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Ann Thorac Surg 2000;69:156-164
© 2000 The Society of Thoracic Surgeons
a Department of Cardiac Surgery, Tagore Heart Care and Research Centre, Jalandhar, Punjab, India
Address reprint requests to Dr Bedi, Department of Cardiac Surgery, Tagore Heart Care and Research Centre, 339 Guru Teg Bahadur Nagar, Jalandhar, Punjab, India
e-mail: bedi{at}jla.usnl.net.in
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Abstract |
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Methods. One hundred patients with severe triple-vessel disease underwent multivessel off-pump CABG. For cardiac stabilization, a combination of local pericardial stabilization sutures and lifting and rotating the heart by means of posterior pericardial sutures were used. For myocardial perfusion, a technique of retrograde coronary sinus perfusion by arterial blood from the ascending aorta was used.
Results. Each patient received an average of 3.8 grafts (range 3 to 5). Complications included conversion to cardiopulmonary bypass (CPB) in 1 patient and a perioperative myocardial infarction in the same patient. In all other patients we were able to perform a satisfactory grafting in all territories with no operative mortality. Rapid recovery allowed 95% of our patients to resume normal activity within 1 month. A predischarge graft angiogram in 35 patients showed 97.8% patency.
Conclusions. These results suggest that off-pump CABG with our techniques is effective and safe. Early clinical outcome and excellent patency rates suggest its more widespread use in selected cases.
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Introduction |
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Conventional CABG is done with cardiopulmonary bypass (CPB) and use of cardioplegia to arrest the heart and create a quiet bloodless field. In recent times, there has been a resurgence in interest in the performance of coronary artery bypass surgery without the use of cardiopulmonary bypass. While previously it was being used only in cases where CPB was not possible [1], it is now being used electively. The off-pump technique seems more logical in patients with severe left ventricular dysfunction or in some cases where cannulation, CPB, or hypothermia are not desirable. A smoother postoperative recovery, reduction in homologous blood transfusion requirement, and a much shorter stay in the intensive care unit (ICU) and in the hospital with a quicker return to normal life are also expected. In developing countries, an important factor that has prompted the interest in beating heart procedures is the major cost saving with the avoidance of CPB. However, with off-pump procedures, there has been a compromise in the completeness of revascularization, with most authors reporting ungrafted circumflex coronary artery disease [2, 3]. Even in the beating heart technique, using the octopus suction stabilizer for multivessel disease approached with a full median sternotomy, all three territories were not grafted [4]. This is one of the major causes of morbidity and mortality.
The excellent long-term patency rates associated with conventional CABG must not be compromised for the sake of initial patient comfort, cosmesis, or cost containment. Absolute prerequisites for beating heart surgery are a quiet bloodless field and avoidance of ischemia during the time the coronary artery is snared.
Basically, two differing concepts arise in minimally invasive CABG: use of CPB with a limited incision or avoidance of CPB. In the former, using the PortAccess system (Heartport, Redwood City, CA), CPB is instituted via lines in the groin and CABG is performed on the arrested heart through limited incisions. However, there is a significant risk of vascular complications with the use of femoral artery cannulation and the endoaortic occlusion catheter. Also, the ascending aorta is not accessible for the attachment of proximal vein grafts [5]. In our opinion, CPB is the most invasive aspect of conventional CABG. It is more important to avoid the detrimental physiologic and cerebral effects of CPB, rather than simply creating alternative, smaller-access incisions. This is also acknowledged by others [6]. We are also against the concept of treating "culprit" lesions in patients with severe multivessel disease who are at high risk of CPB. In this article, we use the term "minimally invasive off-pump CABG" to denote any multivessel CABG performed through a full median sternotomy with a limited skin incision (8 to 10 cm) without the use of CPB. We have tried to acquire the two prerequisites of CABG (ie, a quiet bloodless field and avoidance of ischemia) by new but simple techniques that allow us to perform a complete myocardial revascularization.
The objective of this prospective study was to assess the safety and efficacy of our technique for off-pump CABG. The early clinical results (1- to 14-month follow-up) and early angiographic outcome (in 35 patients) are reported in the first 100 cases who received at least three grafts in all three territories.
