| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
Ann Thorac Surg 2001;72:1528-1534
© 2001 The Society of Thoracic Surgeons
a Eastern Maine Medical Center, Bangor, Maine, USA
b Beth Israel-Deaconess Medical Center, Boston, Massachusetts, USA
c Catholic Medical Center, Manchester, New Hampshire, USA
d Maine Medical Center, Portland, Maine, USA
e Departments of Medicine and of Community and Family Medicine and the Center for Evaluative Clinical Sciences, Dartmouth Medical School, Hanover, New Hampshire, USA
* Address reprint requests to Dr Hernandez, 417 State St, Suite 421, Bangor, ME 04401, USA
e-mail: fhernandez{at}nehi.org
Presented at the Thirty-seventh Annual Meeting of The Society of Thoracic Surgeons, New Orleans, LA, Jan 29–31, 2001.
 |
Abstract |
|---|
 TopFootnotes Abstract IntroductionMaterial and methodsResultsCommentAcknowledgmentsDiscussionReferences |
|---|
Methods. Between 1998 and 2000, 1,741 OPCAB and 6,126 CCAB procedures were performed at these four medical centers. Minimally invasive direct coronary artery bypass grafting procedures were excluded. Data were available for patient and disease risk factors, extent of coronary disease and adverse in-hospital outcomes.
Results. The OPCAB and CCAB groups were somewhat different in their preoperative patient and disease characteristics. The OPCAB patients were more likely to be female and to have peripheral vascular disease. The CCAB patients were more likely to have an ejection fraction less than 0.40 and be urgent or emergent at operation. However, overall predicted risk of in-hospital mortality, based on preoperative factors, was similar in the OPCAB and CCAB groups; the mean predicted risk was 2.6% (p = 0.567). Crude rates of mortality (2.54% OPCAB versus 2.57%. CCAB), intraoperative or postoperative stroke (1.33% versus 1.82%), mediastinitis (1.10% versus 1.37%), and return to the operating room for bleeding (3.46% versus 2.93%) did not differ significantly. The OPCAB patients did have a statistically significant reduction in the need for intraoperative or postoperative intraaortic balloon pump support (2.31% versus 3.41%; p = 0.023) and in the incidence of postoperative atrial fibrillation (21.21% versus 26.31%; p < 0.001). Adjustment for preoperative risk factors and extent of coronary disease did not substantially change the crude results. Median postoperative length of stay was significantly shorter (5 days versus 6 days, p < 0.001) for OPCAB patients than for CCAB patients.
Conclusions. This multicenter study showed that patients having OPCAB are not exposed to a greater risk of short-term adverse outcomes. These data also provided evidence that patients having OPCAB have significantly lower need for intraoperative or postoperative intraaortic balloon pump, lower rates of postoperative atrial fibrillation, and a shorter length of stay.
|
Introduction |
|---|
|
TopFootnotesAbstractIntroductionMaterial and methodsResultsCommentAcknowledgmentsDiscussionReferences |
|---|
In the past 2 years there has been a significant increase in the number of reports dealing with OPCAB procedures. Most of these reports are single-center or single-practice reports [3–8], or reports of surgeons at multiple institutions that use the same retractor-stabilizer system [2]. Although the overall body of knowledge regarding this procedure is increasing, there has been no true multicenter experience reported using varied retractor-stabilizer systems and operative techniques.
The Northern New England Cardiovascular Disease Study Group (NNECDSG) is a regional, voluntary, multidisciplinary group of clinicians, hospital administrators, and health care research personnel who seek to improve continuously the quality, safety, effectiveness, and cost of medical interventions in cardiovascular disease. Four of the NNECDSG centers (Eastern Maine Medical Center, Beth Israel Deaconess Medical Center, Catholic Medical Center, and Maine Medical Center) began OPCAB programs or increased frequency of OPCAB procedures starting in 1998. We report our experience with OPCAB procedures, comparing preoperative risk profiles and in-hospital outcomes of patients undergoing OPCAB with those undergoing conventional coronary artery bypass (CCAB) using CPB.
|
Material and methods |
|---|
|
TopFootnotesAbstractIntroductionMaterial and methodsResultsCommentAcknowledgmentsDiscussionReferences |
|---|
The following data were recorded prospectively for all patients: age, sex, height, weight, cardiac catheterization results (degree of left main coronary artery stenosis, total number of significantly diseased coronary arteries, left ventricular end-diastolic pressure, and ejection fraction), prior CABG operation, comorbid conditions (diabetes, peripheral vascular disease, renal failure, chronic obstructive pulmonary disease [COPD]), preoperative intraaortic balloon pump [IABP], date of operation, priority of operation (emergent, urgent, or elective), and the in-hospital outcomes of intraoperative or postoperative use of an IABP, intraoperative or postoperative stroke, reoperation for bleeding, sternal wound infection or dehiscence requiring operation, postoperative atrial fibrillation, date of discharge, and status at hospital discharge (dead or alive).
