| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
Ann Thorac Surg 1999;68:1612-1618
© 1999 The Society of Thoracic Surgeons
a Department of Cardiothoracic Surgery, Royal Melbourne Hospital, Melbourne, Australia
b Department of Anesthesia, Royal Melbourne Hospital, Melbourne, Australia
Address reprint requests to Dr Royse, Department of Cardiothoracic Surgery, Royal Melbourne Hospital, PO Box 2135, Parkville, Victoria 3050, Australia
e-mail: alistair.royse{at}nwhcn.org.au
 |
Abstract |
|---|
 Top Abstract IntroductionMaterial and methodsResultsCommentReferences |
|---|
Methods. Using the left internal mammary artery and radial artery joined as a composite Y graft, all coronary territories may be grafted.
Results. One in-hospital death from 464 patients (0.2%) occurred. Age (mean ± standard error) was 64.7 ± 0.5 years and number of distal anastomoses 3.4 ± 0.04. Of 1,681 patients from Royal Melbourne Hospital, 346 had this operation. Comparison found no preoperative selection bias and no postoperative differences in complications. Actuarial survival was 0.98 ± 0.01 at 36.1 ± 0.3 months.
Conclusions. Total arterial revascularization may be performed using the left internal mammary artery and radial artery as a composite Y graft. There was no increase in complications. This technique preserves the left internal mammary artery to left anterior descending artery graft.
|
Introduction |
|---|
|
TopAbstractIntroductionMaterial and methodsResultsCommentReferences |
|---|
Sequential grafting uses one conduit for more than one distal anastomosis and is therefore more efficient. Since most patients receive more than two anastomoses, sequential grafts are frequently required when using composite grafts.
Long term angiographic studies have found a very high patency of pedicled (in-situ) left internal mammary artery (LIMA) to the left anterior descending artery [10, 11]. This graft is the most important graft in reducing late mortality [12] or recurrence of angina or infarction [13] following coronary artery bypass surgery. Free internal mammary arteries anastomosed to the aorta have a lower patency [14, 15]. It is generally accepted that any conduit grafted to the left anterior descending artery retains a higher late patency, perhaps due to a greater "run off" for this vessel. It is still unclear however, whether the pedicled (in-situ) nature of this graft is of independent benefit.
This paper describes a simple technique for total arterial revascularization of multivessel coronary disease using composite pedicled arterial grafts where the LIMA to the left anterior descending artery graft is preserved.
|
Material and methods |
|---|
|
TopAbstractIntroductionMaterial and methodsResultsCommentReferences |
|---|
The operations were performed mostly at Royal Melbourne Hospital and Melbourne Private Hospitals, Melbourne, Australia. Data was collected prospectively on a custom database written by the author and colleagues. In-hospital mortality was known for all patients. Mortality within 30 days of operation following discharge from hospital was not routinely collected and this time frame for mortality is consequently not reported. A comparison of preoperative and postoperative variables pertains only to those patients operated on at the Royal Melbourne Hospital (n = 346), because this was the only institution with a complete data set. Follow-up data was from surgeon review or telephone consultation by a nurse research assistant.
Statistical analysis
Univariate analyses was performed using the Fisher’s exact test for dichotomous variables and analysis of variance for continuous variables (SPSS V8.0 SPSS Inc, Chicago, IL). Continuous variables are expressed as mean ± 1 standard error. The Cochrane-Armitage trend test for ordered categorical data as performed using StatXact V3.1 (Cytel Software Corporation, Cambridge, MA). Where appropriate, pwas adjusted for multiple hypothesis testing (p') according to the Ryan-Holm step-down Bonferroni procedure [16]. The 2 sided p or p' less than or equal to 0.05 was considered significant. Actuarial survival was calculated using the Kaplan-Meier method (SPSS V8.0, SPSS Inc).
