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): Daniel J. Goldstein Frederic F. Sardari Ravindra Karanam Paul G. Burns Craig R. Saunders Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Beauford, R. B. Articles by Saunders, C. R. Search for Related Content PubMed PubMed Citation Articles by Beauford, R. B. Articles by Saunders, C. R. Related Collections Coronary disease

Ann Thorac Surg 2003;76:12-17
© 2003 The Society of Thoracic Surgeons

---

Original article: cardiovascular

Multivessel off-pump revascularization in octogenarians: early and midterm outcomes

^a Department of Cardiothoracic Surgery, Newark Beth Israel Medical Center and Saint Barnabas Hospital, Newark, New Jersey, USA
^b Department of Cardiology, Newark Beth Israel Medical Center and Saint Barnabas Hospital, Newark, New Jersey, USA
^c Department of Anesthesiology, Newark Beth Israel Medical Center and Saint Barnabas Hospital, Newark, New Jersey, USA

Accepted for publication December 23, 2002.

^* Address reprint requests to Dr Goldstein, Department of Cardiothoracic Surgery, Newark Beth Israel Medical Center, 201 Lyons Ave, Suite G5, Newark, NJ07112, USA.
e-mail: dgoldstein{at}sbhcs.com

	Abstract

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 
BACKGROUND: Octogenarians are increasingly being referred for coronary artery revascularization. However, the prevalence of comorbid events and the propensity for neurologic dysfunction place octogenarians at higher risk for cardiopulmonary bypass–induced morbidity and mortality. Therefore, octogenarian patients represent a particularly attractive target for application of off-pump coronary artery bypass grafting.

METHODS: From January 1999 to August 2001, 113 octogenarians had off-pump coronary artery bypass grafting. Their data were prospectively entered into the cardiac surgery database and analyzed retrospectively. Follow-up information was obtained through telephone survey.

RESULTS: The mean age of the patients was 83 ± 2.5 years, and the mean number of grafts per patient was 3.3 ± 1. The most prevalent postoperative complication was atrial fibrillation (43%). Postoperative neurologic complications were seen in 5 patients (4%). There was one postoperative death (30-day mortality rate, 0.9%). The mean follow-up was 13.2 ± 7 months and was complete for 90% of the patients. At the time of telephone survey, 85 (87%) of 98 patients were free from angina, and 91 (88%) were free from cardiac-related readmission. There were three late deaths. The majority of octogenarians (66%) reported that in retrospect, they would have the operation again.

CONCLUSIONS: Off-pump multivessel revascularization in octogenarians is associated with excellent early and intermediate outcomes and provides a satisfactory quality of life.

	Introduction

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 
The elderly population in the United States is growing exponentially. It is estimated that by the year 2050, there will be 38 million octogenarians (up from 9 million in 2002) [1; unpublished tables from the Bureau of Labor Statistics]. Increasingly, government initiatives are being created in an attempt to qualify the health status, ascertain the functional limitations, and identify the morbidity and mortality of this elderly group. It is well known that 25% of octogenarians have severe functional limitations secondary to cardiovascular disease [2]. Further, cardiovascular disease has been and continues to be the number one cause of death in people more than 65 years old [3]. Many of these patients have disease refractory to medical therapy, which has led to a marked increase in the number of elderly patients referred for coronary artery revascularization. Over the last decade, numerous investigators have examined the feasibility and the efficacy of cardiac surgical intervention in this population [4–10]. Most remarkably, the preponderance of studies underscores the high-risk profile of elderly patients with their higher prevalence of comorbid events and left ventricular dysfunction and their greater severity of coronary artery disease. Several reports [4, 6, 7, 11] indicate that coronary artery revascularization can be performed with an acceptable mortality in octogenarians, and efforts are now aimed at further decreasing morbidity and mortality after coronary artery bypass grafting (CABG) in this older population.

The growing popularity of off-pump coronary artery bypass (OPCAB) has been fueled by developments in enabling technologies and by early data suggesting improved outcomes after coronary operations performed without cardiopulmonary bypass. Several comparative studies [12–17] have documented reduced transfusion requirements, shortened length of hospital stay, reduced neurologic complications, and reduced hospital costs for OPCAB recipients compared with those undergoing conventional CABG.

