Despite strong clinical evidence in favor of the use of BIMA grafts, their use in current practice remains disappointingly low, being around 5% of patients in the USA and fewer than 10% in Europe. In an effort to add more scientific data to the debate of SIMA or BIMA grafting, the Arterial Revascularization Trial (ART) randomized 3,102 patients in 28 centers in seven countries.19

The 1-year outcomes showed 30-day mortalities of just over 1% in both groups and just over 2% at 1 year, with no significant difference in the incidence of stroke, myocardial infarction, and repeat revascularization (i.e. safety end-point), which were all Inhibitors,research,lifescience,medical around 2%. This clearly demonstrated that there was no increase in mortality Inhibitors,research,lifescience,medical or myocardial infarction with BIMA grafts. Furthermore the use of a second IMA graft added 23 minutes to the operative procedure which in itself took 3–4 hours. The one note of caution was that there was indeed an increase in sternal wound reconstruction Inhibitors,research,lifescience,medical from 0.6% in the

SIMA group to 1.9% in the BIMA group, i.e. an absolute difference of 1.3% or a number needed to harm of 78 patients. However, it is noteworthy that while one-quarter of all patients in the ART Trial had diabetes almost half the patients requiring sternal wound reconstruction had diabetes. It is highly likely that with more judicious patient selection (avoiding BIMA grafts in obese diabetics or those with impaired lung function) and more precise harvesting techniques (skeletonization rather Inhibitors,research,lifescience,medical than pedicle to preserve collateral circulation)20 the incidence of sternal wound Inhibitors,research,lifescience,medical reconstruction would be significantly lower. While the results of recent trials of CABG versus stents in general populations (such as the SYNTAX Trial) and in diabetics (the FREEDOM Trial) confirm the significant superiority of CABG over stents in terms of superior survival and freedom

from subsequent myocardial infarction or repeat revascularization, the low use of BIMA grafts in current practice is a poor reflection of optimal surgical therapy. The recommendations in PF-04691502 cell line guidelines support the use of more arterial grafts during CABG,21,22 and the National Societies Pharmacological Reviews of Cardiothoracic Surgery should give increased recognition to and promote more use of BIMA grafts. OFF-PUMP SURGERY For almost three decades there has been controversy as to the potential benefits of off-pump CABG in relation to on-pump CABG. The initial rationale for off-pump CABG was mainly driven by economic considerations in developing countries where the economic cost of cardiopulmonary bypass made CABG an unrealistic proposition in many patients.