A randomized surgical trial of mitral valve repair with leaflet resection versus leaflet preservation on functional mitral stenosis – primary results of the CAMRA CardioLink-2 trial

Background

The gold standard treatment for mitral valve regurgitation due to prolapse involves surgery with annuloplasty and either leaflet resection or leaflet preservation, with placement of artificial neochordae. It has been suggested that leaflet resection may be prone to functional mitral stenosis, whereby a patient may have a higher mitral gradient at peak exercise compared to a leaflet preservation strategy. Although both techniques are widely used, there has been no prospective randomized study conducted to compare these two techniques, particularly in regard to functional mitral stenosis.

Methods

A total of 104 patients with posterior leaflet prolapse were randomized to undergo mitral repair with either leaflet resection (N=54) or leaflet preservation (N=50) at 7 specialized Canadian cardiac centers. Patient age, proportion of female patients, and mean Society of Thoracic Surgeons risk score was 63.9±10.4 years, 19%, and 1.4% for those who underwent leaflet resection, and 66.3±10.8 years, 16%, and 1.9% for those who underwent leaflet preservation, respectively. The primary endpoint was the mean trans-mitral repair gradient at peak exercise 12-months after repair.

Results

Baseline characteristics were similar between the groups. At 12-months, the mean trans-mitral repair gradient at peak exercise in patients who underwent leaflet resection and preservation was 9.1±5.2 and 8.3±3.3 mmHg (P=0.4), respectively. The two groups had similar mean mitral valve gradient at rest (3.2±1.9 mmHg following resection and 3.1±1.1 mmHg following leaflet preservation, P=0.7). There was no between-group difference for the 6-minute walk distance (451±147 m and 481±95 m for the resection and preservation groups, respectively, P=0.3).

Conclusion

We report the first prospective surgical randomized trial to evaluate commonly used mitral valve repair strategies for posterior leaflet prolapse. Leaflet resection and leaflet preservation both yield acceptable results with no difference in postoperative valve gradient and functional status 12-months after surgical mitral valve repair.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Heart and Stroke Foundation of Canada

The inflammatory response to cardiopulmonary bypass: a therapeutic overview

The demographic of cardiac surgery patients continues to evolve to include older, sicker candidates, all the while maintaining an expectation of excellent outcomes. These latter results can only be achieved by the parallel advancement and re-examination of the technology of cardiopulmonary bypass (CPB); the key tool used daily by surgical teams worldwide. In this review, we will provide an overview of integrated therapeutic strategies that can be utilized to minimize the complex and myriad changes related to inflammation after CPB with the understanding that this may abrogate the detrimental end-organ and systemic effects of blood activation. Therapeutic strategies specifically related to the technology can be classified into those targeting biomaterial dependent or independent processes. The former can be addressed by the utilization of currently available biocompatible surfaces such as with heparin-coated circuits, phosphorylcholine-coated circuits (‘biomembrane mimicry’) and circuits composed of copolymers containing surface-modifying additives. The most important strategies related to biomaterial independent activation include the modification of techniques related to cardiotomy blood management and blood filtration. Finally, all of these strategies must be integrated and tailored with complementary pharmacologic agents such as aprotinin and steroids to optimize anti-inflammatory synergism. Only if we are armed with a comprehensive knowledge of the molecular and cellular basis for these strategies will we be able to continue to evolve our treatment in parallel with our patients to achieve these goals.

Severe Lower Limbs Lymphedema Following Breast Carcinoma Treatment Revealing Radiation-Induced Constrictive Pericarditis

In patients treated for breast carcinoma, unilateral lymphedema of the upper limb is usual. However, to the authors’ knowledge, lower limb lymphedema has never been reported as a complication of breast carcinoma therapy. They report here the first case of a radiation-induced constrictive pericarditis revealed by severe lower limbs lymphedema. A 60-year-old woman was treated for left breast carcinoma with quadrantectomy, axillary lymphadenectomy, and combined radio chemotherapy (60 grays). Three and a half years later she suffered from a diffuse and increasing lower limbs lymphedema, which became huge and disabling. Radiation-induced constrictive pericarditis was evidenced by right cardiac cavities catheterization. A dramatic improvement was rapidly obtained after pericardectomy. Histopathologic analysis of the pericardium did not reveal neoplastic cells. Radiation-induced constrictive pericarditis is usually responsible for lower limbs edema, but lymphedema is exceptional. This case highlights the need to search for a constrictive pericarditis also in the case of lower limbs lymphedema, particularly in a patient treated with mediastinal radiotherapy or combined radio chemotherapy.