Octogenarian patients represent a particularly attractive target for application of OPCAB. The prevalence of comorbid events and the propensity for neurologic dysfunction place octogenarians at higher risk for cardiopulmonary bypass–induced morbidity and mortality. Nevertheless, data documenting the safety and efficacy of OPCAB in these elderly patients are scarce. Here we report our recent experience with a large series of octogenarian patients undergoing beating heart revascularization.

	Material and methods

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 
Patient group
Our prospectively (daily) updated database (CAOS; Intelligent Business Solutions, Clemmons, NC) was queried to identify all patients who underwent CABG at Newark Beth Israel Medical Center and Saint Barnabas Hospital between January 1, 1999, and July 31, 2001. A total of 1,624 were found. Of these, 911 (56%) had OPCAB procedures, and 113 of them were octogenarians. The latter represents our study group. Of note, during this period, 29 octogenarians underwent traditional CABG.

Demographics, clinical profiles, and adverse outcomes were collected. Complications were compared with The Society of Thoracic Surgeons (STS) benchmarks for all CABG patients. Follow-up was obtained by telephone interviews with patients or their referring cardiologists when the patient was unreachable. Information was gathered regarding quality-of-life indicators including anginal symptoms, subsequent hospitalizations, procedures, or both, and date and cause of death where applicable. In addition, the patients were also asked whether or not in retrospect, they would undergo the procedure again.

Operative technique
All patients underwent OPCAB under general endotracheal anesthesia. A continuous-output Swan-Ganz catheter, a transesophageal echocardiographic probe, and arterial pressure monitoring lines were placed. A thorough transesophageal echocardiographic examination was performed to assess wall motion abnormalities, presence and degree of mitral regurgitation, severity of atherosclerotic disease of the aorta, and right and left ventricular function. Major atherosclerotic disease (eg, mobile atheromas or wall thickening) of the aortic arch, descending aorta, or both prompted evaluation of the ascending aorta with an epicardial echo probe. The presence of more than 2+ mitral insufficiency precluded an off-pump procedure, and conventional cardiopulmonary bypass was undertaken with mitral valve repair. Other relative contraindications to OPCAB included extensively calcified vessels, deep intramyocardial vessels, or small (<1.5 mm) target vessels and marked cardiomegaly.

All operations were performed through a median sternotomy. Briefly, the conduits (left internal mammary artery, radial artery, or saphenous vein) were harvested, and the pericardium was opened widely. Elevation and stabilization of the heart was accomplished using four deep pericardial sutures with snare protectors. The right pleura was opened as widely as necessary. Pericardial sutures were not routinely used on the right side of the heart. In general, distal anastomoses were performed first, and the aorta was partially occluded only once. The anastomoses were done with the aid of the Octopus 2 stabilizing system (Medtronic, Inc, Minneapolis, MN). The sequence of revascularization depended on the anat-omy and the surgeon’s preference. Full systemic heparinization and complete protamine sulfate reversal were carried out in most instances. Intracoronary shunts were rarely used. No partial bypass circuits or adjunctive apical retracting devices were used.

Intraoperative Doppler graft-flow assessment (Medi-Stim Butterfly Flowmeter; Medtronic, Inc) was performed at the discretion of the operating surgeon. Transesophageal wall motion, electrocardiographic tracing, and visual and manual inspection of the grafts were all considered in the evaluation of the conduits. Flow rates of less than 15 mL/min and pulsatility indices of less than 5 usually led to immediate graft revision.

	Results

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 
One hundred thirteen consecutive octogenarians underwent OPCAB during the study period. The demographic profile and the clinical characteristics are shown in Table 1. Mean age was 83 ± 2.5 years. The majority (81%) of patients had a history of hypertension. Previous myocardial infarction, tobacco use, diabetes, and congestive heart failure were also prevalent comorbid conditions. The mean left ventricular ejection fraction was 0.51 ± 0.11, and 11% of patients had a history of a previous cerebrovascular accident (CVA). Table 1 also includes the demographic profile of the concurrent cohort of 29 patients who underwent CABG during the same period.

