| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
Ann Thorac Surg 1999;68:383-389
© 1999 The Society of Thoracic Surgeons
a Medical City Dallas Hospital, Dallas, Texas, USA
b Allegheny University Hospital, Medical College Pennsylvania, Pittsburgh, Pennsylvania, USA
Address reprint requests to Dr Mack, 7777 Forest Lane, C-742 Dallas, TX 75230
e-mail: mmack{at}crsti.org
Presented at the Thirty-fourth Annual Meeting of The Society of Thoracic Surgeons, New Orleans, LA, Jan 26–28, 1998.
 |
Abstract |
|---|
 Top Abstract IntroductionPatients and methodsResultsCommentReferences |
|---|
Methods. A prospective study of consecutive patients undergoing MIDCAB LIMA to LAD was undertaken. All procedures were performed through a limited anterior thoracotomy incision with a stabilization device. Selective angiography of the LIMA graft was performed intraoperatively or in the immediate postoperative period.
Results. One hundred and three patients underwent the MICAB procedure. Angiographic evaluation of the anastomosis was obtained in 100 patients (97%). Angiographic graft patency was 99%, with perfect graft patency (no stenosis greater than 50%) being 91%. Three grafts were revised in the operating room. One patient underwent reoperation and 3 more underwent percutaneous transluminal coronary angioplasty. There were two noncardiac mortalities (1.9%), both with patent grafts.
Conclusions. Immediate graft patency after MIDCAB is acceptable, and comparable with conventional CAB data, although meaningful comparison is difficult. The significance of early angiographic findings and the role for early angiography remain to be defined.
|
Introduction |
|---|
|
TopAbstractIntroductionPatients and methodsResultsCommentReferences |
|---|
Coronary angiography has been accepted as the "gold standard" for assessment of graft patency. We, therefore, undertook a prospective study of MICAB patency as determined by immediate angiography.
|
Patients and methods |
|---|
|
TopAbstractIntroductionPatients and methodsResultsCommentReferences |
|---|
80 years old), had previous bypass surgery, (14 [14%]), or significant comorbidities that precluded cardiopulmonary bypass. These included chronic renal insufficiency, cerebral vascular disease, or severe chronic obstructive pulmonary disease (FEV1 
20% of predicted).
|
Harvest of the internal mammary artery was most commonly performed under direct vision using a chest wall retractor to allow pedicle visualization. Video assistance was frequently used to facilitate dissection of the proximal portion of the internal mammary artery. The full length of the internal mammary artery (IMA) was harvested to assure adequate length and to alleviate concerns regarding side branch steal. Division of the LIMA was performed after administration of 1 mg/kg of heparin systemically. Intraluminal instillation of a vasodilator, papaverine, into the LIMA was used at the discretion of the operating surgeon to alleviate spasm from manipulation.
After the LAD was identified on the anterior surface of the heart and a satisfactory target site for anastomosis for ascertained, Silastic snares were placed proximal and distal to the target site. A mechanical stabilization device was placed to provide local immobilization of the anastamotic area. Preconditioning was not routinely employed because in our experience it was found not to be necessary. An end-to-side anastomosis with one or two running sutures was performed. The proximal Silastic snare was tightened to occlude blood flow, but the snare was not used for retraction or stabilization. The distal snare was tightened only if necessary to obtain a bloodless field after the arteriotomy was performed. Frequently, distal retrograde flow was minimal, allowing the snare to be left slack. A carbon dioxide blower was used to clear blood from the operative field and to distend the coronary artery for suture placement, obviating the need to touch the vessel wall with forceps. On completion of the anastomosis, the pericardium was divided and a "trough" created for the LIMA pedicle to lie in a straight line with positioning medial to the reexpanded lung. A small chest tube or Silastic drain was placed in the left pleural space before incision closure.
The patients were routinely extubated in the operating room if not mechanically ventilated preoperatively. Care in the intensive care unit for the first 24 hours was routine, and discharge was planned for between the second and fourth postoperative day after angiographic evaluation was complete.
Angiographic technique
Evaluation of the LIMA conduit was performed either intraoperatively or in the immediate postoperative period ( 96 hours). For those evaluated intraoperatively, arterial access was gained by either the right or left femoral artery with a 6 F LIMA catheter. A portable C-arm digital imaging system (OEC Series 9600 Cardiac Mobile Digital C-Arm; OEC Medical Systems, Salt Lake City, UT) was employed, and standard right anterior oblique and left anterior oblique views were obtained. The full length of the IMA, anastomosis, and distal coronary artery were examined. Additional views were obtained if necessary for complete evaluation.
