ATS
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Massimo Caputo
Malcolm J. Underwood
Franco Ciulli
Gianni D. Angelini
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Caputo, M.
Right arrow Articles by Angelini, G. D.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Caputo, M.
Right arrow Articles by Angelini, G. D.
Related Collections
Right arrow Minimally invasive surgery
Right arrowRelated Article

Ann Thorac Surg 2001;71:1215-1219
© 2001 The Society of Thoracic Surgeons

Original article: cardiovascular

Off-pump coronary operations can be safely taught to cardiothoracic trainees

Massimo Caputo, MDa, Martin H. Chamberlain, FRCSa, Faruk Özalp, FRCSa, Malcolm J. Underwood, FRCSa, Franco Ciulli, MDa, Gianni D. Angelini, FRCSa

a Bristol Heart Institute, Bristol Royal Infirmary, Bristol, United Kingdom

Accepted for publication November 14, 2000.

Address reprint requests to Dr Angelini, Bristol Heart Institute, Bristol Royal Infirmary, Bristol BS2 8HW United Kingdom
e-mail: n.holloway-dee{at}bristol.ac.uk


   Abstract
Top
 Abstract
Introduction
 Material and methods
 Results
 Comment
 Acknowledgments
 References
 
Background. Off-pump coronary artery bypass (OPCAB) operations are evolving rapidly and becoming established in many cardiothoracic centers. For the technique to be widely applicable, teaching methods must be developed for surgical trainees. Early and midterm clinical outcomes of OPCAB performed at our institution by trainees as first operators under supervision were compared to those obtained in patients operated on by consultants.

Methods. Analysis was undertaken on data prospectively inserted in the Patient Analysis & Tracking System. Of the 559 OPCAB operations performed between January 1997 and May 2000, 124 (22%) were carried out by a supervised trainee and 435 (78%) by a consultant.

Results. There was no difference in age, sex, angina class, New York Heart Association functional class, or operative priority and extent of coronary artery disease in the two groups. More patients operated on by consultants had a history of congestive heart failure requiring medical therapy, significantly lower ejection fraction, and higher Parsonnet score compared with patients operated on by trainees. Early and midterm clinical results, in terms of morbidity and mortality, were similar in patients operated on by trainees or by consultants.

Conclusions. Our data show no differences in early and midterm clinical outcome for patients undergoing OPCAB operations performed either by consultants or by trainees under supervision. The improvements in exposure and stabilization techniques, as well as the use of intracoronary shunts, have made it possible and safe to teach trainees off-pump multivessel coronary artery revascularization.


   Introduction
Top
 Abstract
 Introduction
Material and methods
 Results
 Comment
 Acknowledgments
 References
 
Myocardial revascularization on the beating heart is becoming increasingly popular and represents a safe alternative to traditional coronary artery bypass grafting (CABG) [1–7]. At our institution, off-pump coronary artery bypass (OPCAB) has evolved rapidly in the last 5 years and cardiothoracic trainees have been exposed to this new technique as an integral part of our training program. At the same time there is an overriding responsibility to ensure patient safety and late clinical outcome and therefore, the efforts made to teach OPCAB to cardiothoracic trainees must be addressed within this context. Little information is available in the literature on the clinical experience of residency training in off-pump coronary revascularization [8].

This study analyzes the early and midterm clinical outcome of OPCAB procedures performed by supervised trainees or senior surgeons who developed beating heart operations at our institution.


   Material and methods
Top
 Abstract
 Introduction
 Material and methods
Results
 Comment
 Acknowledgments
 References
 
Over a three and half year period (January 1997–May 2000), 2,915 CABG operations were performed at our institution (with a 1.4% hospital mortality), and 559 (19%) of these operations were performed without the use of cardiopulmonary bypass. Of the operations performed using the OPCAB technique, 124 (22%) were done by a supervised trainee (13% of all trainee CABG operations). Residents are introduced to coronary revascularization irrespective of whether the operation is carried out with or without cardiopulmonary bypass.