Technique of exclusive Y graft
Radial artery harvest
The key is to enter the plane deep to the fascia immediately surrounding the radial artery (neurovascular fascia) [5]. The radial artery lies within loose areolar tissue only and is easily harvested (Fig 1). Topical and intraluminal papaverine 1 mg/mL; but no systemic vasodilator is used. Sharp dissection with minimal traction will reduce the incidence of spasm. We use electrocautery as the method of dissection.
|
Y graft construction
This is performed prior to cannulation for cardiopulmonary bypass. The chest wall side of the vessel is opened near the third intercostal branch (equating to the point where the LIMA will pass through a hole made in the pericardium anterior to the phrenic nerve) and lies in the center of the operative field over the thymus (Fig 2). By constructing the anastomosis as one may for a distal anastomosis, a "Y" rather than a "T" is formed. The radial artery vein and the left side of the LIMA fascia are tacked together in case of inadvertent traction to prevent kinking.
|
|
Method of anastomosis
Wherever possible, a parallel method should be used (where the extremities of coronary and conduit incisions match exactly as would be the case for a usual end-to-side anastomosis). Surgeons are familiar with this technique and so it is most easily performed as well as having the least potential for distorting either conduit or coronary artery (Fig 4A).
|
The key to simple anastomosis construction is to place the first few sutures in the order and site displayed in Figure 4 (for a right-handed surgeon using the "forehand" technique of suturing).
Patency and removal of air
Before the most distal anastomosis is tied, the clamp on that conduit should be removed to check for adequate blood flow and to remove air from the conduit. Hemostasis for each anastomosis is then checked prior to removal of the aortic clamp.
Simple rules
Sequential anastomoses are often more technically demanding. The most difficult vessels to graft are vessels near the intermediate artery. Grossly obese patients and those with substantial rotation of their hearts to the left present increasing technical challenge. The radial artery and LIMA are usually of adequate length to graft all coronary branches in all patients, but caution is advised for patients with dilated left ventricles where the left ventricular end-diastolic dimension is 6.5 cm or more.
|
Results |
|---|
|
TopAbstractIntroductionMaterial and methodsResultsCommentReferences |
|---|
Patients were included if the right internal mammary was used with this technique (n = 7) when the radial artery was found to be diseased. Patients were excluded if any aortic anastomosis or venous conduit was used. Three patients were excluded due to poor LIMA flow after vasodilation (presumed subclavian artery disease affecting inflow) and 3 where the LIMA was damaged during harvest. Three of these patients had the same Y graft technique used, excepting that the proximal LIMA was anastomosed to the ascending aorta (since the distance of the proximal LIMA segment to the pericardial reflection is approximately the same as from the ascending aorta) and were excluded. Two patients had saphenous vein graft used to lengthen the radial artery during grafting; 1 patient had damage to the radial artery during grafting and another had less than the full length of radial artery harvested and this was not realized before commencement of coronary grafting. Another had an aortocoronary saphenous vein graft when inadvertent traction on the radial artery resulted in tearing of a circumflex marginal artery and repair required division of the radial artery. All 3 of these patients were excluded from this series. One suffered a myocardial infarct in the territory of the saphenous vein graft and there were no complications in the other 2.
There was 1 in-hospital death resulting in a series mortality of 0.2%. This patient was unstable preoperatively following myocardial infarction, underwent reoperation and required postoperative intraaortic balloon pump. The patient died of renal and cardiac failure 3 days postoperatively.
There were 5 myocardial infarcts, 2 being acute evolving myocardial infarctions at the time of surgery and one being caused by severe tamponade presumably kinking the radial artery. Reoperation with regrafting was performed in 3 patients. Two of these at 3 and 11 months postoperatively were due to kinks in the conduit. Another had supplementary graft to the posterior descending artery at the time of emergency reoperation for tamponade from extrapericardial clot compressing the right ventricle. One patient had the radial artery vein inadvertently sutured to the medial (right) aspect of the LIMA pedicle and this vein lay in front of and compressed the LIMA against the heart. Reoperation cut this suture and no regrafting was required. One patient had atypical chest pains and a 50% stenosed intermediate artery not seen to fill via the graft. Angioplasty was performed but did not resolve the atypical pains in the longer term.