Cardiac catheterizations were performed using standard methods during the course of regular clinical care. The number of diseased coronary vessels was assessed using criteria established by the National Heart, Lung, and Blood Institute Coronary Artery Surgery Study [9]. The priority of the surgical procedure was assessed by the cardiothoracic surgeons. "Emergency" meant that medical factors relating to the patient’s cardiac disease dictated that the operation should be performed within hours to prevent morbidity or death. "Urgent" meant that medical factors required that the patient remain in the hospital before the operation. "Elective" meant that medical factors indicated the need for operation, but the clinical situation allowed discharge from the hospital with later readmission for operation. Dialysis dependent renal failure was defined by the preoperative use of hemodialysis or peritoneal dialysis.
Intraoperative or postoperative use of an IABP was defined as insertion of an IABP during the course of the procedure or at any time thereafter up to discharge. Postoperative bleeding was defined as bleeding that required surgical reexploration after initial departure from the operating room. Postoperative stroke was defined as a new neurologic event occurring postoperatively that persisted for longer than 24 hours after onset and was noted before discharge. Mediastinitis was defined as a sternal infection requiring antibiotic agents and return to the operating room for sternal debridement. Atrial fibrillation was defined as the postoperative occurrence of this rhythm requiring treatment.
For these analyses, we excluded patients undergoing CABG operation incidental to heart valve repair, resection of ventricular aneurysm, or another surgical procedure. Also excluded from these analyses were minimally invasive direct coronary artery bypass grafting (MIDCABG) procedures. Otherwise, these analyses include all patients undergoing isolated coronary bypass procedures during the study period. Data on 777 of these 7,867 patients were part of a previously published report of a single-center experience [7].
Surgical technique
The decision to perform the operation off-pump or on-pump was made by the operating surgeon. Routine monitoring of hemodynamic measurements, O2 saturation, arterial pressure, and urine output was performed according to each institution’s standard practice. The attending anesthesiologist made decisions regarding the anesthetic management. All procedures were done using a median sternotomy incision. The choices of conduit used and of the vessels grafted were made by the surgeon. Heparin doses varied by surgeon. Various techniques were used to afford exposure of all coronary artery segments, and several retractor-stabilizer systems were used according to the individual surgeon’s preference. Likewise, management of on-pump cases with regard to CPB measurements, use of hypothermia, and myocardial protection technique used was determined by the individual surgeon’s preferences. Patients were discharged from the hospital according to each surgeon’s standard practice (postoperative care map, clinical pathway, etc) without regard to the procedure performed.
Statistical analysis
The goal of these analyses was to compare OPCAB with CCAB with respect to patient and disease characteristics and short-term clinical outcomes. Univariate analysis involving 
2 tests for categorical variables and t tests and nonparametric tests for continuous variables were performed to assess the statistical significance of observed differences in patient characteristics between patients having OPCAB or CCAB [10]. We used logistic regression analysis and direct standardization of rates to contrast the effect of OPCAB and CCAB on each clinical outcome after adjustment for potentially confounding variables [11]. Covariates in the multivariate analyses included: age, sex, body mass index, peripheral vascular disease, diabetes, preexisting renal failure, COPD, prior CABG operation, preoperative ejection fraction, left main stenosis, number of diseased vessels, and urgent or emergency priority at operation. These variables are related to operative mortality and other adverse outcomes after CABG operation and have been suggested for risk-adjustment of in-hospital CABG outcomes by Jones [12] and the American College of Cardiology/American Heart Association practice guidelines [13]. Analysis was performed using Stata release 6.0 software [14].
|
Results |
|---|
|
TopFootnotesAbstractIntroductionMaterial and methodsResultsCommentAcknowledgmentsDiscussionReferences |
|---|
Table 1 summarizes the characteristics of these patients and their disease characteristics by type of surgical procedure. The proportion of women was larger among the OPCAB procedures (34.1% versus 27.7%, p < 0.001). Patients receiving OPCAB were slightly less obese (20.3% versus 22.2% for body mass index 31 to 36 and 6.5% versus 7.2% for body mass index 37 or higher, p = 0.043) and somewhat less likely to have diabetes (31.1% versus 33.6%, p = 0.046). They were also less likely to have a left ventricular ejection fraction less than 0.40 (0.132 versus 0.184, p < 0.001). Patients in the OPCAB group more often had peripheral vascular disease (22.5% versus 19.0%, p = 0.001) and were less likely to have urgent or emergency operation (65.4% versus 67.4% were urgent and 5.5% versus 6.9% were emergent, p = 0.001). The patient’s age and the proportions with prior CABG operation, preoperative dialysis dependent renal failure, and COPD were not significantly different.