Anesthetic and surgical technique
Anesthetic technique consisted of propofol infusion at 3 mg · kg-1 · hr-1 combined with alfentanil infusion at 0.5 to 1 µg · kg-1 · min-1. Neuromuscular blockade was achieved by 0.1 to 0.15 mg/kg pancuronium bromide or vecuronium and the lungs ventilated to normocapnia with air and oxygen (45% to 50%). Heparin (100 IU/kg) was administered before the start of the first anastomosis to achieve an activated clotting time of 250 to 350 seconds. On completion of all anastomoses, protamine was given to reverse the effect of heparin and return the activated clotting time to preoperative levels.

The method of exposure to perform the anastomoses consisted of a technique that has been previously reported [9]. Briefly, after median sternotomy the pericardium is opened and a half-folded swab (12 cm wide and 70 cm long) is snared to the posterior pericardium (using a single stitch 0-silk suture), halfway between the inferior vena cava and the left inferior pulmonary vein. Traction is applied to the two limbs of the swab and the snare, which are then fixed to the surgical drapes to facilitate exposure of the target coronary vessels. Stabilization is achieved with a reusable stainless steel stabilizer (Abbey Surgical Limited, Mitcham, Surrey, UK) developed at our institution. Since the beginning of 1999, all anastomoses are performed with an intracoronary shunt to ensure distal perfusion (Flothru Biovascular Inc, St Paul, MN). Visualization is enhanced by using a surgical blower-humidifier (Abbey Surgical Limited, Mitcham, Surrey, UK).

Postoperative management was performed according to standard protocols as previously detailed [10].

Statistical analysis
Intraoperative and postoperative data, including complications and adverse events were recorded and prospectively inserted in the Patient Analysis & Tracking System. Patient follow-ups were carried out from the clinical records and supplemented by telephone interviews. Patients were assessed for survival and subsequent cardiac events, namely recurrent angina with correspondent angina class, myocardial infarction, cardiac catheterization, percutaneous transluminal coronary angioplasty, repeated CABG, and any incidence of atrial fibrillation.

All statistical analyses were performed with the aid of a computerized software package, Statview for Windows (SAS Institute Inc, Cary, NC). Continuous variables were expressed as mean values ± standard deviation, and categorical variables presented as either absolute numbers or percentages. Data were checked for normal distribution before statistical analysis. Categorical variables were analyzed using either the {chi}2 test or Fischer’s exact test. Continuous variables were compared using either the Student’s t test or Mann-Whitney U test when appropriate.


   Results
Top
 Abstract
 Introduction
 Material and methods
 Results
Comment
 Acknowledgments
 References
 
Preoperative characteristics are shown in Table 1. The two groups were similar with respect to age, gender, severity of coronary disease, diabetes mellitus, angina class, and priority of the operation. In the consultant group more patients had past and recent history of congestive heart failures requiring medical therapy, significantly lower ejection fractions, and higher Parsonnet scores compared with patients operated on by trainees.


View this table:
[in this window]
[in a new window]
  		Table 1. Preoperative Characteristicsa

 
Six patients in the consultant group (1.3%) had to be converted into conventional CABG for hemodynamic or electrical instability. The average number of grafts and the coronary anatomical distribution was similar in the two groups (Table 2). The use of arterial conduits other than the left internal mammary artery was significantly more frequent among trainees than consultants. In only 4 patients, when the trainee was the first operator, the consultant had to take over because of the technical difficulties encountered when performing a distal circumflex anastomosis.


View this table:
[in this window]
[in a new window]
  		Table 2. Intraoperative Dataa

 
Postoperative morbidity and mortality are shown in Table 3. There were 5 patient deaths in the consultant group, 4 that were multiorgan failures as a consequence of postoperative low cardiac output syndrome, and 1 respiratory failure. Ten patients in the consultant group and 2 in the trainee pump group had perioperative myocardial infarction according to predefined criteria. The incidence of respiratory, neurologic, and renal complications was similar in patients operated on by consultants or residents, as well as inotropic usage, chest infection rate, blood loss, and transfusion requirement. Intubation time, intensive care unit and hospital stay were not different in the two groups. Because there were significant differences between the patients operated on by consultants and trainees regarding ejection fraction, congestive heart failure, and Parsonnet scores, a subsidiary analysis was carried out excluding patients with an ejection fraction less than 30%, congestive heart failure, and a Parsonnet score more than 20; these included 357 operated on by consultant and 119 patients operated on by trainees. No significant differences in early mortality and in all the postoperative clinical outcomes were observed when the two groups were compared (data not shown).