In those patients who underwent postoperative evaluation, angiography was performed in the cardiac catheterization laboratory. Access for angiography was usually through a left brachial artery approach, and a 4 F LIMA catheter was used to obtain the standard left anterior oblique and right anterior oblique views. Additional views were taken as necessary to obtain accurate assessment of the anastomosis.
|
Results |
|---|
|
TopAbstractIntroductionPatients and methodsResultsCommentReferences |
|---|
|
|
|
A second patient with idiopathic pulmonary fibrosis and cirrhosis developed adult respiratory distress syndrome postoperatively and succumbed to respiratory failure. He was demonstrated to have a patent graft intraoperatively.
Other complications included atrial fibrillation in 8 patients (7.7%), reoperation for bleeding in 4 patients (3.9%), pleural effusion requiring thoracentesis in 5 patients (4.8%), postoperative cerebrovascular accident in 1 patient (0.9%), exacerbation of preexisting renal failure in 1 patient (0.9%), respiration insufficiency in 7 patients (6.8%), and postthoracotomy pain in 5 patients (4.8%).
Intraoperative or immediate postoperative angiography ( 96 hours) was performed on 100 of 103 consecutive patients. Three patients did not receive angiography due to preexisting renal insufficiency (serum creatinine 4.0 mg/mL) or inability to gain peripheral arterial access in the operating room for IMA angiogram (2 patients). All 3 patients are alive and asymptomatic from a cardiac standpoint.
All angiograms were evaluated by the FitzGibbon grading system (Table 5) [3]. Ninety-nine of the 100 grafts evaluated by angiography were patent. One obese patient with an intramyocardial LAD underwent postoperative angiography demonstrating graft occlusion (Table 6). Ninety-one patients (91%) had patent grafts with no significant (greater than or equal to 50%) stenosis (FitzGibbon Grade A). Eight patients had grafts with a significant angiographic abnormality (FitzGibbon Grade B).
|
|
Of the 62 patients who underwent postoperative angiography, 1 patient with an intramyocardial LAD had unsuspected total occlusion. Five additional patients had a significant angiographic abnormality. One patient underwent percutaneous transluminal coronary angioplasty for stenosis of the distal IMA pedicle, and another for a stenosis in the LAD just distal to the anastomosis in 1 patient. In the 3 additional patients, it was elected to follow expectantly without revision after an ischemia study. Positron emission tomography (PET) scan was demonstrated to be normal. All 3 patients are alive and asymptomatic. Two of these patients have undergone repeat angiography at 6 months, with the previously stenotic area of the IMA graft resolving in both patients (Fig 1). One additional patient with a demonstrated patent graft immediately postoperatively has developed graft occlusion 4 months postoperatively and underwent reoperation.
|
|
Comment |
|---|
|
TopAbstractIntroductionPatients and methodsResultsCommentReferences |
|---|
Regarding the technique of intraoperative angiography, numerous issues exist. Should it be performed by the surgeon or by a cardiologist? In our institution, when performing intraoperative angiography, a cardiologist was willing to be available for the procedure, but in some other institutions, when performing intraoperative angiography, the cardiac surgeons themselves have been performing the angiographic study [4]. Another issue is the additional operative time necessary to perform intraoperative angiography. In our patients who underwent intraoperative angiography, an additional 45 to 60 minutes was necessary, although other institutions report being able to perform the intraoperative angiogram in a 15- to 20-minute period.
Also, an issue is the availability of roentgenogram equipment of sufficient quality to accurately judge quality of the anastomosis. Most operating rooms have a C-arm image intensifier that can be used, but does not give state-of-the-art cardiac cath-quality images. Portable digital angiography systems are now commercially available, capable of quality imaging, but add significant capital expenditure to the heart team.
The advantage of obtaining an intraoperative angiogram is the ability to document graft patency before leaving the operating room. Conversely, there is the issue of what to do with the abnormal findings. Some angiographic stenotic lesions may be due to clot or intramural hematoma, which many investigators (A. Calafiore, V. Subramanian, personal communication) have found resolves without additional intervention. In addition, diminished flow has been documented by many other surgeons to be due to spasm, which again resolves after the immediate postoperative period. Therefore, the presence of an angiographic abnormality may lead to an unnecessary revision, which has happened in some centers.
Postoperative angiography offers the benefit of being able to document graft patency before discharge, but involves an additional procedure with the associated additional expense. Nevertheless, this short time interval may allow for some early abnormalities (eg, spasm) to resolve.
