HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Jeffrey P. Gold O. Wayne Isom Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Barbut, D. Articles by Isom, O. W. Search for Related Content PubMed PubMed Citation Articles by Barbut, D. Articles by Isom, O. W. Related Collections Related Article

Ann Thorac Surg 1997;64:454-459
© 1997 The Society of Thoracic Surgeons

---

Original Articles: Cardiovascular

Aortic Atheroma Is Related to Outcome but Not Numbers of Emboli During Coronary Bypass

Departments of Neurology, Anesthesiology, and Cardiothoracic Surgery, Cornell University Medical College, New York, New York

Accepted for publication February 27, 1997.

	Abstract

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Background. The relation between aortic atheroma severity and stroke after coronary artery bypass grafting is established. The relation between atheroma severity and other outcome measures or numbers of emboli has not been determined.

Methods. Using transesophageal echocardiography, we determined the severity of atheroma in the ascending, arch, and descending aortic segments in 84 patients undergoing operations. Seventy patients were monitored using transcranial Doppler ultrasonography.

Results. The incidence of stroke was 33.3% among 9 patients with mobile plaque of the arch and 2.7% among 74 patients with nonmobile plaque (p = 0.011). Cardiac complications were not significantly related to atheroma severity in any aortic segment. Length of stay was significantly related to atheroma severity in the aortic arch (p = 0.025) and descending segment (p = 0.024). The presence of severe atheroma in both the arch and descending segments was associated with significantly longer hospital stays as compared with patients with severe atheroma in neither segment (p = 0.05). Numbers of emboli were greater in patients with severe atheroma at clamp placement, although the differences did not achieve statistical significance.

Conclusions. Aortic atheroma severity is related to stroke and to the duration of hospitalization after coronary artery bypass grafting. The lack of correlation between numbers of emboli and atheroma severity suggests that many emboli may be nonatheromatous in nature.

	Introduction

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Coronary artery bypass grafting is associated with neurologic deficits in substantial numbers of patients [1]. Stroke complicates 5% to 7% of cases [1, 2], and persistent cognitive deficit is observed in 20% of patients up to 3 years after operation [3]. The etiology of this dysfunction is multifactorial and includes hypoperfusion [2, 4], embolization [5, 6], and other poorly understood mechanisms. Over the last decade, the number of elderly patients undergoing bypass procedures has increased significantly, and the decline in mortality and cardiac morbidity achieved by improvements in anesthetic techniques has been largely obscured by rising stroke rates [7]. The severity of aortic atheroma rises sharply with age [8], from 20% in the fifth decade at autopsy to 80% over the age of 75 years [9], and the stroke rate increases from 1% in patients 51 to 60 years old to 7% or more in those older than 75 years [7, 9–11]. Correspondingly, evidence of atheroembolism was present in 4.5% of patients who died after coronary artery bypass grafting in 1982, but was detected in as many as 48% in 1989 [9].

The advent of transesophageal echocardiography (TEE) has enabled surgeons and anesthesiologists to obtain a detailed view of the aorta during operations and to quantify atheromatous plaques according to thickness and the presence of mobile components [12]. The importance of the aorta as a source of atheroemboli and hence as a risk factor for perioperative stroke was highlighted by Katz and associates [12], who found a stroke incidence of 25% among patients with mobile plaque of the arch as opposed to only 2% of patients with nonmobile plaque. Several subsequent studies have confirmed the strong correlation between severe aortic atheroma and stroke or death [13, 14]. The relation between atheroma severity and nonneurologic indices of clinical outcome has not yet been determined.

Emboli—gaseous, fatty, and atheromatous—can now be detected intracranially in vivo using transcranial Doppler ultrasonography (TCD) [6, 15]. A correlation between the numbers of such emboli and aortic atheroma severity has been suggested previously, but not validated [16]. We conducted this study to determine the impact of severe aortic atheromatosis on a number of outcome variables and to define its relation to numbers of emboli.

	Material and Methods

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Patient Selection
We monitored 84 adult patients (69 men, 15 women; mean age, 67 years; range, 37 to 86 years) who were undergoing coronary artery bypass grafting between 1994 and 1996 using TEE and TCD. The procedure involved isolated coronary artery grafting in 83 patients and was combined with valve replacement in 1. The protocol was approved by our institutional review board, and participating patients gave informed consent. We excluded patients who were not anesthetized by participating anesthetists and those in whom a transtemporal window could not be obtained.