Long-Term Follow-Up of Outcomes With F-18-Fluorodeoxyglucose Positron Emission Tomography Imaging–Assisted Management of Patients With Severe Left Ventricular Dysfunction Secondary to Coronary Disease

Background—

Whether viability imaging can impact long-term patient outcomes is uncertain. The PARR-2 study (Positron Emission Tomography and Recovery Following Revascularization) showed a nonsignificant trend toward improved outcomes at 1 year using an F-18-fluorodeoxyglucose positron emission tomography (PET)–assisted strategy in patients with suspected ischemic cardiomyopathy. When patients adhered to F-18-fluorodeoxyglucose PET recommendations, outcome benefit was observed. Long-term outcomes of viability imaging–assisted management have not previously been evaluated in a randomized controlled trial.

Methods and Results—

PARR-2 randomized patients with severe left ventricular dysfunction and suspected CAD being considered for revascularization or transplantation to standard care (n= 195) versus PET-assisted management (n=197) at sites participating in long-term follow-up. The predefined primary outcome was time to composite event (cardiac death, myocardial infarction, or cardiac hospitalization). After 5 years, 105 (53%) patients in the PET arm and 111 (57%) in the standard care arm experienced the composite event (hazard ratio for time to composite event =0.82 [95% confidence interval 0.62–1.07]; P =0.15). When only patients who adhered to PET recommendations were included, the hazard ratio for the time to primary outcome was 0.73 (95% confidence interval 0.54–0.99; P =0.042).

Conclusions—

After a 5-year follow-up in patients with left ventricular dysfunction and suspected CAD, overall, PET-assisted management did not significantly reduce cardiac events compared with standard care. However, significant benefits were observed when there was adherence to PET recommendations. PET viability imaging may be best applied when there is likely to be adherence to imaging-based recommendations.

Clinical Trial Registration—

URL: http://www.clinicaltrials.gov . Unique identifier: NCT00385242.

Assessment of cyclosporine pharmacokinetic parameters to facilitate conversion from C0 to C2 monitoring in heart transplant recipients

BACKGROUND

Cyclosporine (CsA) 2-hour postdose (C2) monitoring is recommended to assess CsA exposure and predict clinical outcomes among heart transplant recipients. We correlated pharmacokinetic parameters and clinical outcomes in stable long-term heart transplant recipients monitored with C0 to develop an algorithm to convert patients from C0 to C2 monitoring.

METHODS

Paired CsA C0-C2 measurements and serum creatinine levels were obtained from 35 heart transplant recipients more than 2 years posttransplantation (mean 8.8+/-4.7 years).

RESULTS

The mean CsA dose and C0, C2, and C0/C2 ratio were 85+/-23 mg/12 hours, 123+/-41 ng/mL, 572+/-274 ng/mL and 4.8+/-2.1, respectively. C0 correlated weakly with C2 (r=.42, P=.011). The CsA dose correlated better with C2 (r=.58; P<.001) than with C0 (r=.37; P=.026). A good correlation was noted between C2 and the C2/C0 ratio (r=.73; P<.001), but none between C0 and the C2/C0 ratio. A borderline significant inverse correlation was noted between C0 and the worst endomyocardial biopsy score (r=-.34; P=.045), whereas none was noted with C2. Serum creatinine level did not correlate with either C2 or C0. Among patients with C0 within our target of 100 to 150 ug/L, six had C2 above 300 to 600 ug/L as suggested by the literature.

CONCLUSIONS

In long-term heart transplant recipients, we could not identify a single pharmacokinetic parameter that could be used to develop an algorithm to convert from C0 to C2 monitoring; however, C2 may be better than C0 for identifying patients at risk of overexposure to CsA.

Delayed thrombin generation is not associated with fibrinopeptide formation during prolonged cardiopulmonary bypass with hirudin anticoagulation

Patients with heparin-induced thrombocytopenia urgently requiring surgery with cardiopulmonary bypass (CPB) present a unique management challenge that must be addressed by the use of alternative anticoagulants. Although clinical success with the direct thrombin inhibitor hirudin has been reported, there is sparse information in the literature supporting the efficacy of this drug as an anti-thrombotic to prevent fibrin formation during CPB. In this report, we describe the efficacy of this drug to prevent thrombin-mediated fibrin formation during CPB.