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Patients and methods |
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Poor left ventricular function was not an exclusion criteria. In fact, we realized that patients with poor left ventricular function are especially suited for this procedure, because the trauma of CPB and cardioplegia was avoided. All these patients (with left ventricular ejection fraction [LVEF] < 20%) had a preoperative thallium scan to document the presence of reversible ischemia. In 2 of these cases, preoperative intraaortic balloon pumping was instituted to lower their pulmonary artery (PA) pressures, which were two-thirds systemic.
The protocol was passed by the institute’s ethics committee. All patients signed an informed consent. Indications for off-pump technique included the following. (1) Patients with associated diseases or conditions in whom cannulation, cross-clamping, or CPB were contraindicated. This included severe chronic obstructive pulmonary disease (COPD), chronic renal failure (on dialysis), and calcified ascending aorta. These formed the initial group of cases. (2) Patients with poor left ventricular function in whom CPB and cardioplegic arrest were thought to be detrimental especially to the interventricular septum. After the initial few cases, we realized that this group of patients tolerated off-pump CABG very well. The sluggish myocardial contractions make the passing of sutures easier. Left ventricular function is much better preserved in off-pump cases. (3) Patients with severe triple-vessel disease for routine elective CABG with technically suitable coronary lesions. This group forms the majority now. All patients are assessed for off-pump CABG, and the decision is made after sternotomy, pericardiotomy, and a trial retraction of the heart to see if this is tolerated.
Preoperative preparation
One of the problems of off-pump surgery is that the temperature of the patient tends to drift and can come down by as much as 3°C to 4°C if precautions are not taken. In all cases the operating room was preheated. The sedated patient was placed on a warm water blanket connected to a Sarns Temperature Control Module (TCM). (3M HealthCare, Ann Arbor, MI). Before draping, an air blanket connected to Bair Hugger (Augustine Medical Inc, Eden Prairie, MN) was used to cover the patient. All scrub solutions were heated to body temperature. After draping, the nozzle of the Bair Hugger was placed under the drapes (making sure that there is no direct contact with skin). With these measures, we have been able to restrict the temperature drift to 1°C to 1.5°C.
Anesthesia
Premedication consisted of oral diazepam (0.2 mg/kg), intramuscular morphine sulphate (0.1 mg/kg), and promethazine (25 mg). In patients with normal ventricular function, induction was done with intravenous thiopentone (3 to 5 mg/kg), morphine (0.5 mg/kg), and vecuronium bromide (0.2 mg/kg) with an oxygen-air-halothane mixture; while patients with left ventricular dysfunction received intravenous diazepam (0.2 to 0.4 mg/kg), morphine, and vecuronium with oxygen-air-isoflurane. A PA thermo-dilution catheter was used in all cases.
Operative technique
All the operations were performed by the same surgeon (H.S.B.). Surgical access in all cases was by a complete midsternotomy. The skin incision was kept limited both superiorly and inferiorly by dissecting small skin flaps.
Initial assessment
The pericardium was opened in all cases after sternotomy before proceeding any further, and the anatomy was assessed for suitability for an off-pump procedure. The area that is the most difficult to approach off-pump is the lateral and posterior wall. Assessment was made of the ease of exposure of these areas by a very gentle trial lifting of the heart to expose these areas. Any gross changes in arterial pressure, PA, cardiac output, 12-lead electrocardiogram (ECG), or ST segment were carefully looked for. In 5 cases, this procedure showed that the heart would not tolerate handling, and so conventional CPB was used (these 5 are not included in the 100 study cases). In all cases, pump standby was available.
Cardiac wall stabilization
One of the basic problems is the difficulty of having a quiet operating field in the presence of a beating heart. Various devices are being marketed for the purpose of stabilizing the heart: the Diamond Grip Rib Spreader/Cardiac Stabilizer (Genzyme Corp., Cambridge, MA), the Origin Cardiac Stabilizer and Stabilizer Foot (Origin, Menlo Park, CA), Mechanical Stabilizer (CTS Inc., Cupertino, CA), and the Octopus Tissue Stabilizer System (Octopus, Medtronic Inc, Minneapolis, MN). All are very bulky to use, get in the way and have the drawback of added cost, which offsets to some extent the advantage of lowering cost from avoidance of use of CPB.
