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Ann Thorac Surg 1996;61:1658-1663
© 1996 The Society of Thoracic Surgeons
Departments of Cardiac Surgery, Anesthesia, and Cardiology, "G. D'Annunzio" Chieti University, Chieti, Italy
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Abstract |
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 TopFootnotes Abstract IntroductionMaterial and MethodsResultsCommentReferences |
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Methods. This procedure was performed in 155 of 162 scheduled patients; in 7 (4.3%) the left anterior descending artery was not suitable or was too small. The chest was opened in the fourth intercostal space (mean wound length, 10.5 cm) and the LIMA was harvested for about 4 cm. The left anterior descending artery was occluded by means of two 4/0 Prolene (Ethicon, Somerville, NJ) sutures, and the proximal suture was snared. The anastomosis was performed with two 8/0 Prolene sutures while the heart was beating. Early postoperatively all patients underwent repeat angiography or a Doppler flow assessment of the LIMA or both.
Results. The LIMA was connected directly to the left anterior descending artery in 144 patients and with interposition of an inferior epigastric artery in 11. In 2 patients the diagonal branch was also grafted using an inferior epigastric artery from the LIMA. One patient (0.6%) died 38 days after the operation due to multiorgan failure. Nine patients (5.8%) had failure requiring a redo operation: 7 (4.5%) early and 2 (1.3%) late. One additional patient had a late percutaneous transluminal coronary angioplasty for anastomotic stenosis. At a mean 5.6 months of follow-up, 143 patients (92.2%) were alive, asymptomatic with or without medical treatment, and without cardiac events.
Conclusions. Left internal mammary artery-to-left anterior descending artery anastomosis performed on a beating heart via a left anterior small thoracotomy is a safe procedure. In selected patients the operation has good early and midterm results.
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Introduction |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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Coronary artery bypass grafting without cardiopulmonary bypass (CPB) via a median sternotomy is a well-established procedure, extensively used by some surgical teams [1–4]. The use of a left thoracotomy to graft one or more coronary arteries was the first approach to myocardial revascularization [5] and is today widely used in redo operations [6].
Recently some authors proposed the use of a left minithoracotomy or a left mediastinotomy to perform an anastomosis between the left internal mammary artery (LIMA) and the left anterior descending coronary artery (LAD), on a beating heart [7, 8], with the aid of a thoracoscope [9, 10], or with the support of femorofemoral bypass [11].
In November 1994 we began our experience with LAD grafting on a beating heart via a left anterior small thoracotomy (LAST). Herein we report the midterm results of patients who underwent this procedure.
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Material and Methods |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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Anatomic Indications
At angiography the distal LAD must be at least 1.5 mm and not be calcified. An intramyocardial vessel, often detectable at angiography, is, of course, an absolute contraindication for this procedure. The anastomotic site is 2 to 4 cm below the second diagonal branch; this is the segment that must be carefully evaluated.
Surgical Technique
Anesthesia is induced with fentanyl and sodium thiopental and is maintained with fentanyl and droperidol. Muscular relaxation was obtained with pancuronium bromide. A Carlens tube was used in the beginning of our experience to avoid left lung ventilation if necessary, but its use has now been discontinued. In the final part of the operation a mixture of N2O and O2 is used to allow rapid awaking of the patient.
The chest is opened via a LAST in the fourth intercostal space (sometimes in the fifth); the pleural cavity is opened routinely. The ribs are retracted and the pericardium is incised vertically (parallel to the sternum). The LAD is inspected and the feasibility of the operation is explored. An intramyocardial, calcified, or small LAD makes the anastomosis impossible. As well, an LAD located beneath the sternum is a contraindication to operation. When one of these possibilities occurs, the chest is closed and the sternal approach is used.
If the LAD is abnormally lateral, the inferior epigastric artery is used to lengthen the LAD. In our experience we used 13 inferior epigastric arteries, ten to extend the LIMA end-to-end, one as a side branch of an in situ LIMA to reach the LAD, and two as a side branch of an LIMA to an LAD to graft an important diagonal branch. The surgical technique was previously reported by us [12].