[Adult apico-aortic shunts. A case followed for 6 years]

An apico-aortic shunt enables a reduction in the aortic transvalvular pressure gradient. It is recommended for patients with symptomatic severe stenosis when anatomical constraints contra-indicate valvular replacement. The authors report the case of a patient who underwent this uncommon procedure, which was indicated due to previous coronary bypass surgery using both mammary arteries, plus massive calcification of the ascending aorta. Angio-haemodynamic investigation and MRI performed three years and five years respectively following the procedure confirmed its efficiency. An analysis of the few reported series confirms the value of this special procedure.

Visceral Kaposi's sarcoma associated with human herpesvirus 8 seroconversion in a heart transplant recipient

A close association between human herpesvirus-8 (HHV-8) and Kaposi's sarcoma (KS) has been shown in transplant recipients, but donor-to-recipient transmission of HHV-8 is uncommon. Herein we report a case of a heart transplant recipient who had a fatal visceral KS in association with HHV-8 seroconversion at 18 months after transplantation with a donor having positive serology discovered after transplantation.

[Mitral insufficiency related to a spasm of the left anterior descending artery. A case report]

We report the case of a female patient of 76 years old admitted to our hospital for a pre-operative assessment of a symptomatic mitral regurgitation (MR) whose transthoracic echocardiography revealed only a trivial regurgitation. The occurrence during hospital stay of an acute pulmonary edema contemporary to the occurrence of a huge MR permitted to suspect the diagnosis of a paroxystic ischemic MR. Angiographic and hemodynamic evaluation revealed only a non-significant atheromateous plaque located in the distal LAD. The infusion of Methylergometrine triggered a severe spasm at the site of that plaque, associated with a huge MR visualized by TTE with restricted movements of both leaflets, responsible for an acute pulmonary edema occurring on the table of the catheterization laboratory. Recovery was quickly obtained after intravenous injection of Nitroglycerin, which removed the spasm and valvular regurgitation. The diagnosis of paroxystic ischemic mitral regurgitation was confirmed and a treatment based on high dosage of calcium-blocker was decided. After a follow-up of more than one year, the patient remains asymptomatic and the regurgitation has never occurred.

Surface Modified Cardiopulmonary Bypass Circuits: Modifying the Inflammatory Response

As a consequence of an aging population demographic, now more than ever, researchers in cardiac surgery must focus on means to improve the methods and technologies related to cardiopulmonary bypass. This review presents a classification of the currently available options for biomaterial modification for cardiopulmonary bypass circuits. Hypotheses are given relating the mechanism of action by which some of these surfaces afford improved biocompatibility. Finally, nonpharmacologic biomaterial-independent strategies for minimizing the effects of cardiopulmonary bypass, such as the use of hemofiltration and leukocyte filtration, and the minimization of the use of cardiotomy suction blood are outlined.

[Heyde syndrome]

OBJECTIVE

Heyde's syndrome associates aortic stenosis and digestive hemorrhage secondary to intestinal angiodysplasia.

OBSERVATION

A 61 year-old man presented with anemia due to martial deficiency and melena, the endoscopic examination of which was negative. The existence of a tight aortic stenosis, suspected on auscultation, suggested the diagnosis of Heyde's syndrome. Angiodysplasia is revealed during oriented enteroscopy. Following valve replacement, the need for transfusion disappeared, together with the anemia.

DISCUSSION

Although some epidemiological studies deny the existence of this syndrome, the observation of authentic cases of resolution of digestive bleeding following surgical replacement of an aortic valve, such as ours, is an argument in favor of the reality of Heyde's syndrome.

Local delivery of NO-donor molsidomine post-PTA improves haemodynamics, wall mechanics and histomorphometry in atherosclerotic porcine SFA

OBJECTIVES

we investigated the therapeutic effect of angioplasty with local drug delivery (LDD) of the wall-accumulating NO-donor molsidomine (M) in the superficial femoral arteries (SFA) of atherosclerotic swine.