Two patients had deep sternal wound infection requiring debridement. Intra-aortic balloon pump was used preoperatively in 2, intraoperatively in 2, and postoperatively in 1. There were two strokes. One resulted from aortic root rupture in the postoperative period following stentless aortic valve replacement. This stroke was caused by hypotension following cardiac arrest and was not related to the coronary procedure. There were no significant hand ischemic or neurological events.
Comparison of preoperative and postoperative variables was performed for patients from Royal Melbourne Hospital only, as a complete data set was present only at this institution. From January 1, 1996 to June 30, 1998 there were 346 patients with exclusive Y graft and 1,335 patients without. No differences in preoperative variables were noted (Table 1). Comparison of postoperative data was made for patients at Royal Melbourne Hospital (Tables 2 and 3) with no differences in complications. Postoperative hemoglobin was slightly, but significantly, lower in the Y graft group and not clinically relevant.
|
|
|
There were 4 late deaths during follow-up for Royal Melbourne Hospital patients and the 8 patients from 1995, resulting in actuarial survival of 0.98 ± 0.01 at 36.1 ± 0.3 months (Fig 5). One patient more than 80 years of age died at 6 months of unknown cause; 1 died of cardiac failure at 1 month; and 2 died suddenly at 6 and 18 months postoperatively. These 2 patients were otherwise well and their deaths may have been caused by arrhythmia. Both had dilated ventricles with poor function. One had undergone a research graft study 3 weeks prior with patent grafts; postmortem examination did not identify a cause of death in this patient.
|
|
Comment |
|---|
|
TopAbstractIntroductionMaterial and methodsResultsCommentReferences |
|---|
The disadvantage of saphenous vein grafts has been late attrition due to the development of disease within the conduit [1]. It is the hope of many surgeons that arterial conduit of all types will replicate the better late patency of the pedicled LIMA to the left anterior descending artery [10, 11]. In this series, most patients had entirely normal arterial conduit harvested having already been exposed to the arterial circulation for an average of 64.7 years.
Until recently, use of bilateral internal mammary artery was infrequent despite excellent results and low mortality and morbidity [12, 17–19]. The pedicled right internal mammary artery is less useful since it will not routinely reach the right coronary artery branches without tension leading to its use predominantly as a free graft, but with lower apparent patency [15]. Cautious use of bilateral internal mammary artery related primarily to the increased risk of sternal wound infection [20] and particularly with diabetics. These patients may present at a younger age and would have more to gain from longer conduit patency, but receive fewer arterial grafts. This Y graft operation avoids bilateral internal mammary artery harvest in the majority of patients.
Additional arteries have been used in an attempt to achieve total arterial revascularization or to reduce the rate of bilateral internal mammary artery harvest [2, 21]. Of these, the radial artery is the simplest and most convenient to harvest and has the lowest morbidity [2, 5]. Total arterial revascularization is therefore possible in at least half of all patients undergoing coronary artery bypass surgery and would be expected to lead to late benefit from reduced conduit disease seen with saphenous vein graft. Late patency will not be known for some years although midterm patency is know in some series [9, 21–23]. The concept is to use arteries only, and avoid any saphenous vein graft.
Very rapid change to practice occurred at our institution [5] where the adoption of total arterial revascularization as a goal far preceded the known late patency of arterial conduit other than LIMA. The change was driven by an impression of lower in-hospital mortality as well as the reduced morbidity related to radial artery harvest. The mortality for this Y graft series is low; and the mortality for the comparison group (Table 2) is also low, the majority also receiving total arterial revascularization.
Since most patients receive three to five coronary anastomoses, many patients will receive saphenous vein graft unless more efficient reconstructive techniques were employed. First, we used sequential grafting and since the radial artery is longer than the internal mammary artery, it can be used to revascularize all of the circumflex or right coronary artery territories as an aortocoronary graft. In this way, most patients may receive total arterial revascularization by using three or four arterial grafts.