The LIMA is harvested for a short length (4 to 5 cm), upward to the superior intercostal space and downward to the level of the inferior rib. The LIMA is harvested skeletonized in the great majority of the cases to have more length. After systemic heparinization (1 mg/kg), the LIMA is injected with 3 mL of a solution containing papaverine (1 mg/mL of saline solution) and is distally clipped [12].
The LAD is then occluded proximally and distally using a 4/0 Prolene (Ethicon, Somerville, NJ) suture with a 25-mm needle passed twice to surround the vessel. To avoid any direct compression of the suture on the coronary wall [10], the needle, after the first bite, is passed through a small piece of silicone tubing. The proximal 4/0 suture is gently snared to ensure an operative field as bloodless as possible (Fig 1).
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). The LAD is then incised with a knife (Sharpoint 15-degree) for 4 to 5 mm. The anastomosis is performed using two sutures of 8/0 Prolene with a 6- or 8-mm needle. Both of them are passed three times at the heel and at the apex; the LIMA is then pulled down to reach the LAD. The two edges of the vessels now face each other, and the anastomosis is completed with two running sutures from both sides.
The LIMA and the LAD are unclamped and hemostasis is carefully checked. A drain is positioned in the left pleural cavity together with a small catheter to infuse an analgesic drug (bupivacaine). The wound is closed as usual.
Postoperative Course
All patients were admitted to the intensive care unit, where blood samples, chest roentgenograms, and electrocardiogram were obtained. The flow pattern in the LIMA was assessed by continuous-wave Doppler echocardiography. As the LIMA remains in its natural position for three intercostal spaces, the flow pattern is easily detectable. The appearance of diastolic flow is considered a demonstration of patency of the anastomosis. This flow pattern is compared with that of the unused right internal mammary artery, the flow of which is mainly systolic (Fig 2).
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Follow-up
All patients were followed up at our outpatient clinic at the end of the first and the sixth postoperative months. All patients performed a stress test and, if possible, myocardial scintigraphy was performed at the time of the first and the second visit, respectively. Doppler flow evaluation was also repeated.
The follow-up was 100% complete; it ranged from 15 days to 13 months (mean, 5.5 months).
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Results |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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. In 7 patients (4.3%) the LAD was not found or considered to be too small. The chest was closed and all patients underwent LIMA-to-LAD grafting via a median sternotomy, with (5) or without (2) cardiopulmonary bypass. In all cases but 1 the LAD was occluded and was not completely visualized in the preoperative angiography; in the remaining patient the angiography was not correctly considered.
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. Thirty-two patients were extubated in the operating room; 77 of the remaining patients were extubated during the first hour and all the others in the first 3 hours after intensive care unit admission. One patient died 38 days after the operation. He was a 65-year-old man with chronic renal failure, left internal carotid artery stenosis, and occlusion of the right internal carotid artery and the left common and external iliac arteries. He underwent left carotid endarterectomy, femorofemoral grafting and LIMA-to-LAD anastomosis via LAST. After an initial uneventful postoperative course, he was reoperated on for massive bleeding from the chest drain. At reoperation a branch of the LIMA was bleeding. Acute anemia caused deterioration of his pulmonary and renal function. He died in multiorgan failure.
Two additional patients were reoperated on for bleeding after 12 and 14 hours; an intercostal artery from the LIMA and from the chest wall were the respective causes of the hemorrhage. Interestingly, both arteries appeared longer than at the moment when the chest was closed the first time.
All patients had one or more flow Doppler evaluations, and 53 of them had early postoperative angiography (1-26 days) (Fig 3).
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The mean postoperative hospital stay was 53 ± 28 hours; this value concerns 147 patients (the patient who died and the 7 patients reoperated on in the same hospitalization were excluded). Seventy-seven percent of our patients were discharged on the second postoperative day. Longer hospitalization was mainly due to routine repeat angiography.
All patients had pulsatile wave color Doppler evaluation of the LIMA. As the basal assessment shows only that the anastomosis is patent, in 21 patients we studied the flow in the LIMA after a stress test to investigate how much flow passed through the anastomosis. We found that the diastolic flow velocity increases the lower the resistance to the flow is (Figs 4, 5). We also studied in 7 patients during angiography, by means of an intracoronary Doppler probe, the possibility of the LIMA to increase acutely diastolic flow after adenosine-induced myocardial hyperemia. All patients showed a physiologic increase in the ratio between basal and induced flow (>2.5). These data clearly emphasize that persistence of LIMA collaterals does not adversely affect the diastolic flow toward the LAD.