View larger version (11K): [in this window] [in a new window]   Fig 1. Kaplan-Meier actuarial probability of survival for 113 octogenarians who underwent off-pump coronary artery bypass grafting. Mean follow-up was 13.2 ± 7 months. (post-op = postoperative.)

	Comment

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

An extensive body of literature exists documenting the experience with conventional CABG in octogenarians. The largest study to date was conducted by Peterson and associates [18]. They surveyed the Medicare Provider Analysis and Review file and found 24,461 octogenarians who had undergone cardiac revascularization. Their study documented a 67% increase in the use of bypass operations for octogenarians across the United States. Noted were statistically significant escalations in length of stay and hospital costs and in hospital and short-term (3-year) mortality compared with younger patients (aged 65 to 70 years). The long-term mortality for patients in this population was similar to that of the general octogenarian population. Morris and colleagues [19] investigated the results of conventional CABG in 474 octogenarians. The mortality rate was 7.8%, and major morbidity included postoperative myocardial infarction (4.1%) and CVA (5.8%). Williams and colleagues [6] specifically examined determinants of mortality in octogenarians undergoing CABG. These included preoperative renal dysfunction, intraoperative intraaortic balloon pump use, and postoperative pulmonary insufficiency, renal dysfunction, and sternal wound infection. The overall mortality rate was 11%. The authors of these studies collectively suggested that CABG in octogenarians is a safe operation with acceptable mortality.

Data are scarce, however, on the use of OPCAB in octogenarians (Table 5). Ricci and colleagues [20] retrospectively reviewed the results of myocardial revascularization with and without cardiopulmonary bypass in octogenarians. Their findings indicated that the risk of CVA was obviated through the use of OPCAB, as there were no postoperative neurologic events in this group of 97 patients. The study noted that the higher incidence of postoperative complications in elderly patients undergoing coronary artery revascularization was significant compared with that in younger patients, but that elderly patients displayed a significantly higher rate of freedom from complications after OPCAB. There was a trend toward a higher mortality (10.3%) in the OPCAB cohort. Similarly, Stamou and co-workers [21] reported their experience with all patients undergoing OPCAB who were 60 years of age or older. Among their 71 octogenarians, the CVA rate was 3% compared with 1% in patients 70 through 79 years old and 0.3% in patients 60 through 69 years old. Differences in mortality rates were significant; patients 80 years old or more had a mortality rate of 6% compared with 3% and 0.3% in the 70- to 79-year-old and the 60- to 69-year-old patients, respectively. In both studies, the patient population included patients having minimally invasive direct CABG and their mean number of grafts was less than 2, which in our opinion is a different study group from that in our study.

To our knowledge, our study of 113 patients represents the largest series of octogenarians undergoing OPCAB with complete revascularization in the literature. In analyzing our results, it is worth pointing out that surgical intervention was undertaken on an urgent or emergent basis in 92 patients (81%). At our institution, urgent operations are those done within the same hospital admission because of anatomy or clinical signs or symptoms. Emergent operations are done within 24 hours of catheterization. Urgent surgical priority alone is considered an independent risk factor for morbidity in cardiac surgical patients [23, 24]. The mean number of grafts in our study was 3.3 per patient, which is commensurate with data for conventional CABG and higher than that reported in the literature with OPCAB.

The most prevalent complication in our patient population was the development of postoperative atrial fibrillation. It is well known that the overall incidence of atrial fibrillation increases incrementally with age, and this factor is multiplied in patients with coronary artery disease [25]. With the exception of atrial fibrillation, the rate of complications was very low. These results parallel the STS benchmark data for all CABG patients irrespective of age or use of cardiopulmonary bypass (see Table 3). Although not available, we presume that the morbidity in octogenarians in the STS database would likely be magnified given their higher risk profile.