Composite grafts [7, 8], allow total arterial revascularization in most patients with reduced conduit use. This is because the length of conduit from the point of inflow to the point of outflow is reduced, thereby minimizing conduit wastage. The LIMA and left radial artery may be harvested simultaneously and the Y graft performed during arm closure. All coronary branches may be revascularized in this way.
It is unclear if the pedicled nature of these composite grafts has independent benefit with respect to late patency. Calafiore has suggested that conduits arising from the aorta may experience more turbulence and potentially endure more intimal damage than composite conduits arising from the LIMA [9].
A theoretical concern may also relate to the possible loss of all conduits if occlusion of the proximal LIMA segment occurred. Since the results of late patency of LIMA to left anterior descending artery are so good, this Y graft operation, being a modified version of this same graft, could have a similar outcome. A possible benefit of avoidance of aortic anastomoses may be by reduced cerebral embolism manifest by reduced neuropsychological dysfunction and stroke. This may result from a greater freedom to move aortic cannulation and clamping sites when aortic atheroma is detected by echocardiography and from reduced aortic manipulation during construction of proximal anastomoses [24].
The LIMA is rarely diseased and radial artery calcification is uncommon, but when it is present of sufficient severity to preclude use, the right internal mammary artery may be harvested and used in the same manner. This vessel is a little shorter, and so more care is needed to avoid excessive redundancy in the conduit lie or to skeletonize it. Since most patients may be revascularized in this way, this operative technique affords considerable flexibility. The surgeon may alter the technique and conduit lie to accommodate variances in vessel size, position, or number of grafts required.
The hypoperfusion syndrome was neither seen nor expected, because the construction of a composite graft increased the flow through the LIMA graft [Royse et al, unpublished data]. The conduit flow reserve, being the maximum potential flow deliverable via the grafts, exceeded the actual flow via the grafts following weaning from cardiopulmonary bypass by 2.3-fold.
Limitations
While in-hospital mortality and preoperative data is known for all patients in this series, detailed postoperative data stored on a custom database currently exists only for patients from Royal Melbourne Hospital. Nonetheless, these patients may act as a guide to complication rates compared to alternative techniques. Resource limitations have led to incomplete late follow up, and this is not easily addressed. Hospital mortality is multifactorial and many factors other than operative technique may influence this outcome.
This paper addresses early clinical outcome. Angiographic data is available for some patients who have participated in two research studies and also for those who have returned with symptoms. Angiography is not examining this Y graft technique specifically, but is examining radial artery patency during a 5-year period. Intermediate results and analysis of the influence of competitive flow from the native coronary circulation will be reported separately.
The influence of this technique on reducing late neuropsychological dysfunction will be reported separately.
Although Table 1 reveals no selection bias during the study period, the surgeons using this technique commenced using it in a highly selective fashion and later applied it in a nonselective fashion. This operation incorporates a number of techniques that can be more technically demanding. It is recommended that limited use of sequential grafting with aortocoronary conduit and limited reliance on the Y graft should occur until familiarity with these techniques be gained. The most difficult anastomoses with this technique involve the intermediate artery or arteries close to it. Technical difficulty also increases in patients with markedly dilated left ventricles or marked obesity. Cautious use of this technique is advised in these situations until the surgeon has gained experience with this operation.
Total arterial revascularization which is entirely pedicled may be performed using the left internal mammary artery and radial artery as a composite Y graft. There was no increase in complications. This technique preserves the LIMA to left anterior descending artery graft [25].