We stabilize a small area of myocardium just adjoining the site of anastomosis by "recreating" the conditions of a redo surgery. This is based on the observation that in a redo CABG, the target area is relatively immobile and stationary as it is tethered down by the pericardial adhesions, which have a stabilizing effect locally on the beating heart, thus making arteriotomy and anastomosis easier [7, 8]. We achieve stabilization of a small area of myocardium surrounding the target area under focus during CABG by using the surrounding pericardium to "anchor" the target area. We first incise the epicardium over the proposed arteriotomy site. We then suture the adjoining pericardium to the epicardium for a length of 2 to 5 cm on the left and right of the proposed arteriotomy site with running suture of 5-0 Prolene (Fig 1). In the case of the obtuse marginal vessels, this suturing is only to the left of the arteriotomy. Sutures are passed to take a small bite of myocardium along with the epicardium. When these sutures are gently pulled up, maximum immobilization of a small area with minimum compromise of muscle function is obtained. The snares proximal and distal to the site of arteriotomy also help in stabilization. All these steps leave a residual target motion of only 1 x 1 x 1 mm.
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Distal anastomosis
After heparinization (1.5 mg/kg heparin iv), the target area is immobilized and snared. For snaring, we use a silicone vascular loop (Retract-O-Tape Air Cushion; Deknatel/DSP, Lubeck, Germany) with blunt needle. Loops are passed deep under and around the coronary artery. An effort is made to isolate as little as possible of the coronary artery to minimize ischemia. The Retract-O-Tapes are either snared with a thin silicone tube over a buttress of a piece of pericardium, vein, or thymic tissue, or if it is felt that the snares will get in the way, then the suture is taken one more time around the artery and pulled up around the buttress. The coronary artery is occluded for 5 min to evaluate signs of ischemic dysfunction (by monitoring ECG, arterial pressure, PA pressure, and regional wall motion abnormalities as seen on the surface), followed by 5 min of reperfusion for preconditioning before occlusion for constructing the anastomosis. The anastomosis is constructed with a running 8-0 Prolene (Ethicon, Somerville, NJ) (for arterial grafts) or 7-0 Prolene (for vein grafts) suture with magnifying loupes (x3.5). Usually, a single running suture is used. Very infrequently, two sutures beginning at the heel and toe of the anastomosis are used. An attempt is made to create two anastomosis with one suture by keeping one end extra long and using it for the second graft (using only one needle). The aim of all this is to further reduce cost. The field is kept bloodless by the use of a Visuflow blower (Research Medical, Inc, Midvale, UT), which produced a clear field without drying the tissues. Blood was not salvaged in any case due to lack of necessary equipment. Heparin was fully neutralized with protamine sulfate at the end of the procedure.
Maintenance of hemodynamic stability
During anastomosis, the heart rate is brought down to 50 to 70 beats per minute by the use of intravenous ß-blockers used with or without intravenous dilzem infusion. Continuous monitoring of ECG, arterial pressure, PA pressure, cardiac output, and wall motion abnormality of the heart (by direct visual assessment; we do not have the facility for transesophageal echocardiography [TEE]) is done. We have found that during anastomosis of the lateral and posterior wall of the heart, the heart is lifted up and the ECG is not a very accurate guide for detecting ischemia. Here, PA pressures are more useful.
Also during this anastomosis, the arterial pressure may fall along with the PA pressure. This responds well to volume, the head-down position (Trendelenburg maneuver) (a finding in concurrence with the experimental work of Grundeman and associates [9]), and intravenous vasoconstrictor (norepinephrine).
Avoidance of ischemia
We have employed a new, though apparently controversial, technique for perfusing the myocardium while the coronary artery is snared. We are against the use of intraluminal shunts because of their inherent risk of damage to intima, dislodgement of atheroma, creation of a dissection, and the hindrance with suturing. We use perfusion of arterial blood through a retrograde coronary sinus cannula. The retrograde cardioplegia catheter with a self-inflating balloon (Gundry RSCP catheter; Medtronic DLP, Grand Rapids, MI; or a Sarns catheter; 3M) is easily inserted transatrially into the coronary sinus through a purse-string suture placed in the low right atrium. Its position is confirmed by palpation and by checking the pressure in the pressure line (20 mm Hg or less with the balloon deflated). An antegrade cardioplegia cannula is now positioned in the ascending aorta and secured with a purse-string in a standard way. It is connected via a multiple perfusion cannula to the coronary sinus cannula, and after de-airing, oxygenated arterial blood at aortic pressure is allowed to perfuse the coronary sinus. The coronary sinus catheter pressure is carefully monitored. In most of the cases, it never went over 40 mm Hg (mean). In 4 cases, it went more than this, and flow was reduced by turning the three-way stopcock until the pressure came down below 40 mm Hg (mean). This perfusion is allowed to continue throughout the procedure, with a careful watch on the pressure. We have proof that perfusion does occur in the blocked areas, as mentioned in Results. The fact that there is a two-way flow of blood (downstream via the normal way, and upstream via the coronary sinus to capillaries) is possible because of the inherent "leak" in the balloon of the catheter. In all cases, as soon as a free graft distal anastomosis is performed, the free graft (saphenous vein graft [SVG] or radial artery [RA]) is connected to a line of the multiport and allowed to perfuse with oxygenated blood.