|
|
Table 3 summarizes the in-hospital clinical outcomes of patients receiving OPCAB and CCAB. There were no statistically significant differences in the rates of in-hospital mortality (2.54% OPCAB versus 2.57% CCAB), stroke (1.33% versus 1.82%), return to the operating room for bleeding (3.46% versus 2.93%, not significant), or mediastinitis requiring reoperation (1.10% versus 1.37%). Patients receiving OPCAB had lower rates of intraoperative or postoperative IABP insertion (2.31% versus 3.41%, p = 0.023) and lower rates of postoperative atrial fibrillation (21.21% versus 26.31%, p < 0.001). Because the patients receiving OPCAB and CCAB were largely similar in preoperative characteristics, multivariate adjustment for patient and diseases characteristics did not substantially change the crude results. The median postoperative length of stay was shorter for the OPCAB group compared with the CCAB group (5 versus 6 days, p < 0.001) for patients discharged alive.
|
|
Comment |
|---|
|
TopFootnotesAbstractIntroductionMaterial and methodsResultsCommentAcknowledgmentsDiscussionReferences |
|---|
There are some limitations to the inference that can be drawn from this observational study. These include the possibility of unresolved confounding by patient or disease characteristics that were not measured in this study and selection bias resulting from the physician decision making that determined which procedure the patient received. For this possibility to be an important source of error the effects would need to be large and the confounding variables would have to be uncorrelated to the variables in the adjustment model. This possibility cannot be excluded but we do not believe that it is likely. With respect to the evaluation of OPCAB procedures, a more important issue may be the scope of this study, which examined only the short-term outcomes of CABG operation. In usual clinical practice most patients do not receive postoperative coronary angiography so there is no obvious method to assess the quality of the distal anastomoses. Off-pump coronary artery bypass is a more technically demanding procedure than CCAB. Despite improvements in current retractor-stabilizer systems, there is still some motion at the point of anastomosis rendering the anastomosis associated with OPCAB technically more difficult. The surgeon and anesthesiologist must develop the ability to access all areas of the heart without causing hemodynamic derangement. Acute graft failure or myocardial damage consequent to hemodynamic derangement may result in the need for an intraoperative or postoperative IABP. In these data intraoperative or postoperative IABP use was lower for OPCAB patients than for CCAB patients.
Is it plausible that OPCAB would result in significantly lower rates of intraoperative or postoperative IABP use, lower rates of atrial fibrillation, and shorter lengths of hospital stay? Cardiopulmonary bypass has been recognized as one of the primary causes of the systemic inflammatory response that occurs after coronary artery bypass operation and may contribute to multiple organ dysfunction and postoperative complications. Avoidance of CPB during coronary artery operation is believed to reduce the inflammatory response. In a study by Matata and colleagues [15] comparing CCAB with OPCAB, there were lower levels of oxidative stress, as measured by blood levels of lipid hydroperoxidases, protein carbonyls, and nitrotyrosine and less systematic inflammatory response among OPCAB patients. A study by Wan and colleagues [16] showed reduced cytokine response, especially interleukin-8 and interleukin-10 and lower postoperative levels of troponin-I among OPCAB patients. However, a randomized study compared acute phase reactants associated with CPB and beating heart operation and concluded that they occurred in both and were likely related to the surgical procedure rather than solely to CPB [17]. We conclude that it is plausible that the OPCAB procedure is associated with less systematic inflammatory response as well as less oxidative stress and myocardial injury, and that these factors may result in the observed trend toward lower morbidity and mortality. However, many of these studies have been small and only one (with 20 patients) was randomized.
The results of this study are similar to those found by other investigators. The trend toward lower rates of morbidity and mortality and shorter length of stay has been reported by several other observational studies [3, 4, 6, 8, 18–20]. Arom and colleagues [3] and Yokoyama and coworkers [20] reported the short-term safety of OPCAB among high-risk groups. Short-term safety has been a consistent finding, but only a few studies of long-term outcomes have been conducted. Arom and colleagues [3] studied long-term (1 year) functional outcomes among 3,077 patients, approximately 10% OPCAB, and they found that OPCAB patients reported significantly more angina symptoms, more hospitalizations, and more postoperative angioplasty than did CCAB patients. They suggested that this finding might be a consequence of incomplete revascularization among the OPCAB patients who received an average of 2.1 grafts whereas the CCAB patients received an average of 3.2 grafts. This trend toward fewer grafts among OPCAB patients was seen in the current study and by other investigators [3, 4, 6, 8, 19, 20]. The difference in the number of grafts performed in OPCAB versus CCAB patients was smaller in our dataset than in the series reported by Arom and colleagues [3]. One recent study on a series of OPCAB patients suggested that this gap in the number of grafts may be narrowing as operators gain more experience [2].
