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

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Donald D. Glower Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by McCreath, B. J. Articles by Stafford-Smith, M. Search for Related Content PubMed PubMed Citation Articles by McCreath, B. J. Articles by Stafford-Smith, M. Related Collections Valve disease

Ann Thorac Surg 2003;75:812-819
© 2003 The Society of Thoracic Surgeons

---

Original article: cardiovascular

Mitral valve surgery and acute renal injury: port access versus median sternotomy

^a Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina, USA
^b Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA

Accepted for publication September 18, 2002.

^* Address reprint requests to Dr Stafford-Smith, Department of Anesthesiology, Box 3094, Duke University Medical Center, Durham, NC 27710, USA.
e-mail: staff002{at}mc.duke.edu

	Abstract

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
BACKGROUND: Many outcomes and complications of minimally invasive and conventional cardiac surgery await comparison. Patients undergoing mitral valve surgery commonly sustain renal injury. Using peak postoperative fractional change of serum creatinine as a marker of renal injury, we tested the hypothesis that mitral valve surgery with port access minithoracotomy (Port) and conventional surgery with a median sternotomy (MS) incision are associated with different degrees of acute renal injury.

METHODS: We evaluated data from all isolated mitral valve operations by a single surgeon between 1990 and 2000 (MS = 90, Port = 227). We also performed a secondary analysis of mitral valve surgeries performed by both MS and Port approaches in a concurrent period from 1996 to 2002 (MS = 93, Port = 240). Univariable and multivariable tests were used to determine the association of surgical technique with peak postoperative creatinine (Cr_maxPost) and peak postoperative fractional change in creatinine (%Cr); p less than 0.05 was considered significant.

RESULTS: In our analysis that accounted for the date of surgery, we observed a highly significant independent association between surgical approach and %Cr, indicating a greater risk of acute renal injury in the MS group (F value 13.33; p = 0.0003). Similar findings were noted in the secondary (time-concurrent) analysis of %Cr (F value 12.65; p = 0.0176).

CONCLUSIONS: We present retrospective evidence of reduced acute renal injury associated with the port access technique in mitral valve surgery patients. Our findings suggest that a port access minithoracotomy approach to mitral valve surgery may be preferable to conventional methods for patients with high renal risk.

	Introduction

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
The development of acute renal dysfunction after cardiac surgery is associated with marked increases in morbidity, mortality, and cost. The incidence of this postoperative complication exceeds 7% and renal replacement therapy is necessary in 1% to 2% of patients [1–3]. Despite advances in dialytic technology mortality for patients requiring dialysis after cardiac surgery is greater than 60% [1, 2]. Even minor kidney injury reflected by a serum creatinine rise that never exceeds the normal range is linked to adverse outcomes [4]. In the absence of effective pharmacologic interventions to prevent or treat acute renal injury [5] it is vital to minimize the risk of sustaining kidney damage during cardiac surgery; prevention is better than a cure.

Minimally invasive cardiac surgery has been variably defined as the avoidance of median sternotomy, cardiopulmonary bypass, or manipulation of the ascending aorta [6]. Although outcomes from several case series of minimally invasive procedures have been reported [7, 8], many of the risks and potential benefits of these procedures have not been rigorously compared with equivalent conventional techniques. Minimally invasive cardiopulmonary bypass systems such as the EndoCPB or EndoDirect Systems (Heartport, Redwood City, CA) permit surgical access to the heart through a minithoracotomy incision, or "port," and have been adopted by some surgeons to facilitate a less invasive approach to mitral valve surgery. Patients undergoing mitral valve surgery are particularly susceptible to kidney damage [2]. However, the association of the port access technique with acute perioperative renal injury has not been previously investigated. Therefore we tested the hypothesis that mitral valve surgery with port access minithoracotomy and conventional surgery with a median sternotomy incision are associated with different degrees of acute renal injury.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
Patient selection
After Institutional Review Board (Duke University Medical Center) approval (IRB Registry 2179-00-12R0ER, approved December 14, 2000), all consecutive adult patients who underwent isolated mitral valve surgery by a single surgeon (DDG) at Duke University Medical Center between March 1990 and October 2000 were identified. In order to form a time-concurrent group, we also identified all patients who underwent isolated mitral valve surgery from May 1996 to March 2002. A temporal description of selection of patient cohorts is shown in Figure 1. Patients undergoing combined procedures (eg, double valve replacement) or those procedures in which an external aortic cross-clamp was required during a port access approach were excluded from data collection. Patients who required perioperative renal replacement therapy or who died within the first 2 postoperative days were also excluded as their serum creatinine values did not accurately reflect the degree of renal injury. Demographic data collection included previously described perioperative variables associated with the development of acute renal dysfunction [1, 3]. These variables were gathered for each subject from a retrospective chart review including age, sex, race, weight, presence of peripheral vascular disease, diabetes mellitus, congestive heart failure, chronic obstructive pulmonary disease, carotid bruit, preoperative serum creatinine 133 µmol/L or greater (1.5 mg/dL), hematocrit, and left ventricular ejection fraction. Data pertaining to cardiopulmonary bypass (CPB) and aortic occlusion duration, use of inotropic agents at the time of admission to the cardiac intensive care unit, and intraoperative use of an intraaortic balloon pump (IABP) insertion in the operating room was obtained from automated anesthesia records using the ARKIVE Information Management System (Arkive IMS, San Diego, CA). The date of surgery was also recorded for each patient. Outcome data were available from the prospectively gathered Duke Quality Measurement and Management Initiative (QMMI) database and included in-hospital death, stroke, infection, and length of hospital stay.