Stroke is reported to occur in 1% to 9% of patients undergoing myocardial revascularization, and increasing age is reported to be the leading risk factor [16, 26]. In a 24-institution randomized trial, Roach and associates [16] found that the incidence of stroke after revascularization is approximately 6% in all patients. In this study, they noted the incidence of neurologic events in octogenarians to be approximately 8%. In the small, retrospective studies we have referenced, the general consensus is that there is a significant reduction in stroke rate after OPCAB compared with conventional revascularization with cardiopulmonary bypass [9, 19–22, 26, 27]. Our results further support these findings. A previous history of neurologic event, seen in 11% (n = 12) of our patients preoperatively, and an incidence of atrial fibrillation postoperatively, seen in 43% (n = 49) of our patients, have both been reported as independent risk factors for CVA [16], yet our postoperative stroke rate was 3.5% (4 patients).

Despite an expected high mortality, only 1 patient died in the perioperative period (0.9% mortality rate). During sternal closure, this patient was noted to have ischemic changes on the electrocardiogram and was in hemodynamically unstable condition, ultimately requiring cardiopulmonary bypass support and redo of one of the grafts. Though the patient recovered from the acute episode, she sustained a CVA later in the hospital course and died on postoperative day 33. There were only three late deaths (one cardiac related), for a 1-year mortality rate of 3.5%.

There are limited data regarding follow-up in octogenarians after OPCAB. Our early outcome analysis correlates strongly with the literature for conventional CABG in suggesting that octogenarians can lead event-free lives after this major operation. Eighty-seven percent of our patients are living free from chest pain, and only 10% required readmission for reasons related to the operation or chest pain. The best indicator of our octogenarians’ satisfaction with the surgical procedure is the fact that knowing what was involved, the majority would undergo it again.

Despite our satisfying results, the study has several limitations. It was a retrospective review, and although a randomized study comparing conventional CABG with OPCAB would be ideal, it is unlikely to occur. Serial neurologic examinations, head imaging, and formal neurocognitive evaluations were not conducted for our series of patients, and hence, minor events, eg, clinically silent strokes, could have gone unrecognized. Last, the decision to proceed with OPCAB versus conventional CABG was made solely at the discretion of the operating surgeon on the basis of anatomy and clinical findings, thus introducing the possibility of selection bias.

The results of the present study strongly suggest that off-pump multivessel revascularization in octogenarians is associated with excellent early and intermediate outcomes and provides a highly satisfactory quality of life. Although extended follow-up is mandatory to confirm these encouraging early findings, we preferentially approach all octogenarians as potential off-pump candidates. ([28, 29, 30])

	Acknowledgments

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 
We gratefully acknowledge Gladys Belarmino, RN, and Therese Evangelista, RN, for their indispensable assistance with maintenance of the CAOS database.