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At follow-up, 143 patients (92.2%) are alive and free of symptoms without a cardiac event. Stress test and myocardial scintigraphy showed no ischemia in any patient. Patients with multiple-vessel disease continue to receive medical treatment.
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Comment |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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Surgical invasiveness is minimal and the patient's comfort is high; furthermore, postoperative hospital stay can be limited to 2 days. We think that this aspect of the LAST operation is due to avoidance of CPB and not due to the position or length of the incision. Other authors [11] are using other routes, using femorofemoral bypass and inducing cold ventricular fibrillation. Patency of the anastomosis can be immediately assessed and flow reserve can be checked noninvasively at any moment. At the end of the procedure, the patient has a patent LIMA on the LAD, which is, to the best of our knowledge, the most important factor for long-term survival after surgical myocardial revascularization [13]. Moreover, pericardial adhesions are mild and the mediastinum is untouched; therefore, redo coronary artery bypass grafting actually becomes the first operation.
However, some concerns exist regarding the LAST operation:
Left Anterior Descending Artery Occlusion
In our experience occlusion of the distal LAD never caused hemodynamic changes or rhythm disturbances. These findings must be emphasized as the LAST does not give the possibility of rapid cannulation of the patient. Nevertheless our policy (the LAD is occluded before preparation of the LIMA and stabilization of the coronary vessel) makes the anastomotic time safe, as the arteriotomy is made several minutes (7 to 10 minutes) after the occlusion.
Technical Feasibility
The LIMA-to-LAD anastomosis is easier via LAST than via a median sternotomy. In fact, the heart in the latter situation rotates with every beat, as the pericardium is opened and the lungs are displaced. Via LAST the heart moves up and down, as the pericardium and the left lung remain in place. Fixation of the LAD is easier to obtain by pulling the artery upward, in the direction of its physiologic movement, by means of radial stitches. Furthermore, the LAD moves toward the surgeon, whereas via median sternotomy, the artery moves away from the surgeon. Finally, the use of two sutures to perform the anastomosis stabilizes the operative field. The LAST operation was not possible in only 4.3% of scheduled patients, and never for technical reasons. With increasing experience this value decreased to 2.0% (1/50) and may be reduced further.
Left Internal Mammary Artery Collaterals
As the LIMA is left in place for about three intercostal spaces, the intercostal, muscular, and sternal collaterals are not occluded as usual. The hemodynamic importance of this anatomic situation is controversial. We know that flow in collaterals occurs in systole, whereas flow in the LAD is diastolic; there is no competition between the different territories if the total amount of flow is sufficient. We have evidence, from our previous experience [12, 14], that the LIMA can carry enough blood for more than one myocardial territory. Others [15] have shown that the LIMA can provide blood to the whole heart. This is clearly shown by negative stress tests and myocardial scintigraphies. Moreover, the flow mapping performed in some of our patients showed a physiologic increase of flow to the LAD after adenosine-induced myocardial hyperemia, demonstrating the limited hemodynamic importance of persistent collaterals.
Cause of Graft Failure
We think that a good anastomotic technique is crucial for the success of this procedure. However, we realize that skeletonized LIMA is able to lengthen in the early postoperative period: in 1 of our patients the cause of early graft occlusion was kinking of a skeletonized LIMA against the sternum. This is an isolated case, but this observation needs further study. In our experience the causes of the graft failure were mainly in the LIMA, with the exception of patients with late anastomotic stenosis. However, as with any new technique, a learning curve is expected and increasing experience has allowed us to have only one graft failure in the last 50 patients.
Conclusion
An LIMA-to-LAD anastomosis in a beating heart via LAST is a different approach to the treatment of coronary artery disease. Its interest, if surgical indications were limited to patients with isolated LAD disease in whom percutaneous transluminal coronary angioplasty is not possible or was unsuccessful, would be only technical. However, we think that the LAST operation can be extended to patients with multiple-vessel disease with a combination of occlusion or mild or peripheral stenoses of coronary vessels different from the LAD. As we know, the natural history of patients with one or two-vessel disease, but with a patent LAD, is favorable. A palliative operation that gives a patent LIMA-to-LAD graft with low risk and high success rate must be considered in some patients, especially in high-risk subgroups. In fact, reduction of postoperative morbidity and consequent shorter postoperative hospital stay are very important end points in a period when cost containment is crucial in any healthcare system.