Anesthesia
Morphine and lorazepam or midazolam served as premedication, and thiopental, fentanyl, and pancuronium was used for induction. Anesthesia before and after bypass was maintained with additional boluses of fentanyl and midazolam. Postoperative care was administered according to institutional standards.

Cardiopulmonary Bypass
Membrane oxygenerators were used in conjunction with nonpulsatile centrifugal pumps. All patients received anticoagulation with sodium heparin to an activated clotting time in excess of 500 seconds. A 40-µm blood filter (Ultipor; Pall Biomedical, East Hills, NY) was incorporated into the arterial perfusion line. Bypass was initiated at flow rates of 2.4 L · min^-1 · m^-2 at a body temperature of 37.5°C and was reduced to 1.6 L · min^-1 · m^-2 at 28°C. We regulated the systemic blood pressure pharmacologically using anesthetic agents and vasoconstrictors to maintain mean arterial pressures between 50 and 80 mm Hg. Operative staff were blinded to the TCD findings during the procedure.

Standard Transesophageal Echocardiography
We performed biplanar (n = 47) or monoplanar (n = 37) TEE on 84 patients after the induction of general anesthesia and endotracheal intubation and again at the end of the surgical procedure. A 5-MHz TEE probe (Acuson, Mountain View, CA) and an Acuson 128 XP system were used. All studies were recorded on standard VHS videotape and interpreted subsequently. We assessed the severity of ascending, arch, and descending aortic atheroma individually and graded each segment according to a standardized system, as follows: grade I, normal to mild intimal thickening; grade II, severe intimal thickening; grade III, atheroma protruding less that 5 mm into the lumen; grade IV, atheroma protruding 5 mm or more into the lumen; and grade V, atheroma with a mobile component [12]. The ascending segment was adequately imaged in only 75 patients, the arch in 83 patients, and the descending segment in all 84 patients. All videotapes were reviewed independently by two echocardiographers, and differences of opinion exceeding one grade were referred to a third person for arbitration.

Intraoperative Transcranial Doppler Ultrasonography Monitoring
We monitored continuously the middle cerebral artery of 70 patients from before aortic cannulation to after discontinuation of bypass using a 2-MHz pulsed-wave TCD probe (Medasonics-CDS, Fremont, CA) placed on the patient's temple at a depth of 4.5 to 6.0 cm. Embolic signals (ES) were defined as high-amplitude, unidirectional, transient signals less than 0.1 second in duration and associated with a characteristic chirping sound. Data were stored on disks and subsequently reviewed and counted manually by a single examiner. Concurrently, the number of aggregate ES were recorded by an automated counter. This number was used only during flurries of embolization too numerous to count manually. We recorded the timing of all major events and the numbers of ES occurring within 4 minutes of aortic cannulation, inception and termination of bypass, aortic clamping, and clamp release.

Neurologic Assessment
Forty-six patients were examined by a neurologist blinded to the TCD data. These patients were examined preoperatively, in the immediate postoperative period, and before discharge. Neurologic evaluation of the remaining 38 patients consisted of chart review only. Stroke was defined as focal perioperative deficit of the central nervous system persisting for more than 24 hours.

Cardiac Evaluation
All cardiac complications were determined during the hospitalization, documented by the responsible cardiologist or anesthetist, and then entered into a data base system. Patient charts and the data base were reviewed subsequently. Complications were classified as minor sustained (supraventricular arrhythmia) or major (ventricular arrhythmia, myocardial infarction, or cardiogenic shock with failure to come off bypass or requirement of intraaortic balloon pump).

Statistical Analysis
Comparison of proportions between groups was performed using ² test or Fisher's exact test, as appropriate. Comparison of continuous quantities between groups was performed using one-way analysis of variance. When analysis of variance revealed significant differences between groups, Scheffé's post hoc test was used for pairwise comparison. All statistical analyses were performed using STATISTICA/W (version 5.0; Stat Soft, Tulsa, OK) on a PC-DOS/Windows 95 platform.

	Results

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
The segmental distribution of TEE-graded aortic atheromas is shown in Figure 1. Overall, mobile atheromatous plaque was present in 17 of 84 patients (20%) in at least one segment. Mobile plaque was present in 10 of 84 patients (11.9%) in the descending segment, in 9 of 83 (10.8%) in the arch, and in 1 of 75 (1.3%) in the ascending segment. Grade IV atheromatous disease was present in 19 of 84 patients (22.6%) in the descending segment, in 6 of 83 (7.2%) in the arch, and in 3 of 75 (4%) in the ascending segment. Combined grade IV or V atheromatous disease was present in only 4 of 75 patients (5.3%) in the ascending segment, in 15 of 83 (18%) in the arch, and in 29 of 84 (34.5%) in the descending segment. Three of 17 patients had mobile plaque in more than one segment.