View larger version (17K): [in this window] [in a new window]   Fig 1. Temporal description of patient selection for the primary (single-surgeon) and secondary (time-concurrent) analyses. MS = median sternotomy.

Anesthesia and surgery
Anesthesia was managed per the attending anesthesiologist’s preference. Use of agents with potential renal effects (eg, intravenous dopamine, antifibrinolytic agents) was not regulated. Antifibrinolytic agent usage changed during the study period. Administration of -aminocaproic acid went from being uncommon to routine during 1992 (10 g intravenous bolus pre-CPB, then 1 g/h x 5 hours) [10]. Aprotinin (high-dose regimen) was generally used for revision surgery after 1995.

The CPB circuit was primed with mannitol (50 g of 20% solution), crystalloid solution (0.9% normal saline) and packed red blood cells to achieve a hematocrit of 0.18 or higher during CPB. Extracorporeal perfusion was maintained using a nonpulsatile flow of 2 to 2.4 L · min^-1 · m^-2. Since 1990 the Cobe CML Duo flatsheet membrane oxygenator (Cobe Laboratories, Lakewood, CO) was used in most cases. Some surgeries were performed using the Terumo Capiox hollow fiber membrane oxygenator (Terumo Cardiovascular Systems, Ann Arbor, MI). The arterial carbon dioxide tension was maintained throughout CPB at 35 to 40 mm Hg (uncorrected for temperature), with the arterial oxygen tension maintained at 150 to 250 mm Hg. Mean arterial pressure was maintained between 50 and 70 mm Hg during CPB using intravenous phenylephrine or sodium nitroprusside as required. Although antegrade and retrograde blood cardioplegia delivered between 6°C and 8°C was the myocardial protection strategy of choice, cardiac fibrillation without aortic occlusion was employed at the discretion of the surgeon. An arterial line filter (Pall Medical, Ann Arbor, MI) was used in the circuit throughout the duration of CPB. Target inflow temperature during CPB was 28°C and patients were actively rewarmed to a nasopharyngeal temperature of 36.5°C before discontinuation of CPB. Except during the period of heparin anticoagulation, shed blood was not reinfused. Postoperative mediastinal shed blood was discarded. Intraoperative cell salvage was used only for redo procedures where a cell saver was used and all salvaged blood was washed before reinfusion. The average crystalloid fluids administered in the first 24 hours postoperatively was 1,000 to 1,500 mL lactated Ringer’s solution and 500 to 1,000 mL hetastarch solution.

Identification of patient groups
During a 3-month period ending August 1996 the surgeon’s approach to the mitral valve changed from a median sternotomy incision and ascending aorta cannulation (patient group MS) to a right anterolateral thoracotomy (7 cm) incision and the use of a minimally invasive CPB system (EndoCPB System) with femoral artery cannulation (patient group PortFem). This port access approach employs an endovascular balloon catheter advanced from the femoral artery to occlude the ascending aorta in the place of an external aortic cross-clamp. From July 1998 onward the port access arterial cannulation site was changed to the ascending aorta (patient group PortA). If endovascular balloon catheter aortic occlusion was contraindicated (eg, aortic ectasia) in port access patients an external aortic cross-clamp was used at the discretion of the surgeon; these procedures were excluded from analysis.