Our early results allow us to state that the LAST operation is safe and reproducible. We believe that this operation will have its place among the techniques of myocardial revascularization, although we recognize that longer follow-up and experience are needed.
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Footnotes |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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Address reprint requests to Dr Calafiore, Department of Cardiac Surgery, "San Camillo de' Lellis" Hospital, Via Forlanini 50, 66100 Chieti, Italy.
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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C. Detter, H. Reichenspurner, D. H. Boehm, M. Thalhammer, A. Schutz, and B. Reichart Single vessel revascularization with beating heart techniques - minithoracotomy or sternotomy? Eur. J. Cardiothorac. Surg., April 1, 2001; 19(4): 464 - 470. [Abstract] [Full Text] [PDF]
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C.-Y. Chan, I.-S. Chiu, S.-J. Wu, and C.-R. Hung A minimal transverse incision with low median sternotomy for pediatric congenital heart surgery Eur. J. Cardiothorac. Surg., March 1, 2001; 19(3): 290 - 293. [Abstract] [Full Text] [PDF]
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L. W. Tang, G. D'Ancona, J. Bergsland, A. Kawaguchi, and H. L. Karamanoukian Robotically Assisted Video-Enhanced-Endoscopic Coronary Artery Bypass Graft Surgery Angiology, February 1, 2001; 52(2): 99 - 102. [Abstract] [PDF]
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J. A. Magovern, T. J. Hunter, and P. D. Yoon Clinical results with left axillary to left anterior descending coronary artery bypass Ann. Thorac. Surg., February 1, 2001; 71(2): 561 - 564. [Abstract] [Full Text] [PDF]
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H. B. Hangler, K. Pfaller, H. Antretter, O. E. Dapunt, and J. O. Bonatti Coronary endothelial injury after local occlusion on the human beating heart Ann. Thorac. Surg., January 1, 2001; 71(1): 122 - 127. [Abstract] [Full Text] [PDF]
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M. Guler, K. Kirali, M. E. Toker, N. Bozbuga, S. N. Omeroglu, E. Akinci, and C. Yakut Different CABG methods in patients with chronic obstructive pulmonary disease Ann. Thorac. Surg., January 1, 2001; 71(1): 152 - 157. [Abstract] [Full Text] [PDF]
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M. Czerny, H. Baumer, J. Kilo, A. Zuckermann, G. Grubhofer, O. Chevtchik, E. Wolner, and M. Grimm Complete revascularization in coronary artery bypass grafting with and without cardiopulmonary bypass Ann. Thorac. Surg., January 1, 2001; 71(1): 165 - 169. [Abstract] [Full Text] [PDF]
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P. C. Kerr, M. Ricci, R. Abraham, G. D'Ancona, and T. A. Salerno Redo left anterior descending artery grafting via left anterior small thoracotomy: an alternative approach Ann. Thorac. Surg., January 1, 2001; 71(1): 384 - 385. [Abstract] [Full Text] [PDF]
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R. Mehran, G. Dangas, S. C. Stamou, A. J. Pfister, M. K. C. Dullum, M. B. Leon, and P. J. Corso One-Year Clinical Outcome After Minimally Invasive Direct Coronary Artery Bypass Circulation, December 5, 2000; 102(23): 2799 - 2802. [Abstract] [Full Text] [PDF]
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L. Sun, J. Zheng, Q. Chang, Y. Tang, J. Feng, X. Sun, and X. Zhu Aortic root replacement by ministernotomy: technique and potential benefit Ann. Thorac. Surg., December 1, 2000; 70(6): 1958 - 1961. [Abstract] [Full Text] [PDF]
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E. Ovrum, G. Tangen, C. Schiott, and S. Dragsund Rapid recovery protocol applied to 5,658 consecutive ""on-pump"" coronary bypass patients Ann. Thorac. Surg., December 1, 2000; 70(6): 2008 - 2012. [Abstract] [Full Text] [PDF]