Other issues exist regarding early postoperative angiography. It is not known whether early graft patency translates to long-term graft patency. Although our follow-up period is short (mean follow-up 6 months), 1 additional patient has required reoperation for graft occlusion of a previously demonstrated patent graft.
Other diagnostic modalities exist to evaluate immediate graft patency, including intraoperative functional flow reserve measurement and Doppler transit time. However, correlation of the accuracy of these techniques with the "gold standard" of angiography has not yet been documented in a large series.
What is the significance of the results obtained in this study, and can these results of immediate intraoperative angiography be compared with existing information on IMA graft patency in conventional coronary artery bypass grafting in a meaningful manner? From 1972 through 1997, there had been at least 34 manuscripts in the literature addressing the issues of patency and/or survival advantage after conventional coronary artery bypass grafting with use of the LIMA. These studies include series from 17 different medical centers, three different multicenter studies, the Coronary Artery Surgery Study (CASS), the Veteran’s Administration Cooperative Trial on Antiplatelet Therapy, and the International Multi-Center Aprotinin Graft Patency Experience (IMAGE). Also published were editorials by Loop and Spencer.
Of the other 32 papers, 8 had no information on graft patency, evaluating the efficacy of LIMA grafting by examining survival advantage compared with saphenous vein conduits. Twenty-four studies from 17 medical centers did contain information regarding angiographic demonstration of graft patency at varying intervals postoperatively. There were 4 studies from the group at St. Louis University, 4 from the Cleveland Clinic, 2 from Milwaukee, with single reports issued by the remaining 14 centers.
Meaningful analysis of published data is difficult due to different inclusion/exclusion criteria for the different studies as well as a varying percentage of patients undergoing LIMA graft patency that were studied at postoperative intervals. Most series, because angiography was not performed in the immediate postoperative period, include only survivors in the studies. One cannot assume that the LIMA graft was patent in nonsurvivors. In a significant proportion of the studies, only a minority of the patients undergoing LIMA grafting were actually studied. Many series were retrospective analyses of the patients, frequently those who happen have undergone a postoperative angiogram for any reason at the institution. In addition, some of the series date to the initial use of LIMA grafting in 1972, and therefore include a "learning curve" perhaps yielding slightly inferior results compared with those that would be inspected in more recent series.
In an attempt to compare early angiography data of LIMA graft patency contained in this study with existing published data on results of LIMA grafting, all articles addressing this issues were reviewed. Of the 24 series containing information on angiographic graft patency after conventional coronary artery bypass surgery, the majority of the studies addressed long-term graft patency. However, seven studies did contain information regarding the results of early angiography ( 1 month) (Table 7) [5–11]. Barner and associates [5] published the angiographic results after LIMA grafting in 307 patients in 1976. One hundred and thirty-nine (45%) of the patients were studied angiographically in the postoperative period at a mean interval of 20 days. Graft patency was documented to be 95% in those studies. Another 2% (3 patients) had a graft stenosis greater than 50%. Nonsurvivors, the percent not stated, were not studied.
|
Tyras and associates in 1980 [6] analyzed results of angiography performed at a 1-month interval after LIMA grafting in 527 of 765 patients (69%). Graft patency was 95% with nonsurvivors (1.4%) excluded.
Grondin and associates in 1984 [7] studied 37 of 40 patients (92%) at 1 month. Two patients died before they could be studied, and 1 patient declined. Graft patency was 97%.
Ivert and associates [8] studied 91 of 99 eligible patients (92%) at a mean interval of 2 weeks after conventional CAB. Graft patency was 94%. Two patients died before early angiography was possible.
Two more recent studies contain information regarding graft patency. Gill and associates [10] studied 25 consecutive patients 4 to 6 h after conventional coronary bypass graft as part of a study comparing MICAB with conventional CAB. All patients were studied and patency was 96%.
Berger and associates [11] reported on 645 patients who underwent angiography as part of the IMAGE study of aprotinin. The percent of patients who received a LIMA graft who were studied was 84%. The angiography was performed at a mean of 10.8 days postoperatively with a graft patency of 98.8%. An additional 7.8% had a graft stenosis greater than 50% (FitzGibbon grade B).