For the secondary time-concurrent analysis, patients operated on by the median sternotomy approach were identified as the MS group and those operated on by the port access approach were identified as the Port group.

Statistical analysis
Univariable comparisons of demographic and renal function data were made using Student’s t tests for continuous variables and ² or Fisher’s exact tests for categorical variables. PortFem and PortA groups were separately analyzed using an analysis of variance test and combined (Port) for comparison with the MS group. Peak fractional change in creatinine (%Cr) was selected as the primary outcome in this study as this marker has been shown to be a reliable indicator of acute renal injury [11]. The association of Port and MS with %Cr was then examined by using multivariable linear regression analyses. First we performed a full-model analysis in which we included all the demographic, comorbidity, and intraoperative data. To follow up this analysis we implemented a stepwise selection so that the final model includes only variables that are significantly (p < 0.10) associated with the outcome (%Cr).

A second analysis of covariance was then performed to identify similar associations with Cr_maxPost. Because of the potential for non-normal distribution of Cr_maxPost values, and to assess generalizability and robustness of results, this analysis was then repeated on ranked data. This approach was used for both, the primary and secondary (time-concurrent) analyses. Additional data analysis included graphic, temporal display of 10-day postoperative serum creatinine patterns between Port and MS groups. Missing postdischarge serum creatinine values from postoperative days 4 to 10 were imputed to equal the final in-hospital serum creatinine value. A p value less than 0.05 was considered significant. All statistical analyses were performed using the SAS statistical software version 8.0 (SAS Institute, Cary, NC)

	Results

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
Primary analysis
A total of 333 patients met the defined selection criteria. Demographic and renal function data were collected for all PortFem (n = 81), PortA (n = 146), and MS (n = 90) patients during this study. Sixteen patients were excluded from the study for the following reasons: Port patients requiring the use of an external aortic cross-clamp (n = 9); incomplete data (MS n = 1); and patients requiring perioperative renal replacement therapy (Port n = 4, MS n = 2). The incidence of new-onset postoperative dialysis in the Port and MS groups was similar (2.1 versus 2.8%; p = 0.75). Univariable analysis of demographic data demonstrated no significant differences between PortFem and PortA groups. Therefore, a combined Port group was used for further comparison with the MS group.

Demographic variables were broadly similar in the Port and MS groups (Table 1). However, some differences were noted including several known renal risk factors that were more common in the MS patients (ie, African-American ethnicity, congestive heart failure, chronic obstructive pulmonary disease, preoperative serum creatinine 133 µmol/L or greater (1.5 mg/dL), low preoperative hematocrit and aortic occlusion time).

View larger version (20K): [in this window] [in a new window]   Fig 2. Daily postoperative fractional change in serum creatinine (Cr) after mitral valve surgery. Data are population-averaged mean values. The day of peak fractional change in creatinine (%Cr) varies among patients. %Crdaily = daily postoperative fractional change in serum creatinine; MS (squares; n = 87) = mitral valve surgery through a median sternotomy incision employing fibrillatory arrest or an external aortic cross-clamp; Port (diamonds; n = 214) = mitral valve surgery through a minithoracotomy incision employing fibrillatory arrest or an endovascular balloon catheter for aortic occlusion.

View this table: [in this window] [in a new window]   Table 8. Multivariable Analysis of Factors Associated With %Cr in the Time-Concurrent Patient Cohort

View larger version (54K): [in this window] [in a new window]   Fig 3. Unadjusted %DeltaCr values for MS and Port groups of patients from the primary (single-surgeon) and secondary (time-concurrent) analyses. Diagonally shaded bar = MS 1990–1996 (n = 87); open bar = Port 1996–2000 (n = 214); horizontally shaded bar = MS 1996–2002 (n = 93); vertically shaded bar = Port 1996–2002. (%DeltaCr = peak postoperative fractional change in creatinine; MS = mitral valve surgery through a median sternotomy incision employing fibrillatory arrest or an external aortic cross-clamp; Port = mitral valve surgery through a minithoracotomy incision employing fibrillatory arrest or an endovascular balloon catheter for aortic occlusion.)