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T. Isomura, H. Suma, T. Horii, T. Sato, T. Kobashi, and H. Kanemitsu Minimally invasive coronary artery revascularization: off-pump bypass grafting and the hybrid procedure Ann. Thorac. Surg., December 1, 2000; 70(6): 2017 - 2022. [Abstract] [Full Text] [PDF]
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E. Kilger, B. Pichler, F. Weis, A. Goetz, P. Lamm, A. Schutz, D. Muehlbayer, and L. Frey Markers of myocardial ischemia after minimally invasive and conventional coronary operation Ann. Thorac. Surg., December 1, 2000; 70(6): 2023 - 2028. [Abstract] [Full Text] [PDF]
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J. E. Tamis-Holland, P. Homel, M. Durani, M. Iqbal, A. Sutandar, B. P. Mindich, and J. S. Steinberg Atrial fibrillation after minimally invasive direct coronary artery bypass surgery J. Am. Coll. Cardiol., November 15, 2000; 36(6): 1884 - 1888. [Abstract] [Full Text] [PDF]
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S. C. Stamou, A. S. Bafi, S. W. Boyce, A. J. Pfister, M. K.C. Dullum, P. C. Hill, S. Zaki, J. M. Garcia, and P. J. Corso Coronary revascularization of the circumflex Ann. Thorac. Surg., October 1, 2000; 70(4): 1371 - 1377. [Abstract] [Full Text] [PDF]
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Y. Suematsu, T. Ohtsuka, K. Miyaji, A. Murakami, T. Miyairi, Z. Eyileten, Y. Kotsuka, and S. Takamoto Right heart mini-pump bypass for coronary artery bypass grafting: experimental study Eur. J. Cardiothorac. Surg., September 1, 2000; 18(3): 276 - 281. [Abstract] [Full Text] [PDF]
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S. R. Gundry, K. Black, and H. Izutani Sutureless coronary artery bypass with biologic glued anastomoses: Preliminary in vivo and in vitro results J. Thorac. Cardiovasc. Surg., September 1, 2000; 120(3): 473 - 477. [Abstract] [Full Text] [PDF]
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E. E. Weinschelbaum, A. Machain, H. A. Raffaelli, V. M. Caramutti, M. R. Favaloro, E. A. Dulbecco, and R. Danielo Off-pump coronary operation at the Favaloro Foundation: results in 264 patients Ann. Thorac. Surg., September 1, 2000; 70(3): 1030 - 1033. [Abstract] [Full Text] [PDF]
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R. Cichon, U. Kappert, J. Schneider, I. Schramm, V. Gulielmos, S. M. Tugtekin, and S. Schuler Robotic-enhanced arterial revascularization for multivessel coronary artery disease Ann. Thorac. Surg., September 1, 2000; 70(3): 1060 - 1062. [Abstract] [Full Text] [PDF]
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T. A. Vassiliades Jr, E. W. Rogers, J. L. Nielsen, and J. L. Lonquist Minimally invasive direct coronary artery bypass grafting: intermediate-term results Ann. Thorac. Surg., September 1, 2000; 70(3): 1063 - 1065. [Abstract] [Full Text] [PDF]
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U. Kappert, J. Schneider, R. Cichon, V. Gulielmos, K. Matschke, S. M. Tugtekin, and S. Schuler Wrist-enhanced instrumentation: moving toward totally endoscopic coronary artery bypass grafting Ann. Thorac. Surg., September 1, 2000; 70(3): 1105 - 1108. [Abstract] [Full Text] [PDF]
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P. Biglioli, C. Antona, F. Alamanni, A. Parolari, T. Toscano, G. Pompilio, and G. Polvani Minimally invasive direct coronary artery bypass grafting: midterm results and quality of life Ann. Thorac. Surg., August 1, 2000; 70(2): 456 - 460. [Abstract] [Full Text] [PDF]
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A. Lichtenberg, C. Hagl, W. Harringer, U. Klima, and A. Haverich Effects of minimal invasive coronary artery bypass on pulmonary function and postoperative pain Ann. Thorac. Surg., August 1, 2000; 70(2): 461 - 465. [Abstract] [Full Text] [PDF]