	References

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 

1. Health, United States: 2001; Current population reports, "Americans with disabilities, 1997," February 2001, 70–3, and related Internet data; Internet releases from the Census Bureau and the National Center for Health Statistics
2. Van Nostrand JF, Furrier SE, Suzman R. Health data on older Americans: United States; 1992. Hyattsville, MD: National Center for Health Statistics, 1993; (Vital and health statistics; Series 3; no. 27)
3. Sahyoun NR, Lentzner H, Hoyert D, Robinson KN. Trends in causes of death among the elderly. Hyattsville, MD: National Center for Health Statistics, 2001; (Aging trends; no 1)
4. Pliam M.B., Zapolanski A., Ryan C.J., Shaw R.E., Mengarelli L. Recent improvement in results of coronary bypass surgery in octogenarians. J Invasive Cardiol 1999;11:281-289.[Medline]
5. Sollano J.A., Rose E.A., Williams D.L., et al. Cost-effectiveness of coronary artery bypass surgery in octogenarians. Ann Surg 1998;228:297-306.[Medline]
6. Williams D.B., Carrillo R.G., Traad E.A., et al. Determinants of operative mortality in octogenarians undergoing coronary bypass. Ann Thorac Surg 1995;60:1038-1043.[Abstract/Free Full Text]
7. Deiwick M., Tandler R., Mollhoff T., et al. Heart surgery in patients aged eighty years and above: determinants of morbidity and mortality. Thorac Cardiovasc Surg 1997;45:119-126.[Medline]
8. Naunheim K.S., Dean P.A., Fiore A.C., et al. Cardiac surgery in the octogenarian. Eur J Cardio-thorac Surg 1990;4:130-135.[Abstract]
9. D’Ancona G., Karamanoukian H., Kawaguchi A.T., Ricci M., Salerno T.A., Bergsland J. Myocardial revascularization of the beating heart in high-risk patients. J Card Surg 2001;16:132-139.[Medline]
10. Batchelor W.B., Anstrom K.J., Muhlbaier L.H., et al. Contemporary outcome trends in the elderly undergoing percutaneous coronary interventions: results in 7,472 octogenarians. National Cardiovascular Network Collaboration. J Am Coll Cardiol 2000;36:723-730.[Abstract/Free Full Text]
11. Mullany C.J., Darling G.E., Pluth J.R., et al. Early and late results after isolated coronary artery bypass surgery in 159 patients aged 80 years and older. Circulation 1990;82(5 Suppl):IV229-IV236.
12. Hart J.C. A review of 140 Octopus off-pump bypass patients over the age of seventy: procedure of choice?. Heart Surg Forum 2001;4(Suppl 1):S24-S29.
13. Prifti E., Bonacchi M., Giunti G., et al. Does on-pump/beating-heart coronary artery bypass grafting offer better outcome in end-stage coronary artery disease patients?. J Card Surg 2000;15:403-410.[Medline]
14. Cleveland J.C., Jr, Shroyer A.L.W., Chen A.Y., Peterson E., Grover F.L. Off-pump coronary artery bypass grafting decreases risk-adjusted mortality and morbidity. Ann Thorac Surg 2001;72:1282-1289.[Abstract/Free Full Text]
15. Weintraub W.S., Craver J.M., Cohen C.L., Jones E.L., Guyton R.A. Influence of age on results of coronary artery surgery. Circulation 1991;84(Suppl 3):226-235.
16. Roach G.W., Kanchuger M., Mangano C.M., et al. Adverse cerebral outcomes after coronary bypass surgery. Multicenter Study of Perioperative Ischemia Research Group and the Ischemia Research and Education Foundation Investigators. N Engl J Med 1996;335:1857-1863.[Abstract/Free Full Text]
17. Demers P., Cartier R. Multivessel off-pump coronary artery bypass surgery in the elderly. Eur J Cardio-thorac Surg 2001;20:908-912.[Abstract/Free Full Text]
18. Peterson E.D., Cowper P.A., Jollis J.G., et al. Outcomes of coronary artery bypass graft surgery in 24,461 patients aged 80 years or older. Circulation 1995;92(9 Suppl):II85-II91.
19. Morris R.J., Strong M.D., Grunewald K.E., et al. Internal thoracic artery for coronary artery grafting in octogenarians. Ann Thorac Surg 1996;62:16-22.[Abstract/Free Full Text]
20. Ricci M., Karamanoukian H.L., Abraham R., et al. Stroke in octogenarians undergoing coronary artery surgery with and without cardiopulmonary bypass. Ann Thorac Surg 2000;69:1471-1475.[Abstract/Free Full Text]
21. Stamou S.C., Dangas G., Dullum M.K.C., et al. Beating heart surgery in octogenarians: perioperative outcome and comparison with younger age groups. Ann Thorac Surg 2000;69:1140-1145.[Abstract/Free Full Text]
22. Yokoyama T., Baumgartner F.J., Gheissari A., Capouya E.R., Panagiotides G.P., Declusin R.J. Off-pump versus on-pump coronary bypass in high-risk subgroups. Ann Thorac Surg 2000;70:1546-1550.[Abstract/Free Full Text]
23. Gersh B.J., Kronmal R.A., Frye R.L., et al. Coronary arteriography and coronary artery bypass surgery: morbidity and mortality in patients ages 65 years or older. A report from the Coronary Artery Surgery Study. Circulation 1983;67:483-491.[Abstract/Free Full Text]
24. Hirose H., Amano A., Takahashi A. Coronary artery bypass grafting for octogenarians: experience in a private hospital and review of the literature. Ann Thorac Cardiovasc Surg 2001;7:282-291.[Medline]
25. Aranki S.F., Shaw D.P., Adams D.H., et al. Predictors of atrial fibrillation after coronary artery surgery. Current trends and impact on hospital resources. Circulation 1997;96:2084-2085.
26. Gardner T.J., Horneffer P.J., Manolio T.A., Hoff S.J., Pearson T.A. Major stroke after coronary artery bypass surgery: changing magnitude of the problem. J Vasc Surg 1986;3:684-687.[Medline]
27. Koutlas T.C., Elbeery J.R., Williams J.M., Moran J.F., Francalancia N.A., Chitwood W.R., Jr Myocardial revascularization in the elderly using beating heart coronary artery bypass surgery. Ann Thorac Surg 2000;69:1042-1047.[Abstract/Free Full Text]
28. Creswell L.L., Schuessler R.B., Rosenbloom M., Cox J.L. Hazards of postoperative atrial arrhythmias. Ann Thorac Surg 1993;56:539-549.[Abstract]
29. Tasdemir O., Vural K.M., Karagoz H., Bayazit K. Coronary artery bypass grafting on the beating heart without the use of extracorporeal circulation: review of 2052 cases. J Thorac Cardiovasc Surg 1998;116:68-73.[Abstract/Free Full Text]
30. Benetti F.J., Naselli G., Wood M. Direct myocardial revascularization without extracorporeal circulation: experience in 700 patients. Chest 1991;100:312-316.[Abstract/Free Full Text]