View larger version (27K): [in this window] [in a new window]   Fig 1. . Segmental distribution of aortic atheromas as determined by transesophageal echocardiography (TEE) in patients having cardiac operations. (I = normal to mild intimal thickening; II = severe intimal thickening; III = protrusion less than 5 mm; IV = protrusion greater than or equal to 5 mm; V = mobile component.)

The mean atheroma grade for each aortic segment was not significantly higher in patients with major cardiac complications than in those with minor or no complications (Table 2). Furthermore, the incidence of major cardiac complications was no different in patients with mobile plaque of the arch or descending aorta than in patients without (see Table 2).

	Comment

Top Footnotes Abstract Introduction Material and Methods Results Comment References

The association between aortic atheromatosis and stroke has been established previously both within and outside the context of cardiac operations [8, 13–15, 19, 20]. In a prospective study involving 250 patients with stroke and 250 controls, Amarenco and colleagues [19] found protruding plaque in 14.4% of patients with stroke but in only 2% of control subjects. Plaques of all thicknesses were associated with stroke, but the association was strongest for plaques more than 4 mm thick. An even stronger association between mobile plaque and stroke has been shown in patients undergoing cardiac procedures [12–14, 20]. Katz and associates [12] found a stroke incidence of 25% in patients with mobile plaque of the arch, as opposed to only 2% in those with nonmobile plaque. In another series, the stroke incidence was determined to be 45% among patients with mobile descending-segment plaque but only 3% in the remainder [14]. The association between protruding atheroma and stroke found by Amarenco and colleagues [19] was strongest for the ascending aorta when combined with the proximal arch, was much weaker for the distal arch, and was absent for descending aortic disease. In agreement with Amarenco and colleagues, we found the association between mobile plaque and stroke to be strong in the arch and weak in the descending segment. This is not surprising because atheromatous cerebral emboli emanating from the aorta can only arise from atheromatous debris in the ascending segment and proximal arch.

The relation between aortic atheroma and cardiac complications after cardiac operations has not yet been established. Although patients with major cardiac complications after cardiac procedures appeared to have slightly more atheromatous aortas, the prevalence of mobile plaques in this subgroup was not significantly higher than in patients without major complications. Similarly, Gold and co-workers [2] found a relation between aortic atheroma and major cardiac complications by combining these with stroke. One mechanism by which aortic atheroma could cause cardiac complications is intraoperative coronary atheroembolization [21, 22]. Several anecdotal reports have described such atheromatous coronary embolization from the aortic root [22], and some cases have had serious consequences [21]. Atheroemboli are also common in the coronary arteries of patients who die during coronary angioplasty, and their presence correlates with cardiac complications after the procedure [23]. Although embolization of atheromatous debris to the coronary arteries may be associated with transient or permanent cardiac ischemia, it does not seem to have as devastating an effect as atheromatous cerebral embolization.

In this study, the severity of aortic atheroma did not correlate significantly with the number of TCD-detected emboli. This finding is somewhat surprising in view of the strong relation between the severity of aortic atheroma and stroke [12, 14, 20] and suggests that a majority of emboli may be nonatheromatous. Large numbers of gaseous emboli would easily obscure the relation between the number of liberated atheromatous emboli and the amount of atheromatous deposit on the aortic wall. All types of cerebral emboli contribute to the neurologic insult. At present, however, there is no certain way using Doppler techniques to differentiate between emboli of differing constitution [24, 25]. Hence, the relative damage caused by atheromatous, gaseous, or other embolic material remains to be determined.

The outcome variables analyzed in this study correlated best with atheroma severity in the arch of the aorta. Not surprisingly, the correlation was poor in the descending segment, reflecting the fact that emboli from this segment do not enter the cerebral circulation. The lack of a relation between outcome and ascending-segment atheroma is likely artifactual and attributable to the difficulty in visualizing this segment using TEE.