The current health care climate places major emphasis on reducing costs and resource utilization while maintaining quality of care and patient satisfaction. Surgeons are being asked to achieve this balance with a patient subset that is increasing in severity of disease and risk of poor outcomes [1, 18]. Conventional coronary artery bypass with CPB is arguably the most carefully studied operative procedure in the history of medicine and is well established in the therapeutic armamentarium for treating ischemic heart disease. Recent advances in retractor-stabilizer systems and techniques of exposure of all surfaces of the heart have resulted in increased interest in and acceptance of multivessel OPCAB procedures. This prospective study of 1,741 consecutive OPCAB patients and 6,126 contemporaneous CCAB patients, who underwent operations at four different institutions, adds to the growing body of knowledge documenting the safety and the efficacy of OPCAB.
With respect to short-term clinical outcomes, OPCAB is a safe alternative to CCAB with CPB. It can be performed on patients with results that compare favorably to standard on-pump coronary artery bypass. Further studies are needed to better define the longer-term clinical and functional results of OPCAB.
|
Acknowledgments |
|---|
|
TopFootnotesAbstractIntroductionMaterial and methodsResultsCommentAcknowledgmentsDiscussionReferences |
|---|
|
Footnotes |
|---|
|
TopFootnotesAbstractIntroductionMaterial and methodsResultsCommentAcknowledgmentsDiscussionReferences |
|---|
|
Discussion |
|---|
|
TopFootnotesAbstractIntroductionMaterial and methodsResultsCommentAcknowledgmentsDiscussionReferences |
|---|
To date, there are only a few, small controlled randomized studies examining beating heart operation, and most available data are from retrospective single-center series from the early enthusiasts. Doctor Hernandez and his colleagues have undertaken the next appropriate step of evaluation by examining outcomes in a multicenter, mainly community hospital setting. From this study we can hope to gain some insight into the "real world" application of beating heart techniques.
In the article, Dr Hernandez appropriately anticipated and addressed the weaknesses of the study, including the role of selection bias. If a selection bias favoring healthy lower risk patients existed in the off-pump group, that would improve outcomes in that group. On the other hand, selection of higher risk patients into the OPCAB group could conceivably improve comparative outcomes in the on-pump group. It is also conceivable that selection of higher risk patients into the OPCAB group could lead to better outcomes in both groups and therefore one would never be able to show a significant mortality difference.
To expand further on the results of Dr Hernandez’s study, these data are from the HCA National Database in 1999, which is a consortium of 79 hospitals in 17 states that performed 17,409 coronary bypass operations in 1999, approximately 5% of all performed in the United States. Three thousand, or 17%, of these were performed off-pump. There was a statistically significant decrement in stroke rate, postoperative renal dysfunction, return to the operating room for bleeding, length of stay, and cost in the off-pump group. Although there was a decrease in mortality to 2.33% compared with 2.97% in the on-pump group, this difference did not reach statistical significance. I believe these data further reinforce the results presented by Dr Hernandez.
Doctor Hernandez’s conclusions are appropriately understated that with respect to short-term outcomes, OPCAB is a safe alternative to conventional bypass operation and that its results compare favorably with standard on-pump. Furthermore, in my opinion, the results of a decrease in the use of intraaortic balloon placement, postoperative atrial fibrillation, and shorter length of stay alone are sufficient cause to expand examination of off-pump techniques. Many surgeons may be waiting for the controlled randomized study demonstrating efficacy before embracing off-pump surgical procedures. However, until now it has been appropriate not to perform the randomized study until the playing field was relatively level between the two arms of the study and enough experience existed with OPCAB so that the off-pump arm did not comparatively suffer from inexperience. Furthermore, there are many new therapies that are clearly embraced as beneficial without the benefit of a randomized study, including use of the left internal thoracic artery and laparoscopic cholecystectomy.
My questions for Dr Hernandez are as follows. What is the number of surgeons in the four institutions and what percentage of these surgeons performed off-pump operations? What was their off-pump experience prior to initiation of the study? In other words, were all surgeons experienced and had they already surmounted the learning curve?
Two, do 1999 outcomes differ from 1998 outcomes and do the results vary from hospital to hospital and from surgeon to surgeon?
Three, how do these outcomes compare with the pre-1998 experience, that is, the era before off-pump? Has the selected use of off-pump operation favorably impacted outcomes compared with the on-pump era?
Four, what has been the subsequent adoption rate in the year 2000 of off-pump operation in these four institutions? Is the percentage of off-pump operations still in the 21% range of the study or have these results influenced, either positively or negatively, the surgeon’s adoption of beating heart operation?
