhus University Hospital, and participating sites.

Midterm to long-term survival after TAVI was encouraging in this high-risk patient population, although a substantial proportion of patients died within the first year.

BACKGROUNDMultiple arterial grafts may result in longer survival than single arterial grafts after coronary-artery bypass grafting (CABG) surgery. We evaluated the use of bilateral internal-thoracic-artery grafts for CABG. METHODSWe randomly assigned patients scheduled for CABG to undergo bilateral or single internal-thoracic-artery grafting. Additional arterial or vein grafts were used as indicated. The primary outcome was death from any cause at 10 years. The composite of death from any cause, myocardial infarction, or stroke was a secondary outcome. RESULTSA total of 1548 patients were randomly assigned to undergo bilateral internalthoracic-artery grafting (the bilateral-graft group) and 1554 to undergo single internal-thoracic-artery grafting (the single-graft group). In the bilateral-graft group, 13.9% of the patients received only a single internal-thoracic-artery graft, and in the single-graft group, 21.8% of the patients also received a radial-artery graft. Vital status was not known for 2.3% of the patients at 10 years. In the intentionto-treat analysis at 10 years, there were 315 deaths (20.3% of the patients) in the bilateral-graft group and 329 deaths (21.2%) in the single-graft group (hazard ratio, 0.96; 95% confidence interval [CI], 0.82 to 1.12; P = 0.62). Regarding the composite outcome of death, myocardial infarction, or stroke, there were 385 patients (24.9%) with an event in the bilateral-graft group and 425 patients (27.3%) with an event in the single-graft group (hazard ratio, 0.90; 95% CI, 0.79 to 1.03). CONCLUSIONSAmong patients who were scheduled for CABG and had been randomly assigned to undergo bilateral or single internal-thoracic-artery grafting, there was no significant between-group difference in the rate of death from any cause at 10 years in the intention-to-treat analysis. Further studies are needed to determine whether multiple arterial grafts provide better outcomes than a single internal-thoracic-artery graft. (Funded by the British Heath Foundation and others; Current Controlled Trials number, ISRCTN46552265.

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Background-Permanent pacemaker (PPM) requirement is a recognized complication of transcatheter aortic valve implantation. We assessed the UK incidence of permanent pacing within 30 days of CoreValve implantation and formulated an anatomic and electrophysiological model. Methods and Results-Data from 270 patients at 10 centers in the United Kingdom were examined. Twenty-five patients (8%) had preexisting PPMs; 2 patients had incomplete data. The remaining 243 were 81.3Ϯ6.7 years of age; 50.6% were male. QRS duration increased from 105Ϯ23 to 135Ϯ29 milliseconds (PϽ0.01). Left bundle-branch block incidence was 13% at baseline and 61% after the procedure (PϽ0.001). Eighty-one patients (33.3%) required a PPM within 30 days.Rates of pacing according to preexisting ECG abnormalities were as follows: right bundle-branch block, 65.2%; left bundle-branch block, 43.75%; normal QRS, 27.6%. Among patients who required PPM implantation, the median time to insertion was 4.0 days (interquartile range, 2.0 to 7.75 days). Multivariable analysis revealed that periprocedural atrioventricular block (odds ratio, 6.29; 95% confidence interval, 3.55 to 11.15), balloon predilatation (odds ratio, 2.68; 95% confidence interval, 2.00 to 3.47), use of the larger (29 mm) CoreValve prosthesis (odds ratio, 2.50; 95% confidence interval, 1.22 to 5.11), interventricular septum diameter (odds ratio, 1.18; 95% confidence interval, 1.10 to 3.06), and prolonged QRS duration (odds ratio, 3.45; 95% confidence interval, 1.61 to 7.40) were independently associated with the need for PPM. Conclusion-One third of patients undergoing a CoreValve transcatheter aortic valve implantation procedure require a PPM within 30 days. Periprocedural atrioventricular block, balloon predilatation, use of the larger CoreValve prosthesis, increased interventricular septum diameter and prolonged QRS duration were associated with the need for PPM. (Circulation. 2011;123:951-960.)Key Words: aortic stenosis Ⅲ electrocardiography Ⅲ pacemakers Ⅲ transcatheter aortic valve Ⅲ transcatheter aortic valve implantation A ortic stenosis (AS) is the most common valvular disease in Europe, 1,2 and age is a significant factor in its natural history. 2 Severe AS occurs in 2% to 4% of adults Ͼ65 years of age. 3,4 Current guidelines recommend aortic valve replacement (AVR) surgery for these patients when they become symptomatic or develop impaired left ventricular systolic function with an ejection fraction Ͻ50%. 5,6 However, the aging population generates greater numbers of patients with severe AS and significant comorbidities, 3 prohibitively raising their perioperative risks for surgical AVR. Since the first successful implant in 2002,7 transcatheter aortic valve implantation (TAVI) has become an increasingly common technology in this cohort. The initial surveillance has been encouraging with respect to procedural success, improvement in quality of life, and short-term and medium-term mortality. 8 -10 Clinical Perspective on p 960Aortic valvular disease is itself associated with cond...