The overall effect of aortic atheromatosis is clearly reflected in LOS, the "gold standard" measure of short-term procedural success. Procedural costs increase by thousands of dollars for each added day of hospitalization. The cost-effectiveness of performing preoperative TEE on all candidates for cardiac procedures in an attempt to identify those at high risk for increased LOS and multisystem complications must be judged against the increased procedural cost in those with unidentified severe aortic atheromatosis.

	Footnotes

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Address reprint requests to Dr Barbut, Starr 607, 520 E 70 St, New York, NY 10021.

	References

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 

1. Shaw PJ, Bates D, Cartlidge NEF, Heaviside D, Julian DG, Shaw DA. Early neurological complications of coronary artery bypass surgery. Br Med J 1985;291:1384–7.[Medline]
2. Gold JP, Charlson ME, Williams-Russo P, et al. Improvement of outcomes after coronary artery bypass: a randomized trial comparing intraoperative high versus low mean arterial pressure. J Thorac Cardiovasc Surg 1995;110:1302–14.[Abstract/Free Full Text]
3. Murkin JM, Baird DL, Martzke JS, Adams SJ, Lok P. Long-term neurological and neuropsychological outcome 3 years after coronary artery bypass surgery [Abstract]. Anesth Analg 1996;82:S328.
4. Stockard JJ, Bickford RG, Schaube JF. Pressure dependent cerebral ischemia during cardiopulmonary bypass. Neurology 1973;23:521–9.[Free Full Text]
5. Blauth CI, Arnold JV, Schulenberg WE, McCartney AC, Taylor KM. Cerebral microembolism during cardiopulmonary bypass: retinal microvascular studies in vivo with fluorescein autoradiography. J Thorac Cardiovasc Surg 1988;95:668–76.[Abstract]
6. Pugsley W, Klinger L, Paschalis C, Treasure T, Harrison M, Newman S. The impact of microemboli during cardiopulmonary bypass on neuropsychological functioning. Stroke 1994;25:1393–9.[Abstract]
7. Gardner TJ, Horneffer PF, Manolio TA, et al. Stroke following coronary artery bypass grafting: a ten-year study. Ann Thorac Surg 1985;40:574–81.[Abstract]
8. Blauth CI, Cosgrove DM, Webb BW, et al. Atheroembolism from the ascending aorta: an emerging problem in cardiac surgery. J Thorac Cardiovasc Surg 1992;103:1104–12.[Abstract]
9. Wareing TH, Davila-Roman VG, Barzilai B, Murphy SF, Kouchoukos NT. Management of the severely atherosclerotic ascending aorta during cardiac operations. J Thorac Cardiovasc Surg 1992;103:453–62.[Abstract]
10. Davila-Roman VG, Barzilai B, Wareing TH, Murphy SF, Kouchoukos NT. Intraoperative ultrasonographic evaluation of the ascending aorta in 100 consecutive patients undergoing cardiac surgery. Circulation 1991;84(Suppl 3):I47–53.
11. Bar-El Y, Goor DA. Clamping of the atherosclerotic ascending aorta during coronary artery bypass operations: its cost in strokes. J Thorac Cardiovasc Surg 1992;104:469–74.[Abstract]
12. Katz ES, Tunick PA, Rusinek H, Ribakove G, Spencer FC, Kronzon K. Protruding aortic atheromas predict stroke in elderly patients undergoing cardiopulmonary bypass: experience with intraoperative transesophageal echocardiography. J Am Coll Cardiol 1992;20:70–7.[Abstract]
13. Hosoda Y, Watanabe M, Hirooka Y, Ohse Y, Tanaka A, Watanabe T. Significance of atherosclerotic changes of the ascending aorta during coronary bypass surgery with intraoperative detection by echography. J Cardiovasc Surg 1991;32:301–6.[Medline]
14. Hartman GS, Yao FSF, Bruefach M, et al. Severity of aortic atheromatous disease diagnosed by transesophageal echocardiography predicts stroke and other outcomes associated with coronary artery bypass grafting surgery: a prospective study. Anesth Analg 1996;83:701–8.[Abstract]
15. Barbut D, Hinton RB, Szatrowski TP, et al. Cerebral emboli detected during bypass surgery are associated with clamp removal. Stroke 1994;25:2398–402.[Abstract]
16. Barbut D, Hinton RB, Hartman GS, et al. Number of emboli detected by TCD during CABG is related to aortic atheroma as assessed by TEE [Abstract]. In: Program and abstracts of the brain and cardiac surgery. September 1994; Key West, Florida.
17. Amarenco P, Duyckaerts C, Tzourio C, Henin D, Bousser M-G, Hauw J-J. The prevalence of ulcerated plaques in the aortic arch in patients with stroke. N Engl J Med 1992;326:221–5.[Abstract]
18. Konstadt SN, Reich DL, Kahn R, Viggiani RF. Transesophageal echocardiography can be used to screen for ascending aortic atherosclerosis. Anesth Analg 1995;81:225–8.[Abstract]
19. Amarenco P, Cohen A, Tzourio C, et al. Atherosclerotic disease of the aortic arch and the risk of ischemic stroke. N Engl J Med 1994;331:1474–9.[Abstract/Free Full Text]
20. Marschall K, Kanchuger M, Kessler K, et al. Superiority of transesophageal echocardiography in detecting aortic arch atheromatous disease: identification of patients at increased risk of stroke during cardiac surgery. J Cardiothorac Vasc Anesth 1994;8:5–13.[Medline]
21. Keon WJ, Heggtveit HA, Leduc J. Perioperative myocardial infarction caused by atheroembolism. J Thorac Cardiovasc Surg 1982;84:849–55.[Abstract]
22. De Morais CF, Lopes EA, Checchi H, Arie S, Pileggi F. Percutaneous transluminal coronary angioplasty—histopathological analysis of nine necropsy cases. Virchows Arch A 1986;410:195–202.
23. Saber RS, Edwards WD, Bailey KR, McGovern TW, Schwartz RS, Holmes DR. Coronary embolization after balloon angioplasty or thrombolytic therapy: an autopsy study of 32 cases. J Am Coll Cardiol 1993;22:1283–8.[Abstract]
24. Spencer MP, Thomas GI, Nicholls SC, Sauvage LR. Detection of middle cerebral artery emboli during carotid endarterectomy using transcranial Doppler ultrasonography. Stroke 1990;21:415–23.[Abstract/Free Full Text]
25. Markus HS, Brown MM. Differentiation between different pathological cerebral embolic materials using TCD in an in-vitro model. Stroke 1993;24:1–5.[Abstract/Free Full Text]