And lastly, do you plan on further expanding the study so that it may be sufficiently powered to detect any mortality benefit?
Once again, I congratulate Dr Hernandez for his pioneering efforts in off-pump surgery and the Northern New England Study Group for their advocacy in outcomes analysis field, and I thank the Society for the opportunity to discuss this article.
DR FREDERICK L. GROVER (Denver, CO): I too very much enjoyed this nice paper from the Northern New England group. I wanted to just add to this by reporting the STS Database results, which were presented at the Southern Thoracic Surgical Association by one of my colleagues, Dr Joe Cleveland. We retrospectively reviewed all patients undergoing coronary bypass from January 1998 through December 1999. There were 118,000 coronary bypasses performed, 90% of these (106,000) were on-pump, and 10% (almost 12,000) were off-pump. One hundred twenty-six centers were involved. A group or hospital had to have performed at least 20 off-pump procedures to be included in the analysis.
The risk-adjusted mortality in the off-pump group was significantly less than the risk-adjusted mortality for the on-pump group. When the odds ratios for death and morbidity were examined there was a significant reduction in these two end points in the off-pump versus the on-pump group, close to a 25% reduction in mortality and somewhat greater reduction in complications. We have also reviewed the VA database, and it shows similar results, up to almost a 35% to 40% reduction.
Although these are retrospective reviews and we realize that there is case selection bias, these are nevertheless very provocative data, and for that reason we are going forward with a proposal for a VA prospective randomizing cooperative study, which will be reviewed in May, and hopefully will be funded to begin in the fall.
I suspect your trends are similar to those in the STS and VA studies and that if you had more patients in your study you would have statistically different significances. I wonder if you could comment on biases and case selection that all of us as surgeons exercise when we select which procedures to perform.
DR SULAIMAN B. HASAN (Charleston, WV): I would like to congratulate Dr Hernandez and his group for an excellent and well presented study. Recently questions have come up about hypercoagulability states after off-pump operation, and we have seen some in our practice as well, vis-a-vis bowel ischemia, venous thrombosis, etc. I wonder if you have some data in this series of patients about that, and also about aortic dissection?
DR HERNANDEZ: I would like to thank Dr Mack and the other discussants for their kind comments. Regarding the question on the learning curve, the data presented included the learning curve on three of the four centers. We have not analyzed the results by time throughout the four centers to see how the operative mortality rates or other outcomes have changed as surgeon experience with the off-pump procedure has increased, but at our own institution we have noticed that as a surgeon’s experience increases complications tended to decrease, and that is one phenomenon we intend to analyze in our docket for future studies.
Regarding the power analysis, Dr Grover’s data showed a decrease in operative mortality. The number of patients in our study places us in what I consider to be a statistical limbo. We have enough numbers to see differences that are relatively small clinically in the preoperative risk factors but do not have enough power to see a difference in the outcome of mortality. The problem, if you will, is that the standard coronary bypass operation is a successful operation with excellent outcomes. If one starts at a mortality rate of 3% and were to produce a 33% reduction in that, down to 2%, power analysis indicates that you need a study of 3,500 patients in each arm for that change to be considered statistically significant, assuming a one-to-one ratio between study and control group. Our study has more of a one-to-three ratio, and at those numbers we would need 2,500 patients in the off-pump group and 7,500 patients in the on-pump group for that 33% reduction in mortality to become statistically significant. We continue to collect data prospectively on all the patients undergoing coronary artery bypass procedures in the region and look forward to further analyses. I suspect a lot of these differences will become statistically significant as the numbers in our group grow.
We believe that the hypercoagulable state is a real phenomenon. One of the weaknesses in our study was that there was no control for heparinization schedules, and we are aware that different surgeons at different institutions are using different heparinization protocols in their off-pump cases; however, we are not aware of any data in the literature that guide us further in this regard.
I would like to thank the discussants for their comments.