MATERIALS AND METHODS

atherosclerotic Pietrin swines (n=14) underwent PTA-LDD-M (4 mg/2 ml) vs contralateral PTA-LDD-Placebo in the SFA using a channelled balloon angioplasty catheter. Invasive and colour Doppler energy (CDE) assessments of haemodynamics and wall mechanics were performed at 24 h (n=4) and 5 months (n=10). Immuno-histolabelling of cell proliferation and histomorphometry were serially performed in perfusion fixed SFA samples.

RESULTS

at 24 h, PCNA-positive nuclei revealed 33+/-14 and 12+/-3 proliferating cells/mm2 at placebo and molsidomine PTA-LDD sites, respectively (p<0.001). At 5 months, PTA-LDD-M vessels, compared with PTA-LDD-P, had increased compliance (66+/-9 vs 11+/-4 ml/mmHg) and lowered impedance (0.11+/-0.05 vs 0.45+/-0.14 mmHg/ml x min(-1)) (p<0.05). CDE revealed low, middle and high velocity peaks at 7.5, 20 and 35, and 8, 15 and 22 cm x s(-1) in systolic and diastolic flows, respectively; and PTA-LDD-M prevented emergence of restenosis-associated increases in low blood velocities (p<0.01). PTA-LDD-M inhibited restenotic intimal thickening and medial thinning which decreased mean lumenal diameter in placebo-treated (2.6+/-0.3) as compared to molsidomine-treated (3.4+/-0.3 mm) vessels (p<0.05).

CONCLUSIONS

in the atherosclerotic porcine SFA model, PTA-LDD with molsidomine consistently improved haemodynamic wall mechanics, lowered cell proliferation and prevented late lumen loss observed with PTA-LDD with placebo.

Hyperprocalcitonemia is related to noninfectious postoperative severe systemic inflammatory response syndrome associated with cardiovascular dysfunction after coronary artery bypass graft surgery

OBJECTIVE

To investigate the role of 3 inflammatory parameters as early markers of severe systemic inflammatory response syndrome (SIRS) induced by coronary artery bypass graft surgery.

DESIGN

Prospective study.

SETTING

University hospital.

PARTICIPANTS

Patients (n = 63) undergoing elective coronary artery bypass graft surgery with cardiopulmonary bypass.

MEASUREMENTS AND MAIN RESULTS

The American College of Chest Physicians/Society of Critical Care Medicine classification was used to diagnose SIRS. Organ system failures were used to define severe SIRS. Serum concentrations of the inflammatory parameters (procalcitonin [PCT], C-reactive protein, leukocyte count) were determined before, during, and after surgery. SIRS occurred in 30 (47%) patients after surgery. Seven patients (11%) showed SIRS with greater-than-or-equal1 organ dysfunction (severe SIRS), whereas patients without SIRS had no organ dysfunction. Significantly higher serum levels of PCT were found in patients with severe SIRS from the 6th postoperative hour until the 3rd postoperative day with a peak level of 10.7 plus minus 13.2 ng/mL. No significant difference was detected between serum PCT of patients with SIRS but without any organ dysfunction and patients without SIRS. PCT levels of these patients remained lower than 1.7 ng/mL. Compared with PCT, plasma concentrations of C-reactive protein peaked later on the 2nd postoperative day and were not able to confirm the severity of SIRS. Leukocyte counts were not significantly modified.

CONCLUSIONS

PCT seems to be an appropriate marker to identify the early development of noninfectious postoperative severe SIRS after coronary artery bypass graft surgery with cardiopulmonary bypass.

[Is chronic or recurrent idiopathic pericarditis an autonomous inflammatory disease?]

PURPOSE

Chronic pericarditis or recurrent pericarditis is mostly considered to be idiopathic even when up-to-date medical investigations are undertaken. The absence of aetiology and the associated inflammatory process are features of a common disease for internists. As there are only a few published reports on this disease, therapeutic options are not easily envisaged.

CURRENT KNOWLEDGE AND KEY POINTS

Idiopathic pericarditis and its evolution, characterized by recurrence or chronicity, has long been diagnosed and studied. Faced with a case of acute pericarditis, no clinical or biological data can preclude evolution towards a chronic or a recurrent form. The two major complications are tamponade and constriction. Classical treatment is aspirin and nonsteroidal anti-inflammatories. Steroids have a spectacular effect but steroid dependence is frequently observed. Colchicine treatment seems to be efficacious and can be used to stop steroid therapy. There are only a few published reports on the importance of immunosuppressive drugs such as azathioprine and cyclophosphamide.