	Comment

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

Although complications for minimally invasive mitral valve surgery have been previously reported [7, 8], specific organ injury has not been compared with traditional techniques [12, 13]. The minimally invasive technique has been previously reported to be "safe" in patients with renal dysfunction [14, 15] However, none of these studies looked specifically at the application of the technique in equivalent mitral valve surgery patients. Outcome data are also limited to reports of small case series [16, 17] or the Port-Access International Registry (PAIR) and reported results relating to adverse renal outcomes are inconsistent [7, 8]. Although the first PAIR study [7] reported a 0.5% renal failure rate in port access mitral valve surgery, a recent Internet-based update of the registry reports a 2.7% renal failure rate in the same updated population (unpublished data accessed from the Heartport-supported [Heartport, Redwood City, CA] World Wide Web site at http://www.heartport.com/webpage_templates/PAIR2000.pdf). Our study is the first comparative report of the association between two different surgical techniques of mitral valve surgery and perioperative renal injury.

Although we believe that the findings of this report are important, there are limitations inherent to our study design. Our study tests a hypothesis on retrospectively collected data and does not have the rigorous controls of a randomized clinical trial. However, serum creatinine values for this study were obtained from the computerized Duke University Medical Center Information Systems and individual patient charts with a yield close to 100%. Other data were gathered from the prospectively gathered quality assurance QMMI database. The study involved patients enrolled over a 10-year period during which major changes occurred in patient management for mitral valve disorders. Prosthetic valve technology, indications for valve repair, anesthetic and medical management, and other factors involved in treatment of mitral valve disease have changed during this time period. Patient referral and selection patterns in our cohort have also varied over time, as highlighted by the difference in demographic data between Port and MS groups. However, multivariable analysis including demographic factors and controlling for the date of surgery should account for the differences in known renal risk factors and minimize any potential bias. Among port access patients the cardiopulmonary bypass technique altered during the study period and the arterial cannulation site changed from the femoral artery to the ascending aorta. Despite the change in technique separate analysis of PortA and PortFem patients failed to reveal any significant differences and therefore they were combined for comparison with the MS patients. Our study examined a consecutive series of patients undergoing isolated mitral valve surgery performed by a single surgeon at a single institution during a period when surgical technique changed. The transition from one technique to the other was gradual; 21 patients in the MS group underwent surgery after the introduction of minimally invasive technology. Although ineligibility for port access surgery may have contributed to higher renal risk for these patients (eg, peripheral vascular disease would contraindicate PortFem surgery), peripheral vascular disease was accounted for in the multivariable analysis.

The selection of a creatinine-based marker (%Cr) as an indicator of acute renal injury was based on the strength of the association of this marker with mortality and other adverse outcomes after cardiac surgery [18]. Peak postoperative creatinine is also independently linked with adverse outcome [11]. As a consequence, we performed a secondary analysis of this variable (Table 3). Although %Cr and Cr_maxPost were selected as good markers of renal filtration function [11, 18] they do not address the numerous other homeostatic roles of the kidney including osmolality, electrolyte and acid-base regulation and production and release of enzymes and hormones. History of nonsteroidal antiinflammatory drugs (NSAID) use was not included in our statistical models. However, routine NSAID administration was introduced in 1998 and was commonly used for Port patients during the first 48 hours after surgery. Any unmeasured bias attributable to NSAID-related nephrotoxicity would be expected to increase renal injury in the Port group, diminishing the effect we observed. Another difference in aortic occlusion times between groups demonstrated a trend toward significantly longer times in the Port group (Table 1). However, this factor was accounted for in the multivariable analysis but was not found to be significantly associated with either marker of renal function. Moreover, any adverse renal effect of longer aortic occlusion times in the port access patients would have decreased the difference in creatinine-derived variables we observed in our analyses. Although our report provides the first comparison of renal injury in a large number of patients undergoing equivalent mitral valve surgery using minimally invasive and traditional methods the data are retrospective and reflect a decade of practice. Although it would be ideal, it is unlikely that a randomized trial will be performed to confirm our findings.