|
Acknowledgments |
|---|
|
References |
|---|
|
TopAbstractIntroductionMaterial and methodsResultsCommentReferences |
|---|
This article has been cited by other articles:
|
|
 |
|
  E. Gongora and T. M. Sundt III Myocardial Revascularization with Cardiopulmonary Bypass Card. Surg. Adult, January 1, 2008; 3(2008): 599 - 632. [Full Text]
|
|
|
|
 |
|
 A. Royse and C. Royse A standardised intraoperative ultrasound examination of the aorta and proximal coronary arteries Interactive CardioVascular and Thoracic Surgery, December 1, 2006; 5(6): 701 - 704. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 S. Na, Y. J. Oh, Y. H. Shim, Y. W. Hong, S. O. Bang, and Y. L. Kwak Effects of milrinone on blood flow of the Y-graft composed with the radial and the internal thoracic artery in patients with coronary artery disease. Eur. J. Cardiothorac. Surg., August 1, 2006; 30(2): 324 - 328. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 D. Glineur, P. Noirhomme, J. Reisch, G. El Khoury, P. Astarci, and C. Hanet Resistance to Flow of Arterial Y-Grafts 6 Months After Coronary Artery Bypass Surgery Circulation, August 30, 2005; 112(9_suppl): I-281 - I-285. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 S.-W. Ryu, B.-H. Ahn, S.-J. Choo, K.-J. Na, Y.-K. Ahn, M.-H. Jeong, and S.-H. Kim Skeletonized Gastroepiploic Artery as a Composite Graft for Total Arterial Revascularization Ann. Thorac. Surg., July 1, 2005; 80(1): 118 - 123. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M. A. Mariani, A. D'Alfonso, and J. G. Grandjean Total Arterial Off-Pump Coronary Surgery: Time to Change Our Habits? Ann. Thorac. Surg., November 1, 2004; 78(5): 1591 - 1597. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
O. Tagusari, J. Kobayashi, K. Bando, K. Niwaya, H. Nakajima, T. Nakatani, T. Yagihara, and S. Kitamura Total Arterial Off-Pump Coronary Artery Bypass Grafting for Revascularization of the Total Coronary System: Clinical Outcome and Angiographic Evaluation Ann. Thorac. Surg., October 1, 2004; 78(4): 1304 - 1311. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
C. Muneretto, G. Bisleri, A. Negri, J. Manfredi, M. Metra, S. Nodari, and L. Dei Cas Off-pump coronary artery bypass surgery technique for total arterial myocardial revascularization: a prospective randomized study Ann. Thorac. Surg., September 1, 2003; 76(3): 778 - 783. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
C. Muneretto, A. Negri, G. Bisleri, J. Manfredi, A. Terrini, M. Metra, S. Nodari, and L. D. Cas Is total arterial myocardial revascularization with composite grafts a safe and useful procedure in the elderly? Eur. J. Cardiothorac. Surg., May 1, 2003; 23(5): 657 - 664. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 C. Muneretto, A. Negri, J. Manfredi, A. Terrini, G. Rodella, S. ElQarra, and G. Bisleri Safety and usefulness of composite grafts for total arterial myocardial revascularization: A prospective randomized evaluation J. Thorac. Cardiovasc. Surg., April 1, 2003; 125(4): 826 - 835. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M. Haase, A. Sharma, A. Fielitz, S. Uchino, J. Rocktaeschel, R. Bellomo, L. Doolan, G. Matalanis, A. Rosalion, B. F. Buxton, et al. On-pump coronary artery surgery versus off-pump exclusive arterial coronary grafting: a matched cohort comparison Ann. Thorac. Surg., January 1, 2003; 75(1): 62 - 67. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
C. Royse, A. Royse, P. Soeding, D. Blake, and J. Pang Prospective randomized trial of high thoracic epidural analgesia for coronary artery bypass surgery Ann. Thorac. Surg., January 1, 2003; 75(1): 93 - 100. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
G. G. Santos and N. A.G. Stolf Reply to Hirose and Amano Eur. J. Cardiothorac. Surg., December 1, 2002; 22(6): 1036 - 1036. [Full Text] [PDF]
|
|
|
|
 |
|