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A. Repossini, S. Moriggia, V. Cianci, O. Parodi, P. Sganzerla, G. Baldrighi, F. Bortone, and V. Arena The LAST operation is safe and effective: MIDCABG clinical and angiographic evaluation Ann. Thorac. Surg., July 1, 2000; 70(1): 74 - 78. [Abstract] [Full Text] [PDF]
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L. Wiklund, M. Johansson, M. Bugge, L.O. G. Radberg, G. Brandup-Wognsen, and E. Berglin Early outcome and graft patency in mammary artery grafting of left anterior descending artery with sternotomy or anterior minithoracotomy Ann. Thorac. Surg., July 1, 2000; 70(1): 79 - 83. [Abstract] [Full Text] [PDF]
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M. Takahashi, G. Watanabe, H. Furuta, T. Doi, N. Tanaka, T. Misaki, M. Takahashi, G. Watanabe, H. Furuta, T. Doi, et al. Grafts for Left Main Trunk Lesion Using MIDCAB Doughnut on Beating Heart Asian Cardiovasc Thorac Ann, June 1, 2000; 8(2): 114 - 117. [Abstract] [Full Text] [PDF]
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J. T. Cremer, T. Wittwer, A. Boning, M. B. Anssar, T. Kofidis, A. Mugge, and A. Haverich Minimally invasive coronary artery revascularization on the beating heart Ann. Thorac. Surg., June 1, 2000; 69(6): 1787 - 1791. [Abstract] [Full Text] [PDF]
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P. Lamm, G. Juchem, P. Weyrich, A. Schutz, and B. Reichart The harmonic scalpel: optimizing the quality of mammary artery bypass grafts Ann. Thorac. Surg., June 1, 2000; 69(6): 1833 - 1835. [Abstract] [Full Text] [PDF]
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A. Diegeler, N. Spyrantis, M. Matin, V. Falk, R. Hambrecht, R. Autschbach, F. W. Mohr, and G. Schuler The revival of surgical treatment for isolated proximal high grade LAD lesions by minimally invasive coronary artery bypass grafting Eur. J. Cardiothorac. Surg., May 1, 2000; 17(5): 501 - 504. [Abstract] [Full Text] [PDF]
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G. S. Kochamba, K. L. Yun, T. A. Pfeffer, C. F. Sintek, and S. Khonsari Pulmonary abnormalities after coronary arterial bypass grafting operation: cardiopulmonary bypass versus mechanical stabilization Ann. Thorac. Surg., May 1, 2000; 69(5): 1466 - 1470. [Abstract] [Full Text] [PDF]
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M. Ricci, H. L. Karamanoukian, R. Abraham, K. Von Fricken, G. D'Ancona, S. Choi, J. Bergsland, and T. A. Salerno Stroke in octogenarians undergoing coronary artery surgery with and without cardiopulmonary bypass Ann. Thorac. Surg., May 1, 2000; 69(5): 1471 - 1475. [Abstract] [Full Text] [PDF]
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V. A. Subramanian and N. U. Patel Transabdominal mimially invasive direct coronary artery bypass grafting (MIDCAB) Eur. J. Cardiothorac. Surg., April 1, 2000; 17(4): 485 - 487. [Abstract] [Full Text] [PDF]
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A. Bhan, S. K. Choudhary, A. Mathur, R. Sharma, M. Sahoo, R. Agrawal, and P. Venugopal Surgical myocardial revascularization without cardiopulmonary bypass Ann. Thorac. Surg., April 1, 2000; 69(4): 1216 - 1221. [Abstract] [Full Text] [PDF]
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A. Lichtenberg, U. Klima, W. Harringer, P. Y. Kim, and A. Haverich Mini-sternotomy for off-pump coronary artery bypass grafting Ann. Thorac. Surg., April 1, 2000; 69(4): 1276 - 1277. [Abstract] [Full Text] [PDF]
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M. J. Mack Reply Ann. Thorac. Surg., March 1, 2000; 69(3): 979 - 980. [Full Text] [PDF]