View this table:
[in this window]
[in a new window]
  		Table 3. Postoperative Dataa

 
The number of off-pump surgical procedures at our institution has steadily increased in the study period (January 1997–May 2000) (Fig 1A), as well as the mean number of grafts per patient (1.6 ± 0.6 in 1997, 2.2 ± 0.9 in 1998, 2.3 ± 0.8 in 1999, and 2.5 ± 0.8 in 2000). At the same time (Fig 1B) there has been a substantial increase in the number of off-pump cases performed by trainees and in the number of grafts per patient. In 1997 almost all OPCAB cases were done by consultants, whereas in the first few months of 2000 almost 50% of OPCAB procedures were performed by trainees under supervision.



View larger version (28K):
[in this window]
[in a new window]
  		Fig 1. (A) Percentage number of off-pump coronary artery bypass (OPCAB) procedures performed by consultants ({blacksquare}) and trainees ({square}) and (B) overall percentage number of OPCAB operations ({square}) and conventional coronary artery bypass grafts ({blacksquare}) in the 4 years of this study period.

 
Table 4 shows the follow-up data in the two groups. The mean duration of follow-up was 19.0 ± 10.7 months (range, 5 to 45 months) in the consultant group and 11.4 ± 7.2 months (range, 5 to 44 months) in the trainee group. In both groups there was a significant decrease in the angina class compared to the preoperative status (p = 0.001). No differences were observed in survival or in the incidence of cardiac events in both groups.


View this table:
[in this window]
[in a new window]
  		Table 4. Midterm Follow-up Resultsa

 

   Comment
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
Acknowledgments
 References
 
This article demonstrates that multivessel off-pump coronary operations are a safe and reproducible surgical technique that can be taught successfully to cardiothoracic surgical residents.

The improvements in immobilization and exposure, particularly of the circumflex and posterior descending coronary artery together with the introduction of modern stabilizers and the use of intracoronary shunts, have made OPCAB safe and easy to teach. This is clearly demonstrated by the high percentage (more than 50%) of obtuse marginal coronary artery anastomoses performed by trainees in this study. The use of intracoronary shunts has proven preservation of segmental wall motion contractility during construction of the distal anastomoses by maintaining myocardial perfusion [11]. Furthermore, intracoronary shunts improve visualization and avoid the need for distal snare occlusion. Avoidance of ischemia allows trainees to perform the anastomoses in an unhurried and technically precise manner.

During the past 5 years, OPCAB operations performed at our institution have increased significantly and, simultaneously, more patients are being operated on by trainees under a consultant’s supervision. In addition, the number of grafts constantly increased from 1997 when the majority of patients were selected for single or double vessel revascularization (mainly the left anterior descending and the right coronary arteries). Although there was no difference in the mean number of grafts performed in the two groups, trainees tended to use more arterial conduits compared to consultants, especially the right mammary artery anastomosed onto the circumflex coronary artery through the transverse sinus.

In comparison with patients operated on by trainees, patients in the consultant group were more likely to present with congestive heart failure, moderate or severe left ventricular dysfunction, and higher Parsonnet scores. This is mainly a reflection of the selection process by which consultants tend to take on higher risk patients.

Cardiothoracic surgical training programs vary greatly in content depending on the particular institution, the interests of its staff referral, and the characteristics of the patients. In a recent article it was shown that Buffalo General Hospital residents were introduced to the off-pump revascularization in the second year of their training after performing CABG on-pump in the first year, using the "ideal" teaching conditions of conventional CABG [8]. In our institution, where training in cardiothoracic operations last 6 years, junior surgeons are exposed to beating heart coronary operations from the second year of their training program, and start performing conventional CABG and OPCAB at the same time, as well as routine participation in the preoperative patient selection and postoperative follow-up. This provides the residents with the opportunity to improve their surgical skill in both types of myocardial revascularization, gaining confidence and adapting their attitude to new developing techniques of bypass grafting. Residents are started on simple off-pump cases, requiring only left anterior descending coronary artery or diagonal grafts, before gradually moving to posterior descending coronary artery grafting. This allows trainees to become progressively used to various techniques of exposure and stabilization before attempting to graft the circumflex system, which remains technically more challenging from a topographic standpoint. By the end of the third year, trainees will have performed between 40 to 50 multivessel OPCAB revascularizations as first surgeons under consultant supervision.