This article has been cited by other articles:

				M. E. Halkos, J. D. Puskas, O. M. Lattouf, P. Kilgo, R. A. Guyton, and V. H. Thourani Impact of preoperative neurologic events on outcomes after coronary artery bypass grafting. Ann. Thorac. Surg., August 1, 2008; 86(2): 504 - 510. [Abstract] [Full Text] [PDF]

				G. N. Djaiani Aortic arch atheroma: stroke reduction in cardiac surgical patients. Seminars in Cardiothoracic and Vascular Anesthesia, June 1, 2006; 10(2): 143 - 157. [Abstract] [PDF]

				M. Skjelland, J. Bergsland, R. Lundblad, P. S. Lingaas, K. A. Rein, S. Halvorsen, J. L. Svennevig, E. Fosse, R. Brucher, and D. Russell Cerebral microembolization during off-pump coronary artery bypass surgery with the Symmetry aortic connector device J. Thorac. Cardiovasc. Surg., December 1, 2005; 130(6): 1581 - 1585. [Abstract] [Full Text] [PDF]

				C. Baufreton, P. Allain, A. Chevailler, F. Etcharry-Bouyx, J. J. Corbeau, D. Legall, and J. L. de Brux Brain Injury and Neuropsychological Outcome After Coronary Artery Surgery Are Affected by Complement Activation Ann. Thorac. Surg., May 1, 2005; 79(5): 1597 - 1605. [Abstract] [Full Text] [PDF]

				S. Bar-Yosef, M. Anders, G. B. Mackensen, L. K. Ti, J. P. Mathew, B. Phillips-Bute, R. H. Messier, H. P. Grocott, and the Neurological Outcome Research Group and CARE I Aortic Atheroma Burden and Cognitive Dysfunction After Coronary Artery Bypass Graft Surgery Ann. Thorac. Surg., November 1, 2004; 78(5): 1556 - 1562. [Abstract] [Full Text] [PDF]

				J. P. Gold, K. E. Torres, W. Maldarelli, I. Zhuravlev, D. Condit, and J. Wasnick Improving Outcomes in Coronary Surgery: The Impact of Echo-Directed Aortic Cannulation and Perioperative Hemodynamic Management in 500 Patients Ann. Thorac. Surg., November 1, 2004; 78(5): 1579 - 1585. [Abstract] [Full Text] [PDF]