The results of our study are novel and prompt speculation as to a possible mechanistic interpretation. The major differences between the MS and Port procedures relate to the location and size of incision and the method of aortic occlusion. Other studies have failed to demonstrate any major differences in outcome between sternotomy and minithoracotomy incisions [19, 20]. The method of aortic occlusion represents an important difference between the MS and Port techniques. It has been proposed that aortic manipulation increases embolization of ascending aorta atheroma; extensive evidence supports the relationship of ascending aortic arteriosclerosis and atheroemboli with postcardiac surgery complications including acute renal injury [21–23]. A mechanistic rationale that could explain the findings of our study is that different rates of atheroemboli-related complications, including acute renal injury, result from differences between the two methods of aortic occlusion. Port patients who had external aortic clamps (n = 9) demonstrated markedly greater Cr_maxPost and %Cr values compared with other Port and MS patients (Table 5). However, neither value reached statistical significance. Since there were only 9 patients in this external clamp group, this finding may be considered only suggestive of greater renal dysfunction in Port patients who had an external clamp placed. The higher creatinine values in this group of 9 patients are consistent with our theory that aortic manipulation from cross-clamp versus endo-balloon occlusion may increase atheroembolic injury in the kidneys. Endovascular balloon occlusion may cause less aortic wall distortion than external cross-clamping [24]. However, balloon migration may probably also be associated with detachment of atheroemboli. The original rationale for use of the port access approach to mitral valve surgery was to safely achieve surgical goals with reduced pain, accelerated recovery, and improved cosmesis [7, 16]. Our observation of reduced perioperative renal injury with the port access technique suggests that this technique may be beneficial in patients at high risk for postoperative renal dysfunction. It is also interesting to note that there has been no major change in the degree of perioperative renal injury as represented by %Cr in the MS group of patients whether operated during the period from 1990 to 1996 (primary cohort) or from 1996 to 2002 (secondary cohort; see Fig 3). This probably indicates that the procedure as a whole has consistently posed a risk of renal injury over time rather than increasing patient morbidity.

In summary, we present retrospective evidence that port access mitral valve surgery is associated with less acute renal injury than conventional techniques. A trend toward reduced major adverse outcomes was also observed. Our findings suggest that a port access approach to mitral valve surgery may be indicated for patients at high risk of perioperative acute renal dysfunction.

	Acknowledgments

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
This work was supported by the Division of Cardiothoracic Anesthesia and Critical Care Medicine of the Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina. The authors gratefully acknowledge the secretarial efficiency of Christopher G. Keith and LaTanya Rhames, Department of Anesthesiology, Duke University Medical Center, in the preparation of this manuscript.