In conclusion, we believe that in the current era of myocardial revascularization it is essential to expose trainees to both on-pump and off-pump techniques, given the fact that beating heart revascularization is likely to become an integral part of coronary operations. We also believe that at present, OPCAB training programs should be limited to institutions that perform a significant minimum number of these operations per year, with senior surgeons proficient in using the technique. Our commitment will be both to encourage and control the evolution of beating heart coronary operations by making changes that are governed by educational purposes and therefore, transferring our experience to young cardiothoracic surgeons.


   Acknowledgments
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
 Acknowledgments
References
 
The Garfield Weston Trust, The National Heart Research Fund, and the British Heart Foundation supported this work. We would also like to thank Mr AJ Bryan for his helpful comments during the preparation of this article.


   References
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
 Acknowledgments
 References
 

  1. Buffolo E., de Andrade C.S., Branco J.N., Teles C.A., Aguiar L.F., Gomes W.J. Coronary artery bypass grafting without cardiopulmonary bypass. Ann Thorac Surg 1996;61:63-66.[Abstract/Free Full Text]
  2. Ascione R., Lloyd C.T., Underwood M.J., Lotto A.A., Pitsis A.A., Angelini G.D. Inflammatory response after coronary revascularization with or without cardiopulmonary bypass. Ann Thorac Surg 2000;69:1198-1204.[Abstract/Free Full Text]
  3. Ascione R., Lloyd C.T., Underwood M.J., Lotto A.A., Pitsis A.A., Angelini G.D. Economic outcome of off-pump coronary artery bypass surgery: a prospective randomized study. Ann Thorac Surg 1999;68:2237-2242.[Abstract/Free Full Text]
  4. Lotto A.A., Caputo M., Ascione R., Lloyd C.T., Lucchetti V., Angelini G.D. Evaluation of myocardial metabolism and function during beating heart coronary surgery. Eur J Cardiothorac Surg 1999;16(Suppl 1):S112-S116.[Abstract/Free Full Text]
  5. Ascione R., Lloyd C.T., Underwood M.J., Gomes W.J., Angelini G.D. On-pump versus off-pump coronary revascularization: evaluation of renal function. Ann Thorac Surg 1999;68:493-498.[Abstract/Free Full Text]
  6. Borst C., Grundeman P.F. Minimally invasive coronary artery bypass grafting: an experimental perspective. Circulation 1999;99:1400-1403.[Free Full Text]
  7. Poirier N.C., Carrier M., Lesperance J., et al. Quantitative angiographic assessment of coronary anastomoses performed without cardiopulmonary bypass. J Thorac Cardiovasc Surg 1999;117:292-297.[Abstract/Free Full Text]
  8. Karamanoukian H.L., Panos A.L., Bergsland J., Salerno T.A. Perspectives of a cardiac surgery resident in-training on off-pump coronary bypass operation. Ann Thorac Surg 2000;69:42-46.[Abstract/Free Full Text]
  9. Pitsis A.A., Angelini G.D. Off pump coronary bypass grafting of the circumflex artery. Eur J Cardiothorac Surg 1999;16:478-479.[Abstract/Free Full Text]
  10. Ascione R., Caputo M., Calori G., Lloyd C.T., Underwood M.J., Angelini G.D. Predictors of atrial fibrillation after conventional and beating heart coronary surgery: a prospective, randomized study. Circulation 2000;102:1530-1535.[Abstract/Free Full Text]
  11. Lucchetti V., Capasso F., Caputo M., et al. Intracoronary shunt prevents left ventricular function impairment during beating heart coronary revascularization. Eur J Cardiothorac Surg 1999;15:255-259.[Abstract/Free Full Text]