				G. B. Mackensen, L. K. Ti, B. G. Phillips-Bute, J. P. Mathew, M. F. Newman, H. P. Grocott, and the Neurologic Outcome Research Group Cerebral embolization during cardiac surgery: impact of aortic atheroma burden Br. J. Anaesth., November 1, 2003; 91(5): 656 - 661. [Abstract] [Full Text] [PDF]

				R. K. Grooters, D. A. Ver Steeg, M. J. Stewart, K. C. Thieman, and R. F. Schneider Echocardiographic comparison of the standard end-hole cannula, the soft-flow cannula, and the dispersion cannula during perfusion into the aortic arch Ann. Thorac. Surg., June 1, 2003; 75(6): 1919 - 1923. [Abstract] [Full Text] [PDF]

				J. R. Doty, R. E. Wilentz, J. D. Salazar, R. H. Hruban, and D. E. Cameron Atheroembolism in cardiac surgery Ann. Thorac. Surg., April 1, 2003; 75(4): 1221 - 1226. [Abstract] [Full Text] [PDF]

				V. Vijay and J. P. Gold Late Complications of Cardiac Surgery Card. Surg. Adult, January 1, 2003; 2(2003): 521 - 537. [Full Text]

				S Eifert, H Reichenspurner, T Pfefferkorn, B Baur, C von Schlippenbach, T E Mayer, G Hamann, and B Reichart Neurological and neuropsychological examination and outcome after use of an intra-aortic filter device during cardiac surgery Perfusion, January 1, 2003; 18(1_suppl): 55 - 60. [Abstract] [PDF]

				A A Albert, C J Beller, B Arnrich, J A Walter, U P Rosendahl, A Hetzel, H Priss, and J Ennker Is there any impact of the shape of aortic end-hole cannula on stroke occurrence? Clinical evaluation of straight and bent-tip aortic cannulae Perfusion, December 1, 2002; 17(6): 451 - 456. [Abstract] [PDF]

				P. Bergman, L. Hadjinikolaou, and J. van der Linden Aortic atheroma is related to number of particulates captured by intra-aortic filtration in CABG Eur. J. Cardiothorac. Surg., October 1, 2002; 22(4): 539 - 544. [Abstract] [Full Text] [PDF]

				M. J. A. Robson, R. P. Alston, I. J. Deary, P. J. D. Andrews, and M. J. Souter Jugular Bulb Oxyhemoglobin Desaturation, S100{beta}, and Neurologic and Cognitive Outcomes After Coronary Artery Surgery Anesth. Analg., October 1, 2001; 93(4): 839 - 845. [Abstract] [Full Text] [PDF]

				N. Trehan, M. Mishra, R. R. Kasliwal, and A. Mishra Reduced neurological injury during CABG in patients with mobile aortic atheromas: a five-year follow-up study Ann. Thorac. Surg., November 1, 2000; 70(5): 1558 - 1564. [Abstract] [Full Text] [PDF]

				H. Reichenspurner, J. A. Navia, G. Berry, R. C. Robbins, D. Barbut, J. P. Gold, and B. Reichart PARTICULATE EMBOLI CAPTURE BY AN INTRA-AORTIC FILTER DEVICE DURING CARDIAC SURGERY J. Thorac. Cardiovasc. Surg., February 1, 2000; 119(2): 233 - 241. [Abstract] [Full Text] [PDF]

				H. J. Willens and K. M. Kessler Transesophageal Echocardiography in the Diagnosis of Diseases of the Thoracic Aorta* : Part II--Atherosclerotic and Traumatic Diseases of the Aorta Chest, January 1, 2000; 117(1): 233 - 243. [Abstract] [Full Text] [PDF]

				K. A. Eagle, R. A. Guyton, R. Davidoff, G. A. Ewy, J. Fonger, T. J. Gardner, J. P. Gott, H. C. Herrmann, R. A. Marlow, W. C. Nugent, et al. ACC/AHA guidelines for coronary artery bypass graft surgery: A report of the American College of Cardiology/ American Heart Association task force on Practice Guidelines (Committee to revise the 1991 Guidelines for Coronary Artery Bypass Graft Surgery) J. Am. Coll. Cardiol., October 1, 1999; 34(4): 1262 - 1347. [Full Text] [PDF]

This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Jeffrey P. Gold O. Wayne Isom Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Barbut, D. Articles by Isom, O. W. Search for Related Content PubMed PubMed Citation Articles by Barbut, D. Articles by Isom, O. W. Related Collections Related Article