|
References |
|---|
|
TopFootnotesAbstractIntroductionMaterial and methodsResultsCommentAcknowledgmentsDiscussionReferences |
|---|
This article has been cited by other articles:
|
|
 |
|
  K. Nishiyama, M. Horiguchi, S. Shizuta, T. Doi, N. Ehara, R. Tanuguchi, Y. Haruna, Y. Nakagawa, Y. Furukawa, M. Fukushima, et al. Temporal Pattern of Strokes After On-Pump and Off-Pump Coronary Artery Bypass Graft Surgery. Ann. Thorac. Surg., June 1, 2009; 87(6): 1839 - 1844. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 V. A. Ferraris, F. H. Edwards, D. M. Shahian, and S. P. Ferraris Risk Stratification and Comorbidity Card. Surg. Adult, January 1, 2008; 3(2008): 199 - 246. [Full Text]
|
|
|
|
|
|
F. Hernandez Jr, J. R. Brown, D. S. Likosky, R. A. Clough, A. L. Hess, R. M. Roth, C. S. Ross, C. M. Whited, G. T. O'Connor, and J. D. Klemperer Neurocognitive Outcomes of Off-Pump Versus On-Pump Coronary Artery Bypass: A Prospective Randomized Controlled Trial Ann. Thorac. Surg., December 1, 2007; 84(6): 1897 - 1903. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 E. L. Hannan, C. Wu, C. R. Smith, R. S.D. Higgins, R. E. Carlson, A. T. Culliford, J. P. Gold, and R. H. Jones Off-Pump Versus On-Pump Coronary Artery Bypass Graft Surgery: Differences in Short-Term Outcomes and in Long-Term Mortality and Need for Subsequent Revascularization Circulation, September 4, 2007; 116(10): 1145 - 1152. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 E. Sisillo, M. R. Marino, G. Juliano, C. Beverini, L. Salvi, and F. Alamanni Comparison of on pump and off pump coronary surgery: risk factors for neurological outcome Eur. J. Cardiothorac. Surg., June 1, 2007; 31(6): 1076 - 1080. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M. Mishra, R. Malhotra, A. Karlekar, Y. Mishra, and N. Trehan Propensity Case-Matched Analysis of Off-Pump Versus On-Pump Coronary Artery Bypass Grafting in Patients With Atheromatous Aorta Ann. Thorac. Surg., August 1, 2006; 82(2): 608 - 614. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 D. N. Wijeysundera, W. S. Beattie, G. Djaiani, V. Rao, M. A. Borger, K. Karkouti, and R. J. Cusimano Off-Pump Coronary Artery Surgery for Reducing Mortality and Morbidity: Meta-Analysis of Randomized and Observational Studies J. Am. Coll. Cardiol., September 6, 2005; 46(5): 872 - 882. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
R. Jin, L. F. Hiratzka, G. L. Grunkemeier, A. Krause, and U. S. Page III Aborted Off-Pump Coronary Artery Bypass Patients Have Much Worse Outcomes Than On-Pump or Successful Off-Pump Patients Circulation, August 30, 2005; 112(9_suppl): I-332 - I-337. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M. L. Williams, L. H. Muhlbaier, J. N. Schroder, J. A. Hata, E. D. Peterson, P. K. Smith, K. P. Landolfo, R. H. Messier, R. D. Davis, and C. A. Milano Risk-Adjusted Short- and Long-Term Outcomes for On-Pump Versus Off-Pump Coronary Artery Bypass Surgery Circulation, August 30, 2005; 112(9_suppl): I-366 - I-370. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 L. L. Creswell, J. C. Alexander Jr., T. B. Ferguson Jr., A. Lisbon, and L. A. Fleisher Intraoperative Interventions: American College of Chest Physicians Guidelines for the Prevention and Management of Postoperative Atrial Fibrillation After Cardiac Surgery Chest, August 1, 2005; 128(2_suppl): 28S - 35S. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
F. Onorati, M. D. Feo, P. Mastroroberto, A. d. Virgilio, A. Esposito, M. Polistena, A. Renzulli, and M. Cotrufo Unstable angina and non-ST segment elevation: surgical revascularization with different strategies Eur. J. Cardiothorac. Surg., June 1, 2005; 27(6): 1043 - 1050. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 P. S. Myles and D. McIlroy Fast-Track Cardiac Anesthesia: Choice of Anesthetic Agents and Techniques Seminars in Cardiothoracic and Vascular Anesthesia, March 1, 2005; 9(1): 5 - 16. [Abstract] [PDF]
|
|
|
|
 |
|
 J. Pepper Controversies in Off-pump Coronary Artery Surgery Clin. Med. Res., February 1, 2005; 3(1): 27 - 33. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 E. A Black, S. Ghosh, K. Sin, T. Spyt, and R. Pillai Off-Pump Coronary Artery Bypass Surgery Asian Cardiovasc Thorac Ann, December 1, 2004; 12(4): 379 - 386. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