Related Article

Invited commentary
Louis P. Perrault
Ann. Thorac. Surg. 2001 71: 1219. [Extract] [Full Text] [PDF]



This article has been cited by other articles:


Home page
 Ann. Thorac. Surg.Home page
C. K. Haan, S. Milford-Beland, S. O'Brien, D. Mark, M. Dullum, T. B. Ferguson, and E. D. Peterson
Impact of Residency Status on Perfusion Times and Outcomes for Coronary Artery Bypass Graft Surgery
Ann. Thorac. Surg., June 1, 2007; 83(6): 2103 - 2110.
[Abstract] [Full Text] [PDF]

Home page
 Ann. Thorac. Surg.Home page
S. P. Collison, A. Agarwal, and N. Trehan
Controversies in the use of intraluminal shunts during off-pump coronary artery bypass grafting surgery.
Ann. Thorac. Surg., October 1, 2006; 82(4): 1559 - 1566.
[Abstract] [Full Text] [PDF]

Home page
 ICVTSHome page
A. Karagounis, G. Asimakopoulos, G. Niranjan, O. Valencia, and V. Chandrasekaran
Complex off-pump coronary artery bypass surgery can be safely taught to cardiothoracic trainees
Interactive CardioVascular and Thoracic Surgery, June 1, 2006; 5(3): 222 - 226.
[Abstract] [Full Text] [PDF]

Home page
 Ann. Thorac. Surg.Home page
G. Asimakopoulos, A. P. Karagounis, O. Valencia, D. Rose, G. Niranjan, and V. Chandrasekaran
How Safe Is It to Train Residents to Perform Off-Pump Coronary Artery Bypass Surgery?
Ann. Thorac. Surg., February 1, 2006; 81(2): 568 - 572.
[Abstract] [Full Text] [PDF]

Home page
 Ann. Thorac. Surg.Home page
G. J. Murphy, C. A. Rogers, M. Caputo, and G. D. Angelini
Acquiring Proficiency in Off-Pump Surgery: Traversing the Learning Curve, Reproducibility, and Quality Control
Ann. Thorac. Surg., November 1, 2005; 80(5): 1965 - 1970.
[Abstract] [Full Text] [PDF]

Home page
 Ann. Thorac. Surg.Home page
C. Alexiou, G. Doukas, M. Oc, B. Oc, L. Hadjinikolaou, and T. J. Spyt
Effect of Training in Mitral Valve Repair Surgery on the Early and Late Outcome
Ann. Thorac. Surg., July 1, 2005; 80(1): 183 - 188.
[Abstract] [Full Text] [PDF]

Home page
 Eur. J. Cardiothorac. Surg.Home page
C. A. Rogers, J. S. Ganesh, N. R. Banner, R. S. Bonser, and On behalf of the steering Group
Cumulative risk adjusted monitoring of 30-day mortality after cardiothoracic transplantation: UK experience
Eur. J. Cardiothorac. Surg., June 1, 2005; 27(6): 1022 - 1029.
[Abstract] [Full Text] [PDF]

Home page
 Eur Heart JHome page
G. J Murphy, R. Ascione, and G. D Angelini
Coronary artery bypass grafting on the beating heart: surgical revascularization for the next decade?
Eur. Heart J., December 1, 2004; 25(23): 2077 - 2085.
[Abstract] [Full Text] [PDF]

Home page
 J. Thorac. Cardiovasc. Surg.Home page
C. A. Rogers, B. C. Reeves, M. Caputo, J. S. Ganesh, R. S. Bonser, and G. D. Angelini
Control chart methods for monitoring cardiac surgical performance and their interpretation
J. Thorac. Cardiovasc. Surg., December 1, 2004; 128(6): 811 - 819.
[Full Text] [PDF]

Home page
 J. Thorac. Cardiovasc. Surg.Home page
M. Caputo, B. C. Reeves, C. A. Rogers, R. Ascione, and G. D. Angelini
Monitoring the performance of residents during training in off-pump coronary surgery
J. Thorac. Cardiovasc. Surg., December 1, 2004; 128(6): 907 - 915.
[Abstract] [Full Text] [PDF]

