There is ongoing debate regarding the efficacy of the radial artery (RA) as an aortocoronary conduit, with few solid data regarding long-term clinical results. We sought to determine if the use of the RA as the second arterial conduit, beside left internal thoracic artery (LITA), would improve long-term clinical outcome after CABG as compared to saphenous vein graft (SVG). Between March 2001 and November 2003, 200 patients underwent isolated CABG and were randomized in 1:1 fashion to receive either LITA and RA grafts or LITA and SVGs. The primary end point was composite of cardiovascular mortality, non-fatal myocardial infarction and need for repeat myocardial revascularization (either surgical or percutaneous). There was no significant difference in absolute survival, with 12 deaths in each group during the study period (log rank = 0.01, p = 0.979). There were 3 and 2 cardiac deaths in RA and SVG groups, respectively. There was no difference in long-term clinical outcome between the groups (log rank = 0.450, p = 0.509). Eleven patients in RA group had one or more non-fatal events; 7 patients suffered a myocardial infarction, 9 patients underwent percutaneous coronary angioplasty, and 1 patient required redo coronary surgery. Likewise, 13 patients in SVG group had non-fatal event; 7 patients had myocardial infarction, 13 patients had percutaneous coronary intervention and 3 patients required redo coronary surgery. Angiograms were performed in 23 patients in RA group (patency rate 92 %) and 24 in SVG group (patency rate 86 %) (p = 0.67). In this small randomised study our data indicate that there is no difference in the 8 year clinical outcomes in relatively young patients between those having a RA or a saphenous vein graft used as a second conduit, beside LITA, for surgical myocardial revascularisation.

The Randomized Comparison of the Clinical Outcomes of Single versus Multiple Arterial Grafts (ROMA) trial (NCT03217006) [ 1] is the largest randomized trial testing the hypothesis that multiple arterial grafting (MAG) provides superior clinical outcomes compared to single arterial grafting (SAG) in patients undergoing coronary artery bypass surgery (CABG). Trial activities started in January 2017, the first patient was enrolled in January 2018, and the last one (# 4375) was enrolled on 14 April 2023. Here, we summarize the first 7 years of ROMA activities, with particular focus on those aspects that may potentially be relevant for trialists interested in designing or implementing other large cardiac surgery trials. As the trial is ongoing and the primary analysis has not been performed yet, no outcomes or individual patient data are provided. The stimulus to design a second large MAG trial came after evaluating the results of the 5-year analysis of the Arterial Revascularization Trial (ART) in 2016 [ 2]. Following almost 50 years of observational MAG versus SAG comparisons that in general favoured MAG [ 3] and in the presence of convincing evidence of better mid- and long-term patency rates of arterial versus venous grafts [ 4] ART was generally expected to confirm the superiority of MAG and to move the field towards its larger adoption [ 5]. The 5-year analysis of ART was surprising due to the almost perfect overlap of the survival and event-free survival curves of the 2 treatment arms [ 2]; in addition, the frequent utilization of the radial artery as an additional arterial graft in the SAG group, and the high crossover rate (that likely reflected the lack of confidence of the ART surgeons with the use of the bilateral internal thoracic artery), raised key concerns over whether ART could meaningfully test the MAG hypothesis when the final data were available. This was the key motivation to design a new MAG trial, building on the lessons learned from ART—the collaboration with the ART investigators at the early stage was very important to inform the design of ROMA (Table 1).

The successful outcome of a cardiac surgery procedure is significantly dependent on the management of cardiopulmonary bypass (CPB). Even if a cardiac operation is technically well-conducted, a patient may suffer CPB-related complications that could result in severe comorbidities, reduced quality of life, or even death. However, the role of clinical perfusionists in perioperative patient care, which is critical, is often overlooked. Therefore, the European Association for Cardio-Thoracic Surgery (EACTS), the European Association of Cardiothoracic Anaesthesiology (EACTA), and the European Board of Cardiovascular Perfusion (EBCP) have agreed to develop joint clinical practice guidelines (CPGs) for CPB due to its significant impact on patient care and significant variations in practice patterns between countries. The European guidelines, based on the EACTS standardized framework for the development of CPGs, cover the entire spectrum of CPB management in adult cardiac surgery. This includes training and education of clinical perfusionists, machine hardware, disposables, preparation for initiation of CPB, a complete set of procedures during CPB to help maintain end-organ function and anticoagulation, weaning from CPB, and the gaps in evidence and future research directions. This comprehensive coverage ensures that all aspects of CPB management are addressed, providing clinicians with a standardized approach to CPB management based on the latest evidence and best practices. To ensure better integration of these evidence-based recommendations into daily practice, this review aims to provide a general understanding of guideline development and an overview of essential treatment recommendations for CPB management.

It is generally accepted that radial artery (RA) grafts have better mid-term patency rate compared to saphenous vein grafts. However, the clinical correlates of the improved patency rate are still debated. Observational studies have suggested increased survival and event-free survival for patients who receive an RA rather than a saphenous vein, but they are open to bias and confounders. The only evidence based on randomized data is a pooled meta-analysis of 6 randomized controlled trial comparing the RA and the saphenous vein published by the RADial artery International Alliance (RADIAL). In the RADIAL database, improved freedom from follow-up cardiac events (death, myocardial infarction and repeat revascularization) was found at 5-year follow-up in the RA arm. The most important limitation of the RADIAL analysis is that most of the included trials had an angiographic follow-up in the first 5 years and it is unclear whether the rate of repeat revascularization (the main driver of the composite outcome) was clinically indicated due to per-protocol angiographies. Here, we present the protocol for the long-term analysis of the RADIAL database. By extending the follow-up beyond the 5th postoperative year (all trials except 1 did not have angiographic follow-up beyond 5 years), we aim to provide data on the role of RA in coronary artery bypass surgery with respect to long-term outcomes.

The Conclusion returns to the issues of the definition of inner purity, and addresses the place of inner purity and pollution in the broader context of Greek belief. It then presents general observations regarding the language of inner purity and impurity, and provides an overview of their seats and qualifiers. This language is compared with the terminology employed in the later epigraphic evidence, before the discussion moves on to general conclusions regarding continuities of thought and historical patterning. Finally, it lays down general conclusions regarding the synchronic and diachronic aspects of inner purity beliefs, and discusses the role and status of inner purity in the various subsystems analysed.

Anemia is a frequently observed comorbidity in patients with heart failure (HF) and it contributes to increased morbidity and mortality. Even though the etiology of anemia in HF patients is polymorphic, chronic inflammation and iron deficiency (ID) are reported as the most frequent underlying causes. Anemia is a strong prognostic marker in both acute and chronic HF, while ID, even in the absence of anemia, has a negative impact on patients' symptoms, functional capacity, and quality of life (QOL). In chronic HF, functional ID is often present due to impaired iron utilization, but it may coexist with absolute ID, where iron stores are depleted. Intravenous (IV) iron therapy has been shown to have a beneficial effect on improving functional status, reducing symptoms, and lowering the rate of hospital readmissions. This has led to its inclusion in the latest guidelines of the European Society of Cardiology (ESC) as a recommended treatment for symptomatic patients with heart failure with reduced ejection fraction (HFrEF). Several studies have also described a consistent trend toward reduced mortality. The aim of this paper is to summarize current knowledge on the importance of ID and the therapeutic effects of iron supplementation in HFrEF patients. Timely recognition and correction of ID should be considered a cornerstone of individualized HfrEF management.