	References

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 

1. Mangano C.M., Diamondstone L.S., Ramsay J.G., Aggarwal A., Herskowitz A., Mangano D.T. Renal dysfunction after myocardial revascularization: risk factors, adverse outcomes, and hospital resource utilization. The Multicenter Study of Perioperative Ischemia Research Group. Ann Intern Med 1998;128:194-203.[Abstract/Free Full Text]
2. Chertow G.M., Lazarus J.M., Christiansen C.L., et al. Preoperative renal risk stratification. Circulation 1997;95:878-884.[Abstract/Free Full Text]
3. Conlon P.J., Stafford-Smith M., White W.D., et al. Acute renal failure following cardiac surgery. Nephrol Dial Transplant 1999;14:1158-1162.[Abstract/Free Full Text]
4. Mora-Mangano C., Boisvert D., Zhou S., Herskowitz A., Mangano D. Small reductions in renal function following CABG independently predict hospitalization. Anesth Analg 2000;90(Suppl):SCA35.
5. Vijayan A., Miller S.B. Acute renal failure: prevention and nondialytic therapy. Semin Nephrol 1998;18:523-532.[Medline]
6. Mack M., Acuff T., Yong P., Jett G.K., Carter D. Minimally invasive thoracoscopically assisted coronary artery bypass surgery. Eur J Cardiothorac Surg 1997;12:20-24.[Abstract]
7. Galloway A.C., Shemin R.J., Glower D.D., et al. First report of the Port Access International Registry. Ann Thorac Surg 1999;67:51-56.[Abstract/Free Full Text]
8. Glower D.D., Siegel L.C., Frischmeyer K.J., et al. Predictors of outcome in a multicenter port-access valve registry. Ann Thorac Surg 2000;70:1054-1059.[Abstract/Free Full Text]
9. Cockcroft D.W., Gault M.H. Prediction of creatinine clearance from serum creatinine. Nephron 1976;16:31-41.[Medline]
10. Stafford-Smith M., Phillips-Bute B., Reddan D.N., Black J., Newman M.F. The association of epsilon-aminocaproic acid with postoperative decrease in creatinine clearance in 1502 coronary bypass patients. Anesth Analg 2000;91:1085-1090.[Abstract/Free Full Text]
11. Stafford-Smith M., Phillips-Bute P., Reddan D., Milano C., Newman M., Winn M. The association of postoperative peak and fractional change in serum creatinine with mortality after coronary bypass surgery. Anesthesiology 2000;93(Suppl):A240.
12. Baldwin J.C. Editorial (con) re minimally invasive port-access mitral valve surgery. J Thorac Cardiovasc Surg 1998;115:563-564.[Free Full Text]
13. Verrier E.D. Editorial (pro) re minimally invasive port-access mitral valve surgery. J Thorac Cardiovasc Surg 1998;115:565-566.[Free Full Text]
14. Diegeler A., Matin M., Falk V., et al. Indication and patient selection in minimally invasive and off-pump coronary artery bypass grafting. Eur J Cardiothorac Surg 1999;16(Suppl 1):S79-82.[Abstract/Free Full Text]
15. Riess F.C., Moshar S., Bader R., et al. Clinical outcome of patients with and without renal impairment undergoing a minimally invasive LIMA-to-LAD bypass operation. Heart Surg Forum 2000;3:313-318.[Medline]
16. Glower D.D., Landolfo K.P., Clements F., et al. Mitral valve operation via port access versus median sternotomy. Eur J Cardiothorac Surg 1998;14(Suppl 1):S143-147.[Abstract/Free Full Text]
17. Gulielmos V., Wunderlich J., Dangel M., et al. Minimally invasive mitral valve surgery—clinical experiences with a PortAccess system. Eur J Cardiothorac Surg 1998;14(Suppl 1):S148-153.[Abstract/Free Full Text]
18. Stafford-Smith M., Reddan D.N., Phillips-Bute B., Newman M.F., Winn M.P. Association of perioperative creatinine-derived variables with mortality and other outcomes after coronary bypass surgery. Anesth Analg 2001;92(Suppl):SCA28.
19. Gulielmos V., Brandt M., Dill H.M., et al. Coronary artery bypass grafting via median sternotomy or lateral minithoracotomy. Eur J Cardiothorac Surg 1999;16(Suppl 2):S48-52.[Abstract/Free Full Text]
20. Walther T., Falk V., Metz S., et al. Pain and quality of life after minimally invasive versus conventional cardiac surgery. Ann Thorac Surg 1999;67:1643-1647.[Abstract/Free Full Text]
21. Davila-Roman V.G., Kouchoukos N.T., Schechtman K.B., Barzilai B. Atherosclerosis of the ascending aorta is a predictor of renal dysfunction after cardiac operations. J Thorac Cardiovasc Surg 1999;117:111-116.[Abstract/Free Full Text]
22. Blauth C.I., Cosgrove D.M., Webb B.W., et al. Atheroembolism from the ascending aorta. An emerging problem in cardiac surgery. J Thorac Cardiovasc Surg 1992;103:1104-1112.[Abstract]
23. Mackensen G., Ti L., Swaminathan M., et al. Apolipoprotein E phenotype influences the effect of ascending aorta atheroma burden on peak postoperative serum creatinine following CABG surgery. Anesth Analg 2001;92(Suppl):SCA46.
24. Liddicoat J.R., Doty J.R., Stuart R.S. Management of the atherosclerotic ascending aorta with endoaortic occlusion. Ann Thorac Surg 1998;65:1133-1135.[Abstract/Free Full Text]

This article has been cited by other articles:

				P. Modi, A. Hassan, and W. R. Chitwood Jr. Minimally invasive mitral valve surgery: a systematic review and meta-analysis Eur. J. Cardiothorac. Surg., November 1, 2008; 34(5): 943 - 952. [Abstract] [Full Text] [PDF]

				M. Stafford-Smith Evidence-Based Renal Protection in Cardiac Surgery Seminars in Cardiothoracic and Vascular Anesthesia, March 1, 2005; 9(1): 65 - 76. [Abstract] [PDF]

				R. L. Mehta Acute Renal Failure and Cardiac Surgery: Marching in Place or Moving Ahead? J. Am. Soc. Nephrol., January 1, 2005; 16(1): 12 - 14. [Full Text] [PDF]

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Donald D. Glower Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by McCreath, B. J. Articles by Stafford-Smith, M. Search for Related Content PubMed PubMed Citation Articles by McCreath, B. J. Articles by Stafford-Smith, M. Related Collections Valve disease