P. Widimsky, Z. Straka, P. Stros, K. Jirasek, J. Dvorak, J. Votava, L. Lisa, T. Budesinsky, M. Kolesar, T. Vanek, et al. One-Year Coronary Bypass Graft Patency: A Randomized Comparison Between Off-Pump and On-Pump Surgery Angiographic Results of the PRAGUE-4 Trial Circulation, November 30, 2004; 110(22): 3418 - 3423. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 N. C. Patel, N. U. Patel, D. F. Loulmet, J. C. McCabe, and V. A. Subramanian Emergency conversion to cardiopulmonary bypass during attempted off-pump revascularization results in increased morbidity and mortality J. Thorac. Cardiovasc. Surg., November 1, 2004; 128(5): 655 - 661. [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]
|
|
|
|
|
|
N. D. Desai, M. P. Pelletier, H. R. Mallidi, G. T. Christakis, G. N. Cohen, S. E. Fremes, and B. S. Goldman Why Is Off-Pump Coronary Surgery Uncommon in Canada? Results of a Population-Based Survey of Canadian Heart Surgeons Circulation, September 14, 2004; 110(11_suppl_1): II-7 - II-12. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
P. Saxena and R. K. W. Tam Combined off-pump coronary artery bypass surgery and pulmonary resection Ann. Thorac. Surg., August 1, 2004; 78(2): 498 - 501. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J. S. Steinberg Postoperative atrial fibrillation: a billion-dollar problem J. Am. Coll. Cardiol., March 17, 2004; 43(6): 1001 - 1003. [Full Text] [PDF]
|
|
|
|
 |
|
 P. A. Berdat, K. Muller, J. Schmidli, B. Kipfer, F. Eckstein, F. F. Immer, and T. Carrel Totally arterial off-pump vs. on-pump coronary revascularization: comparison of early outcome Interactive CardioVascular and Thoracic Surgery, March 1, 2004; 3(1): 176 - 181. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
Z. Straka, P. Widimsky, K. Jirasek, P. Stros, J. Votava, T. Vanek, P. Brucek, M. Kolesar, and R. Spacek Off-pump versus on-pump coronary surgery: final results from a prospective randomized study Prague-4 Ann. Thorac. Surg., March 1, 2004; 77(3): 789 - 793. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 P.-G. Chassot, P. van der Linden, M. Zaugg, X. M. Mueller, and D. R. Spahn Off-pump coronary artery bypass surgery: physiology and anaesthetic management{dagger} Br. J. Anaesth., March 1, 2004; 92(3): 400 - 413. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
H. B. Ward and R. F. Kelly OPCAB vs CABG: Who, What, When, Where? Chest, March 1, 2004; 125(3): 815 - 816. [Full Text] [PDF]
|
|
|
|
|
|
M. J. Racz, E. L. Hannan, O. W. Isom, V. A. Subramanian, R. H. Jones, J. P. Gold, T. J. Ryan, A. Hartman, A. T. Culliford, E. Bennett, et al. A comparison of short- and long-term outcomes after off-pump and on-pump coronary artery bypass graft surgery with sternotomy J. Am. Coll. Cardiol., February 18, 2004; 43(4): 557 - 564. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
R. Sharony, E. A. Grossi, P. C. Saunders, A. C. Galloway, R. Applebaum, G. H. Ribakove, A. T. Culliford, M. Kanchuger, I. Kronzon, and S. B. Colvin Propensity case-matched analysis of off-pump coronary artery bypass grafting in patients with atheromatous aortic disease J. Thorac. Cardiovasc. Surg., February 1, 2004; 127(2): 406 - 413. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 N. E. Khan, A. De Souza, R. Mister, M. Flather, J. Clague, S. Davies, P. Collins, D. Wang, U. Sigwart, and J. Pepper A Randomized Comparison of Off-Pump and On-Pump Multivessel Coronary-Artery Bypass Surgery N. Engl. J. Med., January 1, 2004; 350(1): 21 - 28. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
Y. Wu, G. L. Grunkemeier, and J. R. Handy Jr Coronary artery bypass grafting: Are risk models developed from on-pump surgery valid for off-pump surgery? J. Thorac. Cardiovasc. Surg., January 1, 2004; 127(1): 174 - 178. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 A. H Olivencia-Yurvati, N. Wallace, S. Ford, and R. T Mallet Leukocyte filtration and aprotinin: synergistic anti-inflammatory protection Perfusion, January 1, 2004; 19(1_suppl): S13 - S19. [Abstract] [PDF]
|
|
|
|
|
|
S. Al-Ruzzeh, T. Athanasiou, S. George, and M. Amrani Methodological approach in adopting off-pump coronary artery bypass surgery in a British cardiothoracic unit: Harefield experience Perfusion, January 1, 2004; 19(1_suppl): S61 - S66. [Abstract] [PDF]
|
|
|
|
|
|