 S. C. Ho, C. F. Royse, A. G. Royse, A. Penberthy, and R. McRae Persistent Pain After Cardiac Surgery: An Audit of High Thoracic Epidural and Primary Opioid Analgesia Therapies Anesth. Analg., October 1, 2002; 95(4): 820 - 823. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
G. Sakaguchi, E. Tadamura, M. Ohnaka, K. Tambara, K. Nishimura, and M. Komeda Composite arterial Y graft has less coronary flow reserve than independent grafts Ann. Thorac. Surg., August 1, 2002; 74(2): 493 - 496. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
G.G. Santos, N.A.G. Stolf, L.F.P. Moreira, V.L.S. Haddad, R.M.C. Simoes, S.R.V. Carvalho, A.A. Salgado, and S.F. Avelar Jr. Randomized comparative study of radial artery and right gastroepiploic artery in composite arterial graft for CABG Eur. J. Cardiothorac. Surg., June 1, 2002; 21(6): 1009 - 1014. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
A. T. Yilmaz, E. Ozal, N. Barindik, C. Gunay, and H. Tatar The results of radial artery Y-graft for complete arterial revascularization Eur. J. Cardiothorac. Surg., May 1, 2002; 21(5): 794 - 799. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J. B. Christensen, J. T. Lund, E. Kassis, and H. Kelbaek Complete arterial coronary revascularisation using radial artery conduit for double thoracic artery inlet flow: arterial sling operation Eur. J. Cardiothorac. Surg., March 1, 2002; 21(3): 391 - 394. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
A. M. Calafiore, M. D. Mauro, S. D'Alessandro, G. Teodori, G. Vitolla, M. Contini, A. L. Iaco, and G. Spira Revascularization of the lateral wall: Long-term angiographic and clinical results of radial artery versus right internal thoracic artery grafting J. Thorac. Cardiovasc. Surg., February 1, 2002; 123(2): 225 - 231. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J. Tatoulis, A. G. Royse, B. F. Buxton, J. A. Fuller, P. D. Skillington, J. C. Goldblatt, R. P. Brown, and M. A. Rowland The radial artery in coronary surgery: a 5-year experience--clinical and angiographic results Ann. Thorac. Surg., January 1, 2002; 73(1): 143 - 148. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M. Ochi, N. Hatori, R. Bessho, M. Fujii, Y. Saji, S. Tanaka, and H. Honma Adequacy of flow capacity of bilateral internal thoracic artery T graft Ann. Thorac. Surg., December 1, 2001; 72(6): 2008 - 2011. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
O. Lund, J. Christensen, S. Holme, K. Fruergaard, A. Olesen, E. Kassis, and U. Abildgaard On-pump versus off-pump coronary artery bypass: independent risk factors and off-pump graft patency Eur. J. Cardiothorac. Surg., November 1, 2001; 20(5): 901 - 907. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
A. L. Iaco, G. Teodori, G. Di Giammarco, M. Di Mauro, L. Storto, V. Mazzei, G. Vitolla, B. Mostafa, and A. M. Calafiore Radial artery for myocardial revascularization: long-term clinical and angiographic results Ann. Thorac. Surg., August 1, 2001; 72(2): 464 - 468. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
A. Royse Reply to Alverez Eur. J. Cardiothorac. Surg., April 1, 2001; 19(4): 543 - 544. [Full Text] [PDF]
|
|
|
|
|
|
A. G. Royse, C. F. Royse, K. L. Groves, and G. Yu Reply Ann. Thorac. Surg., July 1, 2000; 70(1): 341 - 342. [Full Text] [PDF]
|
|
|
|
|
|
A. G. Royse, C. F. Royse, J. Tatoulis, L. E. Grigg, P. Shah, D. Hunt, N. Better, and S. F. Marasco Postoperative radial artery angiography for coronary artery bypass surgery Eur. J. Cardiothorac. Surg., March 1, 2000; 17(3): 294 - 304. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
A. G. Royse, C. F. Royse, K. L. Groves, and G. Yu Blood flow in composite arterial grafts and effect of native coronary flow Ann. Thorac. Surg., November 1, 1999; 68(5): 1619 - 1622. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 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 |