There are four published studies containing angiographic information regarding graft patency after MICAB (Table 8) [10, 12–14]. Schaff and associates [12] studied 15 of 16 patients (94%) after successful LIMA bypass of the LAD via the MICAB approach. All were patent; however, 3 were revised in the operating room due to kinking of the LIMA in 1, an anastomosis was revised in the second, and no problem was found in the third patient.
|
Gill and associates [10] in the MICAB arm of the previously mentioned study was able to study all 29 patients at an interval of 4 to 6 hours postoperatively. Twenty-eight grafts were patent (97.5%); however, 19% had a stenosis of greater than or equal to 50% (FitzGibbon grade B). These were followed, and later follow-up angiography (mean 10 months) has revealed anastomotic irregularities to have resolved in 4 patients (I.S., Gill personal communication).
Our series yielded substantially similar results to other MICAB series. Although our patency rate of 99% was acceptable, a significant stenosis of 50% in 8 additional patients caused us some concern. This led to reintervention (either repeat CAB or PTCA) in the earlier part of our series. However, due to our own experience as well as others, both published and by personal communication, we have adopted a practice of conservative management with observation only if no ischemia is demonstrated in the revascularized target vessel distribution. Gratifyingly, we have demonstrated resolution of stenotic lesions in 2 patients at 6 months on repeat angiography.
Further data to help answer whether the LIMA graft patency with MICAB is comparable with that of conventional CAB hopefully will be gained from a current, ongoing multicenter study (POEM). The POEM study (patency, outcomes, economics, MIDCAB) is enrolling 400 nonrandomized, but consecutive patients undergoing conventional CAB (200) and MICAB (200) to compare LIMA graft patency by each approach. The primary end point will be a 6-month angiographic graft patency. Results should be available in late 1999.
In conclusion, results of this study demonstrate that graft patency with LIMA grafting by the minimally invasive approach is comparable with published series with conventional bypass surgery. Although the studies are not strictly comparable due to variability in inclusion and exclusion criteria in each study, MICAB results appear to be equivalent to conventional CAB. Hopefully, the current ongoing multicenter study will be able to give a more definitive comparison.
Important remaining questions include the role of early angiography after MICAB. Should every MICAB be evaluated by early angiography? From our experience, we believe that at least early in a center’s experience of MICAB, immediate angiographic evaluation is crucial to demonstrate adequacy of the procedure. Information helpful to the surgeon early in his or her MICAB experience can be gained by angiography that helps modify techniques.
A very difficult question is how to evaluate the significance of early angiographic findings. Our early management included revision of significant angiographic abnormalities; however, based on our experience, along with many anecdotal reports from other centers, that early, stenotic angiographic lesions frequently resolve, it is currently our practice to obtain a functional ischemia study on any patient with a patent graft and angiographic stenosis (FitzGibbon grade B) and follow the patient without further invention if no ischemia is demonstrable. Current ongoing studies hopefully will answer whether other less cumbersome intraoperative evaluation tools may eventually be able to supplant immediate angiography. It is our recommendation, however, if a center is relatively inexperienced in MIDCAB surgery, that intraoperative or early postoperative angiographic documentation of graft patency is indicated. It serves not only to document results but helps ensure not only surgeon self-confidence but instills confidence in the referring physicians. If any significant concern regarding the angiogram exists, however, prompt revision or angioplasty should be performed until a center gains experience in knowing which findings are safe to observe.