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L. Wiklund, M. Johansson, G. Brandrup-Wognsen, M. Bugge, G. Radberg, and E. Berglin Difficulties in the interpretation of coronary angiogram early after coronary artery bypass surgery on the beating heart Eur. J. Cardiothorac. Surg., January 1, 2000; 17(1): 46 - 51. [Abstract] [Full Text] [PDF]
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R. J. Damiano Jr, W. J. Ehrman, C. T. Ducko, H. A. Tabaie, E. R. Stephenson Jr, C. P. Kingsley, and C. E. Chambers INITIAL UNITED STATES CLINICAL TRIAL OF ROBOTICALLY ASSISTED ENDOSCOPIC CORONARY ARTERY BYPASS GRAFTING J. Thorac. Cardiovasc. Surg., January 1, 2000; 119(1): 77 - 82. [Abstract] [Full Text] [PDF]
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H. S. Bedi, A. Suri, M. S. Kalkat, B. S. Sengar, V. Mahajan, R. Chawla, and V. P. Sharma Global myocardial revascularization without cardiopulmonary bypass using innovative techniques for myocardial stabilization and perfusion Ann. Thorac. Surg., January 1, 2000; 69(1): 156 - 164. [Abstract] [Full Text] [PDF]
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 T Wittwer, J Cremer, P Boonstra, J Grandjean, M Mariani, A Mugge, H Drexler, P den Heijer, E-R v Leitner, A Hepp, et al. Myocardial "hybrid" revascularisation with minimally invasive direct coronary artery bypass grafting combined with coronary angioplasty: preliminary results of a multicentre study Heart, January 1, 2000; 83(1): 58 - 63. [Abstract] [Full Text] [PDF]
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M. F. Szwerc, D. H. Benckart, R. J. Wiechmann, E. B. Savage, G. W. Szydlowski, G. J. Magovern Jr, and J. A. Magovern Partial versus full sternotomy for aortic valve replacement Ann. Thorac. Surg., December 1, 1999; 68(6): 2209 - 2213. [Abstract] [Full Text] [PDF]
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M. Ono, S. Takamoto, and T. Ohtsuka Right ventricular rupture in minimally invasive direct coronary artery bypass grafting Eur. J. Cardiothorac. Surg., November 1, 1999; 14(5): 536 - 537. [Abstract] [Full Text] [PDF]
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A. M. Calafiore, M. Contini, A. L. Iaco, N. Maddestra, L. Paloscia, T. Iovino, and M. Di Mauro Angiographic anatomy of the grafted left internal mammary artery Ann. Thorac. Surg., November 1, 1999; 68(5): 1636 - 1639. [Abstract] [Full Text] [PDF]
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U. Kappert, V. Gulielmos, M. Knaut, R. Cichon, J. Schneider, and S. Schueler The application of the Octopus(R) stabilizing system for the treatment of high risk patients with coronary artery disease Eur. J. Cardiothorac. Surg., November 1, 1999; 16(suppl_2): S7 - S9. [Abstract] [Full Text] [PDF]
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J. D Fonger Integrated myocardial revascularization Eur. J. Cardiothorac. Surg., November 1, 1999; 16(suppl_2): S12 - S17. [Abstract] [Full Text] [PDF]
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R. D. L. Stanbridge and L. K. Hadjinikolaou Technical adjuncts in beating heart surgery Comparison of MIDCAB to off-pump sternotomy: a meta-analysis Eur. J. Cardiothorac. Surg., November 1, 1999; 16(suppl_2): S24 - S33. [Abstract] [Full Text] [PDF]
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G. Wimmer-Greinecker, G. Matheis, S. Dogan, T. Aybek, S. Mierdl, P. Kessler, and A. Moritz Patient selection for Port-AccessTM multi vessel revascularization Eur. J. Cardiothorac. Surg., November 1, 1999; 16(suppl_2): S43 - S47. [Abstract] [Full Text] [PDF]
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V. Gulielmos, M. Brandt, H.-M. Dill, M. Knaut, R. Cichon, K. Matschke, and S. Schueler Coronary artery bypass grafting via median sternotomy or lateral minithoracotomy Eur. J. Cardiothorac. Surg., November 1, 1999; 16(suppl_2): S48 - S52. [Abstract] [Full Text] [PDF]
