The role of hybrid CABG PCI compared with sole PCI and sole conven- tional CABG awaits the results of the ongoing observational study of hybrid coronary revascularization by the National Heart, Lung, and Blood Institute. 8.2. Protein and Gene Therapy Several proteins, such as vascular endothelial growth factor, acidic fibroblast growth factor, and basic fibroblast growth factor, induce angiogenesis1262; as a result, interest has grown in using these substances to stimulate myocardial perfusion. One RCT found that patients who were given 100 mcg of basic fibroblast growth factor became angina free, and nu- clear perfusion testing appeared to show improved perfu- sion.1262 Another RCT has suggested that the intracoronary injection of high-dose angiogenic molecules yields improve- ment in symptoms, exercise time, functional capacity, and myocardial perfusion.1263 Alternatively, gene therapy may be used to induce angiogenesis, but conceptual concerns with intravascular gene therapy, such as peripheral uptake into nontarget tissues and subsequent unintended effects, have been raised. 8.3. Teaching CABG to the Next Generation: Use of Surgical Simulators Over the past decade, pressure on hospitals and physicians to ensure high quality and safety has increased. Public reporting of outcomes, common in many states, has been endorsed by the STS. In addition, healthcare reform has placed great emphasis on the efficiency of care. These factors, coupled with the increased complexity of patients referred for CABG, the decreased number of qualified physicians specializing in cardiac surgery, and the restrictions on resident work hours, make the teaching of surgical techniques to the next genera- tion a substantial challenge. Given the success of simulator training of airline and military personnel, it has the potential to have a major impact on surgical training paradigms. 