|
References |
|---|
|
TopAbstractIntroductionPatients and methodsResultsCommentReferences |
|---|
This article has been cited by other articles:
|
|
 |
|
  J. R. Kapoor, A. L. Gienger, R. Ardehali, R. Varghese, M. V. Perez, V. Sundaram, K. M. McDonald, D. K. Owens, M. A. Hlatky, and D. M. Bravata Isolated Disease of the Proximal Left Anterior Descending Artery: Comparing the Effectiveness of Percutaneous Coronary Interventions and Coronary Artery Bypass Surgery J. Am. Coll. Cardiol. Intv., October 1, 2008; 1(5): 483 - 491. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 A. D'Onofrio, N. Abbiate, P. Magagna, and A. Fabbri Intraoperative coronary angiography in postinfarction ventricular free wall rupture: how technology can change diagnostic and therapeutic timing Interactive CardioVascular and Thoracic Surgery, August 1, 2008; 7(4): 733 - 735. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 L. Balacumaraswami, Y. Abu-Omar, J. Selvanayagam, D. Pigott, and D. P. Taggart The effects of on-pump and off-pump coronary artery bypass grafting on intraoperative graft flow in arterial and venous conduits defined by a flow/pressure ratio J. Thorac. Cardiovasc. Surg., March 1, 2008; 135(3): 533 - 539. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 V. Falk and F. W. Mohr Minimally Invasive Myocardial Revascularization Card. Surg. Adult, January 1, 2008; 3(2008): 697 - 710. [Full Text]
|
|
|
|
 |
|
 P. K. Hol, K. Andersen, H. Skulstad, P. S. Halvorsen, P. S. Lingaas, R. Andersen, J. Bergsland, and E. Fosse Epicardial Ultrasonography: A Potential Method for Intraoperative Quality Assessment of Coronary Bypass Anastomoses? Ann. Thorac. Surg., September 1, 2007; 84(3): 801 - 807. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
T. Schachner, G. M. Feuchtner, J. Bonatti, N. Bonaros, A. Oehlinger, E. Gassner, O. Pachinger, and G. Friedrich Evaluation of Robotic Coronary Surgery With Intraoperative Graft Angiography and Postoperative Multislice Computed Tomography Ann. Thorac. Surg., April 1, 2007; 83(4): 1361 - 1367. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
Y. Ben-Gal, R. Mohr, R. Braunstein, A. Finkelstein, N. Hansson, A. Hendler, Y. Moshkovitz, and G. Uretzky Revascularization of Left Anterior Descending Artery With Drug-Eluting Stents: Comparison With Minimally Invasive Direct Coronary Artery Bypass Surgery Ann. Thorac. Surg., December 1, 2006; 82(6): 2067 - 2071. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 T. Schachner, J. Bonatti, N. Bonaros, R. Poeltl, G. Feuchtner, G. Laufer, O. Pachinger, and G. Friedrich Risk factors of postoperative nephropathy in patients undergoing innovative CABG and intraoperative graft angiography. Eur. J. Cardiothorac. Surg., September 1, 2006; 30(3): 431 - 435. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M. Argenziano, M. Katz, J. Bonatti, S. Srivastava, D. Murphy, R. Poirier, D. Loulmet, L. Siwek, U. Kreaden, D. Ligon, et al. Results of the prospective multicenter trial of robotically assisted totally endoscopic coronary artery bypass grafting. Ann. Thorac. Surg., May 1, 2006; 81(5): 1666 - 1675. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
S. G. Raja Drug-Eluting Stents and the Future of Coronary Artery Bypass Surgery: Facts and Fiction. Ann. Thorac. Surg., March 1, 2006; 81(3): 1162 - 1171. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
S. Fraund, G. Herrmann, A. Witzke, J. Hedderich, G. Lutter, M. Brandt, A. Boning, and J. Cremer Midterm Follow-Up After Minimally Invasive Direct Coronary Artery Bypass Grafting Versus Percutaneous Coronary Intervention Techniques Ann. Thorac. Surg., April 1, 2005; 79(4): 1225 - 1231. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
A. Lichtenberg, U. Klima, H. Paeschke, M. Pichlmaier, S. Ringes-Lichtenberg, T. Walles, H. Goerler, and A. Haverich Impact of multivessel coronary artery disease on outcome after isolated minimally invasive bypass grafting of the left anterior descending artery Ann. Thorac. Surg., August 1, 2004; 78(2): 487 - 491. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
P. K. Hol, P. S. Lingaas, R. Lundblad, K. A. Rein, K. Vatne, H.-J. Smith, S. Nitter-Hauge, and E. Fosse Intraoperative angiography leads to graft revision in coronary artery bypass surgery Ann. Thorac. Surg., August 1, 2004; 78(2): 502 - 505. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
T. C. Dessing, R. P.J. Budde, R. Meijer, P. F.A. Bakker, C. Borst, and P. F. Grundeman Geometry assessment of coronary artery anastomoses with construction errors by epicardial ultrasound Eur. J. Cardiothorac. Surg., August 1, 2004; 26(2): 257 - 261. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