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A. Pavie, L. Lima, N. Bonnet, M. Regan, R. Aktar, and I. Gandjbakhch Perioperative management in minimally invasive coronary surgery Eur. J. Cardiothorac. Surg., November 1, 1999; 16(suppl_2): S53 - S57. [Abstract] [Full Text] [PDF]
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A. Diegeler, M. Matin, V. Falk, C. Binner, T. Walther, R. Autschbach, and F.-W. Mohr Quality assessment in minimally invasive coronary artery bypass grafting Eur. J. Cardiothorac. Surg., November 1, 1999; 16(suppl_2): S67 - S72. [Abstract] [Full Text] [PDF]
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V. Gulielmos, M. Knaut, R. Cichon, K. Matschke, U. Kappert, M. Brandt, J. Hoffmann, and S. Schueler Experiences with a minimally invasive surgical technique for the treatment of coronary artery multivessel disease in 100 patients Eur. J. Cardiothorac. Surg., October 1, 1999; 14(4): 347 - 352. [Abstract] [Full Text] [PDF]
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A. A. Pitsis and G.D. Angelini Off pump coronary bypass grafting of the circumflex artery Eur. J. Cardiothorac. Surg., October 1, 1999; 16(4): 478 - 479. [Abstract] [Full Text] [PDF]
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R. De Paulis, F. Tomai, A. Gaspardone, L. Colagrande, P. Nardi, A. Ghini, F. Versaci, A. P. de Peppo, P. A. Gioffre, and L. Chiariello CORONARY FLOW RESERVE EARLY AND LATE AFTER MINIMALLY INVASIVE CORONARY ARTERY BYPASS GRAFTING IN PATIENTS WITH TOTALLY OCCLUDED LEFT ANTERIOR DESCENDING CORONARY ARTERY J. Thorac. Cardiovasc. Surg., October 1, 1999; 118(4): 604 - 609. [Abstract] [Full Text] [PDF]
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T. Wittwer, J. Cremer, U. Klima, T. Wahlers, and A. Haverich Myocardial "hybrid" revascularization: Intermediate results of an alternative approach to multivessel coronary artery disease J. Thorac. Cardiovasc. Surg., October 1, 1999; 118(4): 766 - 767. [Full Text]
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T. H. Spooner, J. C. Hart, and J. Pym A two-year, three institution experience with the Medtronic Octopus: systematic off-pump surgery Ann. Thorac. Surg., October 1, 1999; 68(4): 1478 - 1481. [Abstract] [Full Text] [PDF]
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V. Gulielmos, M. Brandt, M. Knaut, R. Cichon, F. M. Wagner, U. Kappert, and S. Schuler The Dresden approach for complete multivessel revascularization Ann. Thorac. Surg., October 1, 1999; 68(4): 1502 - 1505. [Abstract] [Full Text] [PDF]
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E. R. Stephenson Jr, C. T. Ducko, S. Sankholkar, E. M. Hoenicke, G. A. Prophet, and R. J. Damiano Jr Computer-assisted endoscopic coronary artery bypass anastomoses: a chronic animal study Ann. Thorac. Surg., September 1, 1999; 68(3): 838 - 843. [Abstract] [Full Text] [PDF]
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C. T. Lloyd, A. M. Calafiore, P. Wilde, R. Ascione, L. Paloscia, C. R. Monk, and G. D. Angelini Integrated left anterior small thoracotomy and angioplasty for coronary artery revascularization Ann. Thorac. Surg., September 1, 1999; 68(3): 908 - 911. [Abstract] [Full Text] [PDF]
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S. Yavuz, M A. Celkan, C. Eris, M. Mavi, T. Turk, O. Tiryakioglu, Y. Ata, V. Koca, and I A. Ozdemir Minimally Invasive Coronary Artery Bypass: Experience in 114 Patients Asian Cardiovasc Thorac Ann, September 1, 1999; 7(3): 177 - 181. [Abstract] [Full Text] [PDF]
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A Diegeler, M Matin, V Falk, C. Binner, T. Walther, R Autschbach, and F.W Mohr Indication and patient selection in minimally invasive and 'off-pump' coronary artery bypass grafting Eur. J. Cardiothorac. Surg., September 1, 1999; 16(suppl_1): S79 - S82. [Abstract] [Full Text] [PDF]
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