Sequence of grafting
After initially trying different sequences, we have now developed a set routine. The easiest grafts are done first and allowed to perfuse. This generally translates to an initial LAD-LIMA/SVG followed by RCA-RIMA/RA/SVG. In the case of the free grafts, the conduit is connected to a side arm of the multiport cardioplegia set and perfused by arterial blood from the ascending aorta. All proximal anastomoses are performed in the end-SVG with 6-0 Prolene and the RA with 7-0 Prolene. Most of the free RA are anastomosed directly to the aorta. However, with our observation of an increased incidence of spasm in the RA, we now tend to put the proximal of the RA onto the hood of a SVG or as a T graft onto the LIMA.
Bypass graft angiography was performed in 35 patients with informed consent on the day before discharge.
Follow-up
The mean follow-up time was 6.8 months (range 1 to 14 months). Follow-up information was collected through direct patient contact in all cases. All patients had serial ECG and two-dimensional echo and exercise testing at 3 months postop.
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Results |
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Exposure and immobilization of the target site allowed accurate anastomosis. Intraoperative vasoconstrictor (norepinephrine) was required in 55 patients intraoperatively. It was required for an additional 6 to 24 hours in 24 patients in the ICU at a dose of 0.01 to 0.1 µg/kg/min. These patients had low arterial pressures associated with a high cardiac index with a very low systemic vascular resistance.
In 3 patients in whom a large main right coronary artery (RCA) was being grafted, there was 1 to 2 mm ST segment elevation during the last stages of the suturing. This could be managed while the anastomosis was hurriedly completed and the graft subsequently perfused. In all the rest of the anastomosis, there was no period of ECG changes or gross hemodynamic instability. In fact, now we are able to perform the anastomosis very meticulously (anastomosis time is now longer than in the earlier stages), as there is no racing against the clock.
On temporary release of the distal snare after the coronary arteriotomy, we have found a vigorous backbleeding of dark blood (as seen during retrograde blood cardioplegia infusion), indicating that the myocardium is being perfused and is utilizing the oxygen from the arterial blood perfused via the coronary sinus. This visual proof of perfusion was seen in 10 out of 10 cases in LAD, 7 out of 10 cases in the circumflex area, and 5 out of 10 cases in main RCA. In 1 case, there was 2-mm ST segment elevation in the chest leads on snaring the LAD, which reverted completely on starting the retrograde perfusion.
In 12 patients, endarterectomy of the RCA was required. This is surprisingly easy on the beating heart, because the beating heart provides excellent traction-countertraction to get the atheroma out. Distally, a complete endarterectomy was possible, while proximally the atheroma was cut cleanly. The arteriotomy was allowed to bleed freely to avoid distal embolisation. Snaring was done only after the endarterectomy was completed.
Intraoperative complication
In 1 patient with unstable angina, while snaring down on the LAD, it was realized that the right ventricular (RV) wall adjoining the LAD was edematous and unhealthy. There was excessive bleeding from the RV wall where the Retract-O-Tape needle had gone through. This did not respond to the usual methods of local pressure and reversal of heparin, and needed pledgetted sutures for control. We now avoid the use of snares in areas and situations where the myocardium is unhealthy (eg, evolving MI) and use intraluminal coronary blockers (Flowrester; Biovascular, Inc, St. Paul, MN) and blower for visualization. Some blood loss in these cases (about 50 mL) during the anastomoses is anticipated. We have no experience so far with intraluminal shunts.