L. Balacumaraswami, Y. Abu-Omar, K. Anastasiadis, B. Choudhary, D. Pigott, S.-K. Yeong, and D. P. Taggart Does off-pump total arterial grafting increase the incidence of intraoperative graft failure? J. Thorac. Cardiovasc. Surg., August 1, 2004; 128(2): 238 - 244. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
F. Filsoufi, R. S. Farivar, L. Aklog, C. A. Anderson, R. H. Chen, S. Lichtenstein, J. Zhang, and D. H. Adams Automated distal coronary bypass with a novel magnetic coupler (MVP system) J. Thorac. Cardiovasc. Surg., January 1, 2004; 127(1): 185 - 192. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 F. Eefting, H. Nathoe, D. van Dijk, E. Jansen, J. Lahpor, P. Stella, W. Suyker, J. Diephuis, H. Suryapranata, S. Ernst, et al. Randomized Comparison Between Stenting and Off-Pump Bypass Surgery in Patients Referred for Angioplasty Circulation, December 9, 2003; 108(23): 2870 - 2876. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
B. Sonmez, H. Arbatli, S. Tansal, N. Yagan, M. Unal, E. Demirsoy, F. Tukenmez, and O. Yilmaz Real-time patency control with thermal coronary angiography in 1401 coronary artery bypass grafting patients Eur. J. Cardiothorac. Surg., December 1, 2003; 24(6): 961 - 966. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J. Bonatti, M. Danzmayr, T. Schachner, and G. Friedrich Intraoperative angiography for quality control in MIDCAB and OPCAB Eur. J. Cardiothorac. Surg., October 1, 2003; 24(4): 647 - 649. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
R. K. Wolf and V. Falk Intraoperative assessment of coronary artery bypass grafts J. Thorac. Cardiovasc. Surg., September 1, 2003; 126(3): 634 - 637. [Full Text] [PDF]
|
|
|
|
|
|
P. A. Kurlansky Is there a hypercoagulable state after off-pump coronary artery bypass surgery? What do we know and what can we do? J. Thorac. Cardiovasc. Surg., July 1, 2003; 126(1): 7 - 10. [Full Text] [PDF]
|
|
|
|
|
|
R. K. Wolf, E. L. Alderman, M. P. Caskey, A. R. Raczkowski, M. K. Dullum, D. C. Lundell, A. C. Hill, N. Wang, and M. A. Daniel Clinical and six-month angiographic evaluation of coronary arterial graft interrupted anastomoses by use of a self-closing clip device: a multicenter prospective clinical trial J. Thorac. Cardiovasc. Surg., July 1, 2003; 126(1): 168 - 177. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 E. Naseri and M. Sevinc Comparison of Off-Pump Versus Conventional Coronary Revascularization Asian Cardiovasc Thorac Ann, December 1, 2002; 10(4): 322 - 325. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M. J. Mack and F. G. Duhaylongsod Through the open door! Where has the ride taken us? J. Thorac. Cardiovasc. Surg., October 1, 2002; 124(4): 655 - 659. [Full Text] [PDF]
|
|
|
|
|
|
S. Fraund, H. Behnke, A. Boening, and J. Cremer Immediate postoperative extubation after minimally invasive direct coronary artery surgery (MIDCAB) Interactive CardioVascular and Thoracic Surgery, September 1, 2002; 1(1): 41 - 45. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
K. V Arom, R. W Emery, T. F Flavin, V. R Kshettry, and P. Janey Surgical Steps Toward Complete Revascularization in Off-Pump Coronary Bypass Asian Cardiovasc Thorac Ann, September 1, 2002; 10(3): 201 - 205. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 P. P T. de Jaegere and W. J L Suyker OFF-PUMP CORONARY ARTERY BYPASS SURGERY Heart, September 1, 2002; 88(3): 313 - 318. [Full Text] [PDF]
|
|
|
|
 |
|
 A. Diegeler, H. Thiele, V. Falk, R. Hambrecht, N. Spyrantis, P. Sick, K. W. Diederich, F. W. Mohr, and G. Schuler Comparison of Stenting with Minimally Invasive Bypass Surgery for Stenosis of the Left Anterior Descending Coronary Artery N. Engl. J. Med., August 22, 2002; 347(8): 561 - 566. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
C. Detter, T. Deuse, F. Christ, D. H. Boehm, H. Reichenspurner, and B. Reichart Comparison of two stabilizer concepts for off-pump coronary artery bypass grafting Ann. Thorac. Surg., August 1, 2002; 74(2): 497 - 501. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
W. Cheng, T. A. Denton, G. P. Fontana, S. Raissi, C. Blanche, R. M. Kass, K. E. Magliato, J. Mirocha, and A. Trento Off-pump coronary surgery: Effect on early mortality and stroke J. Thorac. Cardiovasc. Surg., August 1, 2002; 124(2): 313 - 320. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
P. K. Hol, E. Fosse, R. Lundblad, S. Nitter-Hauge, P. Due-Tonnessen, K. Vatne, and H.-J. Smith The importance of intraoperative angiographic findings for predicting long-term patency in coronary artery bypass operations Ann. Thorac. Surg., March 1, 2002; 73(3): 813 - 818. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
|