Home page
 Ann. Thorac. Surg.Home page
R. J. F. Baskett, D. Kalavrouziotis, K. J. Buth, G. M. Hirsch, and J. A. P. Sullivan
Training Residents in Mitral Valve Surgery
Ann. Thorac. Surg., October 1, 2004; 78(4): 1236 - 1240.
[Abstract] [Full Text] [PDF]

Home page
 Ann. Thorac. Surg.Home page
R. Ascione, B. C. Reeves, M. Pano, and G. D. Angelini
Trainees operating on high-risk patients without cardiopulmonary bypass: a high-risk strategy?
Ann. Thorac. Surg., July 1, 2004; 78(1): 26 - 33.
[Abstract] [Full Text] [PDF]

Home page
 JRSMHome page
G J Murphy and G D Angelini
Coronary artery bypass grafting on the beating heart: changing the paradigm
J R Soc Med, July 1, 2004; 97(7): 313 - 316.
[Full Text] [PDF]

Home page
 Ann. Thorac. Surg.Home page
H. Yokoyama, S. Takase, Y. Misawa, K. Takahashi, Y. Sato, and H. Satokawa
A simple technique of introducing intracoronary shunts for off-pump coronary artery bypass surgery
Ann. Thorac. Surg., July 1, 2004; 78(1): 352 - 354.
[Abstract] [Full Text] [PDF]

Home page
 Ann. Thorac. Surg.Home page
J. T. Reston, S. J. Tregear, and C. M. Turkelson
Meta-analysis of short-term and mid-term outcomes following off-pump coronary artery bypass grafting
Ann. Thorac. Surg., November 1, 2003; 76(5): 1510 - 1515.
[Abstract] [Full Text] [PDF]

Home page
 J. Thorac. Cardiovasc. Surg.Home page
R. Ascione and G. D. Angelini
Off-pump coronary artery bypass surgery: The implications of the evidence
J. Thorac. Cardiovasc. Surg., April 1, 2003; 125(4): 779 - 781.
[Full Text] [PDF]

Home page
 Ann. Thorac. Surg.Home page
R. J. F. Baskett, K. J. Buth, J.-F. Legare, A. Hassan, C. H. Friesen, G. M. Hirsch, D. B. Ross, and J. A. Sullivan
Is it safe to train residents to perform cardiac surgery?
Ann. Thorac. Surg., October 1, 2002; 74(4): 1043 - 1049.
[Abstract] [Full Text] [PDF]

Home page
 Ann. Thorac. Surg.Home page
M. Caputo, A. J. Bryan, R. Capoun, B. Mahesh, F. Ciulli, J. Hutter, and G. D. Angelini
The evolution of training in Off-Pump coronary surgery in a single institution
Ann. Thorac. Surg., October 1, 2002; 74(4): S1403 - 1407.
[Abstract] [Full Text] [PDF]

Home page
 Eur. J. Cardiothorac. Surg.Home page
X. M. Mueller, P.-G. Chassot, J. Zhou, K. M. Eisa, C. Chappuis, H. T. Tevaearai, and L. K. von Segesser
Hemodynamics optimization during off-pump coronary artery bypass: the 'no compression' technique
Eur. J. Cardiothorac. Surg., August 1, 2002; 22(2): 249 - 254.
[Abstract] [Full Text] [PDF]

Home page
 Ann. Thorac. Surg.Home page
M. Yeatman, M. Caputo, P. Narayan, A. Kumar Ghosh, R. Ascione, I. Ryder, and G. D. Angelini
Intracoronary shunts reduce transient intraoperative myocardial dysfunction during off-pump coronary operations
Ann. Thorac. Surg., May 1, 2002; 73(5): 1411 - 1417.
[Abstract] [Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Massimo Caputo
Malcolm J. Underwood
Franco Ciulli
Gianni D. Angelini
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Caputo, M.
Right arrow Articles by Angelini, G. D.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Caputo, M.
Right arrow Articles by Angelini, G. D.
Related Collections
Right arrow Minimally invasive surgery
Right arrowRelated Article

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
ANN THORAC SURG ASIAN CARDIOVASC THORAC ANN EUR J CARDIOTHORAC SURG
J THORAC CARDIOVASC SURG ICVTS ALL CTSNet JOURNALS