Conversion to CPB
This was required in 1 patient. This was 1 of the patients who had ST changes during a main RCA-RA grafting. The ST changes recurred after sternal closure. On reopening, it was seen that the radial artery seemed to be in spasm. Although this did respond to topical papaverine/dilzem and increasing the dose of intravenous dilzem, it was decided to supplement the RA with a vein graft distal to the radial artery anastomosis site. This was performed on CPB without aortic cross-clamping. On probing, it was found that a stitch had taken both the walls of the radial artery graft. This was also corrected. The patient did well subsequently.
Intraoperative problem
One of the problems with off-pump surgery is the difficulty with the proximal anastomoses, as it is sometimes difficult to apply a partial occlusion clamp on an ascending aorta at full systemic pressure (as opposed to the low-pressure aorta on full CPB). For this reason (and also because of the high incidence of spasm in the free radial arteries with proximal anastomoses on the aorta), our policy from now on is to have as many in situ arterial grafts as possible (in situ left interval mammary artery [LIMA], right internal mammary artery [RIMA], right gastroepiploic artery [RGEA]) with a T graft from the IMA whenever feasible.
In most patients recovery was quick and uneventful. Ninety patients were extubated within 6 hours of reaching ICU, and their ICU stay was 24 hours (Table 2).
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Early graft patency
In 35 patients in whom predischarge angiography was performed, of the 132 anastomosis studied, 129 were patent (Figs 2 to 7). One LIMA had a 40% stenosis just proximal to the anastomosis site (Fig 8). This patient was asymptomatic, had a negative a tread mill test, and is being followed up closely. Three grafts were blocked: an SVG to a small acute marginal branch of the RCA, an SVG to D1, and a sequential RA to OM1 and OM2 (the OM2 being occluded). Of some concern was the finding of spasm in the RA (responding only partially in some to intragraft nitroglycerin) in 6 of the 22 RA grafts studied. These patients have been noted for a repeat study after 1 year. No stenosis was seen at the site of vessel loops/snares.
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Exercise testing
Six-month exercise testing was performed in 34 patients. It showed signs of ischemia in 2 patients at stage 4 with an early recovery. Both these patients had had a routine predischarge graft angiogram; in 1 there was occlusion of a sequential graft to OM2, in the other, all grafts were patent.
There is a reduction in cost (about US $1,000) due to saving of perfusion equipment such as oxygenators, prime fluids, and cannulas, and also due to a shorter ICU and hospital stay and less need for blood products. When this is multiplied by the number of patients per year, the amount saved is staggering. The ICU management of these patients in terms of fluid, electrolyte, and respiratory care is simpler.
These differences have been noted by others for single and double grafts [10, 11], with a cost saving of US $1,000 to $1,200 [11] to $3,000 [10] per case. Del Rizzo and associates [12] calculated a 50% savings with off-pump surgery in high-risk patients (Canadian $5,997 per patient vs $11,997 as estimated for conventional surgery). We are now conducting a prospective comparison with conventional CABG group.
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Comment |
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The CPB apparatus itself is another source of complications, such as cannulation-related injuries and gas and particulate embolism, which may result in cerebrovascular events.
Patients with severe COPD with spirometric data below 50% of predicted and patients with chronic failure on dialysis do much better with off-pump CABG, as the deleterious effects of CPB on lung and kidney functions, respectively, are avoided.
Because the heart lung machine was not used, we encountered none of the complications commonly associated with CPB (renal, neurologic, and respiratory systems). The off-pump technique has obvious advantages in patients with calcific aorta.
Minimally invasive direct coronary artery bypass techniques have been increasingly accepted as an alternative to the use of CPB. CABG without the trauma of cardiopulmonary bypass has been shown to be associated with earlier recovery, less need for homologous blood [2, 13, 14], low mortality [2, 14], and low cost [10–12, 14].
However, a major compromise is that of undergrafting in multivessel coronary artery disease. Tasdemir and associates [2] identified nongrafted circumflex stenoses as a risk factor for morbidity and mortality. In cardiac surgery and angioplasty, incomplete revascularization has been clearly identified as a main contributor to higher hospital morbidity and mortality, need for repeated hospitalization, reintervention and long-term complication rate [15]. Talwalkar and associates [7] noted that access to the circumflex and posterior descending coronary arteries is difficult because of their position on the back of the heart. They have used off-pump techniques to bypass the obtuse marginal coronary artery in only 1 case so far. Buffolo and associates [10] did not use the off-pump CPB technique in patients with disease of obtuse marginal branches. Their average number of grafts was 1.7 per patient.