FUTURE PROSPECTS AND PROJECTS

Through our own experience and literature review, we propose to consider chronic and/or recurrent pericarditis as an autonomous inflammatory disease of the pericardium. Thus, large-scale studies concerning the treatment should improve the outcome of patients.

Comparison of clinical and echocardiographic characteristics of Streptococcus bovis endocarditis with that caused by other pathogens

The aim of our study was to compare the clinical, echographic, and prognostic features of Streptococcus bovis (S. bovis) endocarditis with those caused by other streptococci and pathogens in a large sample of patients with definite endocarditis by Duke criteria, using transesophageal echocardiography. Two hundred six patients (149 men, mean age 57 +/- 15 years) with a diagnosis of infective endocarditis formed the study population. All patients underwent multiplane transesophageal echocardiography and blood cultures. Cerebral, thoracoabdominal computed tomographic scan was performed in almost all patients (95%). All patients with S. bovis endocarditis underwent colonoscopy. Incidence of S. bovis endocarditis in our sample was 19%. Patients with S. bovis endocarditis were older than other groups. Multiple valve involvement, native valves, and large vegetations (>10 mm) were more frequent in patients with S. bovis. There was a significantly higher occurrence of embolism in the S. bovis group. Splenic embolism and multiple embolisms were significantly more frequent in patients with S. bovis. Gastrointestinal lesions, anemia, and spondylitis were observed more frequently with S. bovis endocarditis. In addition to the requirement for gastrointestinal examination for S. bovis endocarditis, our study underlines the need for systematic screening for vertebral and splenic localizations, and suggests the use of early surgery to prevent the high risk of embolism in these patients.

Evaluation of endovascular techniques for creating a porcine femoral artery occlusion model

PURPOSE

To determine the optimal endovascular approach to achieve long-term occlusion of large arteries, while preserving the integrity of periarterial tissue, in an animal model of ischemia.

METHODS

Femoral artery occlusions were created in 16 pigs using detachable balloons, coils, or blinded stent-grafts. Feasibility, safety, primary and long-term success, and the degree of neovascularization were determined over a 6-month period by serial angiography and histological analyses. Four animals served as untreated controls.

RESULTS

Overall primary success for all occlusion devices was 100%. The 6-month occlusion rate using detachable balloons or coils was 33% and 0%, respectively; however, all arteries occluded with blinded stent-grafts remained obstructed to the end of the study. There was no significant difference in capillary densities and collateralization of periarterial areas when occluded arteries were compared with nonoccluded controls in the same animal. No increase in collateralization was observed following endovascular arterial occlusion.

CONCLUSIONS

Percutaneous insertion of blinded stent-grafts easily, safely, and reliably creates long-term arterial occlusion in pigs, which may make this a more appropriate model for studying the effects of angiogenic factors in vivo.

Late results of double-valve replacement with biologic or mechanical prostheses

BACKGROUND

We previously showed that the risk of reoperation for structural degeneration of bioprostheses was higher in cases involving patients older than 65 years (p = 0.003) and double-valve replacement (p = 0.02). The purpose of this study was to compare late outcome of mitral-aortic valve replacement using bioprostheses or mechanical valves.

METHODS

The bioprosthesis group included all mainland France residents (n = 48) between 55 and 65 years old operated on between 1980 and 1995 for mitral-aortic valve replacement using bioprostheses. The mechanical valve group was obtained by matching each of these patients with a patient operated on using mechanical valves at approximately the same time during the study.

RESULTS

In the bioprosthesis group, 10-year survival was 45%+/-8% versus 62%+/-7% in the mechanical valve group (not significant). The linearized reoperation rate was 6.8 per patient-year versus 1.1 per patient-year (p = 0.001), and the linearized reoperative mortality rate was 1.8 per patient-year and 0.7 per patient-year (not significant), respectively.

CONCLUSIONS

The reoperative mortality risk after mitral-aortic valve replacement using two bioprostheses does not significantly decrease overall survival after age 65 years.