A. Boening, C. Friedrich, J. Hedderich, J. Schoettler, S. Fraund, and J. T. Cremer Early and medium-term results after on-pump and off-pump coronary artery surgery: a propensity score analysis Ann. Thorac. Surg., December 1, 2003; 76(6): 2000 - 2006. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J. T. Reston, S. J. Tregear, and C. M. Turkelson Meta-analysis of short-term and mid-term outcomes following off-pump coronary artery bypass grafting Ann. Thorac. Surg., November 1, 2003; 76(5): 1510 - 1515. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
D. L. Ngaage Off-pump coronary artery bypass grafting: the myth, the logic and the science Eur. J. Cardiothorac. Surg., October 1, 2003; 24(4): 557 - 570. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
S. Al-Ruzzeh, G. Ambler, G. Asimakopoulos, R. Z. Omar, R. Hasan, B. Fabri, A. El-Gamel, A. DeSouza, V. Zamvar, S. Griffin, et al. Off-Pump Coronary Artery Bypass (OPCAB) Surgery Reduces Risk-Stratified Morbidity and Mortality: A United Kingdom Multi-Center Comparative Analysis of Early Clinical Outcome Circulation, September 9, 2003; 108(90101): II-1 - 8. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
A. J. Chong, C. R. Hampton, and E. D. Verrier Microvascular Inflammatory Response in Cardiac Surgery Seminars in Cardiothoracic and Vascular Anesthesia, September 1, 2003; 7(3): 333 - 354. [Abstract] [PDF]
|
|
|
|
|
|
H. M. Nathoe, D. van Dijk, E. W.L. Jansen, W. J.L. Suyker, J. C. Diephuis, W.-J. van Boven, A. B. de la Riviere, C. Borst, C. J. Kalkman, D. E. Grobbee, et al. A Comparison of On-Pump and Off-Pump Coronary Bypass Surgery in Low-Risk Patients N. Engl. J. Med., January 30, 2003; 348(5): 394 - 402. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 R Ascione and G.D Angelini OPCAB surgery: a voyage of discovery back to the future Eur. Heart J., January 2, 2003; 24(2): 121 - 124. [Full Text] [PDF]
|
|
|
|
|
|
G. P. Eising, M. Pfauder, M. Niemeyer, P. Tassani, H. Schad, R. Bauernschmitt, and R. Lange Retrograde autologous priming: is it useful in elective on-pump coronary artery bypass surgery? Ann. Thorac. Surg., January 1, 2003; 75(1): 23 - 27. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
D. Royston, T. Kovesi, and N. Marczin The unwanted response to cardiac surgery: Time for a reappraisal? J. Thorac. Cardiovasc. Surg., January 1, 2003; 125(1): 32 - 35. [Full Text] [PDF]
|
|
|
|
|
|
R. Ascione, M. Caputo, and G. D. Angelini Off-pump coronary artery bypass grafting: not a flash in the pan Ann. Thorac. Surg., January 1, 2003; 75(1): 306 - 313. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
R. Salenger, J. S. Gammie, and T. J. Vander Salm Postoperative Care of Cardiac Surgical Patients Card. Surg. Adult, January 1, 2003; 2(2003): 439 - 469. [Full Text]
|
|
|
|
|
|
T. M. Dewey and M. J. Mack Myocardial Revascularization Without Cardiopulmonary Bypass Card. Surg. Adult, January 1, 2003; 2(2003): 609 - 625. [Full Text]
|
|
|
|
|
|
M. J. Mack and F. G. Duhaylongsod Through the open door! Where has the ride taken us? J. Thorac. Cardiovasc. Surg., October 1, 2002; 124(4): 655 - 659. [Full Text] [PDF]
|
|
|
|
|
|
S. J. Hoff, S. K. Ball, W. H. Coltharp, D. M. Glassford Jr, J. W. Lea IV, and M. R. Petracek Coronary artery bypass in patients 80 years and over: is off-pump the operation of choice? Ann. Thorac. Surg., October 1, 2002; 74(4): S1340 - 1343. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
K.-B. Kim, C. H. Kang, W.-I. Chang, C. Lim, J. H. Kim, B. M. Ham, and Y. L. Kim Off-pump coronary artery bypass with complete avoidance of aortic manipulation Ann. Thorac. Surg., October 1, 2002; 74(4): S1377 - 1382. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 P. P T. de Jaegere and W. J L Suyker OFF-PUMP CORONARY ARTERY BYPASS SURGERY Heart, September 1, 2002; 88(3): 313 - 318. [Full Text] [PDF]
|
|
|
|
|
|
N. C. Patel, A. P. Deodhar, A. D. Grayson, D. M. Pullan, D. J.M. Keenan, R. Hasan, and B. M. Fabri Neurological outcomes in coronary surgery: independent effect of avoiding cardiopulmonary bypass Ann. Thorac. Surg., August 1, 2002; 74(2): 400 - 406. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
R. Ascione, S. Al-Ruzzeh, K. Amer, and G. D Angelini Subsystem organ function during coronary surgery Perfusion, July 1, 2002; 17(4): 295 - 303. [Abstract] [PDF]
|
|
|
|
 |
|
 D. B. Mark and M. F. Newman Protecting the Brain in Coronary Artery Bypass Graft Surgery JAMA, March 20, 2002; 287(11): 1448 - 1450. [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 |