Some authors [16–18] advocate an integrated "hybrid" approach for selected patients with multivessel disease. Here a two-stage approach is used: off-pump bypass of the LAD/RCA with staged PTCA/stenting of the other arteries. However, the current failure rate and need for reintervention of PTCA/stenting is likely to compromise the results. The additional cost also is quite prohibitive. Tasdemir and associates [2] concluded that in technically suitable cases, which consist of those with graftable LAD and without circumflex system disease, off-pump CABG could be considered a safe and efficient technique. They admitted that a suboptimal result must be anticipated if graftable circumflex coronary artery disease is ignored, as it is preferable to completely revascularize to retrieve as much viable myocardium as possible.
The very low incidence (1 patient with RCA endarterectomy) of atrial fibrillation is another positive aspect of off-pump procedures. However, this could also be due to the liberal use of ß-blockers in the perioperative period. We feel that a standard median sternotomy (with a small skin incision) is the approach of choice for precise harvesting of both the internal mammary arteries, for retrograde cannulation of the coronary sinus and perfusion with arterial blood, for access to all the areas of the heart, for performing proximal anastomoses to the ascending aorta, and for ease of conversion to CPB should the need arise. We reserve a minithoracotomy with videoscopic dissection of the LIMA only for LAD (with or without diagonal) lesions.
The decisive factor in the acceptance of off-pump CABG will be angiographic patency rate. The standard of comparison will be the well-documented on-pump conventional CABG. Anastomotic failure remains the most important complication. In earlier series [15], a reoperation rate of 5.2% within the first postoperative month was reported because of anastomotic failure. Gundry and associates [3] reported a three-fold increase in reinterventions in patients who had CABG without CPB as compared with CPB. However, others [10, 14] have demonstrated graft patency rates of 84% to 93% with off-pump bypass using a median sternotomy approach. Recently, Calafiore and associates [19] have demonstrated a 98.8% patency of LAD-LIMA anastomosis for beating heart surgery using specialized instrumentation. Mack and associates [20] in a review of all published articles (27) on LIMA grafting in conventional CABG reported early (< 1 month) graft patency of 94% to 99% vs a 91% to 99% patency for beating heart procedures (from five recent series).
In our series, overall, 97.8% of anastomoses were angiographically patent. The three failures were of a vein graft to a small acute marginal artery, a vein graft to a D1, and the second graft (OM2) of a sequential radial artery graft. This probably reflects a learning curve, as both occurred early in the series. Our high graft patency may be because of the fact that access was not limited and time constraint was usually not there. Also, this series of multivessel bypass has logically followed a larger series of single and double off-pump CABG (by midsternotomy or lateral thoracotomy with videoscopic dissection of LIMA). Thus, the reported disadvantages of off-pump techniques (incompleteness of revascularization, suboptimal anastomosis because of technical difficulties, increased risk of acute graft occlusion) [7, 10, 15, 21, 22] have hopefully been eliminated with our techniques.
Our initial results are very encouraging. Our technique is very cost effective, easily available, and reproducible.
Conclusion
Our methods for stabilization and avoidance of ischemia have enabled us to perform global revascularization in 100 patients, with 97.8% early patency in the 35 patients studied by angiography.
By avoiding CPB, off-pump CABG may offer a safer, more effective option not only in complex high-risk cases but also in selected elective cases with technically suitable anatomy. A major factor of importance is that of cost saving by avoidance of a heart lung machine. In our high-risk patients, the myocardial protective effect of the beating heart in the absence of CPB was reflected by the lack of intraoperative ventricular arrhythmias, the reduced requirement of inotropic drugs (other than vasoconstrictor, norepinephrine), the low incidence of postoperative atrial and ventricular arrhythmias, the much shortened ICU and hospital stay, and low blood loss and subsequent transfusion requirements.
It behooves us to not abdicate our responsibility of performing a complete revascularization and either encouraging our cardiologists to angioplasty the remaining vessel(s) or accepting a suboptimal revascularization.
A reduction of morbidity and cost without a compromise in quality is the primary motivation. The operation, though more difficult on the surgeon, is definitely much easier on the patient.
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H. S. Bedi and M. Singh Kalkat Retrograde perfusion of oxygenated blood during off pump revascularization to avoid ischemia Eur. J. Cardiothorac. Surg., February 1, 2000; 17(2): 193 - 194. [Full Text] [PDF]
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