RT-PCR detection of the Na,K-ATPase beta3-isoform in human heart

The Na,K-ATPase is a heterodimer composed of an alpha-catalytic and a beta-glycoprotein subunit. At present, three different alpha-polypeptides (alpha1, alpha2, alpha3) and two distinct beta-isoforms (beta1 and beta2) have been detected in human heart. The aim of the present study was to determine whether or not the beta3-isoform of the Na,K-ATPase can be detected in human heart. Using the highly sensitive method of RT-PCR, we here show that human heart expresses the beta3-isoform of the Na,K-ATPase. Given the differences in pharmacological properties of the nine different Na,K-ATPase isoenzymes (containing all combinations of the subunit isoforms), the study of beta3-isoform regulation in human heart may be of interest in understanding the altered response of human myocardium to digitalis therapy during heart failure.

Simultaneous Measurements of Arterial Diameter and Blood Pressure to Determine the Arterial Compliance, Wall Mechanics and Stresses In vivo

BACKGROUND

to develop a periarterial dimensional clip-probe which, associated with endovascular pressure measurement, real-time digital signal processing/data treatment systems, enables characterisation of the basic wall mechanics in given arterial sites.

DESIGN

experimental study.

MATERIAL

a facing pair of ultrasonic crystals was incorporated in periarterial highlight probes, made of sterilisable silicone and manufactured from computer-designed stainless steel casts. The A/D converted diameter and pressure (from an endovascular micro-tip probe) signals, triggered by the ECG, were on-line processed to provide their respective profiles during an averaged cardiac cycle, and subsequently the arterial wall physics. The technique was tested in the iliac and renal arteries in eight pigs.

RESULTS

the technique was found to indicate adequately that arterial responses to distending blood pressure, as given by Petersons modulus and relative pulsatility, were identical in renals and iliacs. In contrast, the compliance, circumferential incremental elastic modulus and midwall circumferential stress were higher in iliacs than in renals, whereas arterial stiffness of the renals surpassed that of the iliacs.

DISCUSSION

the technique with sterilisable probes produces in vivo pressure-diameter relationships, arterial compliance, and wall mechanics and stresses, whatever the arterial size. The porcine iliacs and renals are elastic and viscorigid arteries, respectively.

Mechanical circulatory support for advanced heart failure: effect of patient selection on outcome

BACKGROUND

Use of wearable left ventricular assist systems (LVAS) in the treatment of advanced heart failure has steadily increased since 1993, when these devices became generally available in Europe. The aim of this study was to identify in an unselected cohort of LVAS recipients those aspects of patient selection that have an impact on postimplant survival.

METHODS AND RESULTS

Data were obtained from the Novacor European Registry. Between 1993 and 1999, 464 patients were implanted with the Novacor LVAS. The majority had idiopathic (60%) or ischemic (27%) cardiomyopathy; the median age at implant was 49 (16 to 75) years. The median support time was 100 days (4.1 years maximum). Forty-nine percent of the recipients were discharged from the hospital on LVAS; they spent 75% of their time out of the hospital. For a subset of 366 recipients, for whom a complete set of data was available, multivariate analysis revealed that the following preimplant conditions were independent risk factors for survival after LVAS implantation: respiratory failure associated with septicemia (odds ratio 11.2), right heart failure (odds ratio 3.2), age >65 years (odds ratio 3.01), acute postcardiotomy (odds ratio 1.8), and acute infarction (odds ratio 1.7). For patients without any of these factors, the 1-year survival after LVAS implantation including the posttransplantation period was 60%; for the combined group with at least 1 risk factor, it was 24%.

CONCLUSIONS

Careful selection, specifically implantation before patients become moribund, and improvement of management may result in improved outcomes of LVAS treatment for advanced heart failure.

Clinical evaluation of heparin-coated circuits for routine coronary artery bypass grafting surgery: a prospective randomized study

The aim of this study was to demonstrate the clinical and biological benefits of heparin-coated circuits in routine coronary artery bypass grafting (CABG). A prospective, randomized study was conducted in 80 patients undergoing routine CABG. Patients were randomized to either noncoated circuits (Group 1) or heparin-coated circuits (Group 2). A complete clinical evaluation was performed preoperatively at Days 0, 1, 2, and 3 and at discharge day and combined with extensive laboratory tests for hemostasis and inflammatory response. This study did not prove any major statistically significant clinical benefit of heparin-coated circuits in low risk patients. Postoperative bleeding, significantly less in the heparin-coated group, did not decrease significantly the number of transfused patients. Biological values were not changed significantly except for factor II and monocytes, which were higher in Group 2. Heparin-coated circuits offer minimal clinical and biological benefits for routine CABG surgery. However, they may prove beneficial for complex procedures or at-risk patients.