This article has been cited by other articles:

				L. J. Dacey, D. S. Likosky, T. J. Ryan Jr, J. F. Robb, R. D. Quinn, J. T. DeVries, M. J. Hearne, B. J. Leavitt, R. F. Dunton, R. A. Clough, et al. Long-Term Survival After Surgery Versus Percutaneous Intervention in Octogenarians With Multivessel Coronary Disease Ann. Thorac. Surg., December 1, 2007; 84(6): 1904 - 1911. [Abstract] [Full Text] [PDF]

				Y. Gerber, C. S. Rihal, T. M. Sundt III, J. M. Killian, S. A. Weston, T. M. Therneau, and V. L. Roger Coronary Revascularization in the Community: A Population-Based Study, 1990 to 2004 J. Am. Coll. Cardiol., September 25, 2007; 50(13): 1223 - 1229. [Abstract] [Full Text] [PDF]

				P. Y. Etienne, S. Papadatos, D. Glineur, Y. Mairy, E. El Khoury, P. Noirhomme, and G. El Khoury Reduced Mortality in High-Risk Coronary Patients Operated Off Pump With Preoperative Intraaortic Balloon Counterpulsation Ann. Thorac. Surg., August 1, 2007; 84(2): 498 - 502. [Abstract] [Full Text] [PDF]

				M. Basaran, O. Selimoglu, H. Ozcan, H. Ogus, E. Kafali, C. Ozcelebi, and T. N. Ogus Being an elderly woman: is it a risk factor for morbidity after coronary artery bypass surgery? Eur. J. Cardiothorac. Surg., July 1, 2007; 32(1): 58 - 64. [Abstract] [Full Text] [PDF]

				S S Panesar, T Athanasiou, S Nair, C Rao, C Jones, M Nicolaou, and A Darzi Early outcomes in the elderly: a meta-analysis of 4921 patients undergoing coronary artery bypass grafting--comparison between off-pump and on-pump techniques Heart, December 1, 2006; 92(12): 1808 - 1816. [Abstract] [Full Text] [PDF]

				K. Matsuura, J. Kobayashi, O. Tagusari, K. Bando, K. Niwaya, H. Nakajima, T. Yagihara, and S. Kitamura Off-Pump Coronary Artery Bypass Grafting Using Only Arterial Grafts in Elderly Patients Ann. Thorac. Surg., July 1, 2005; 80(1): 144 - 148. [Abstract] [Full Text] [PDF]

				T. Suzuki, M. Okabe, M. Handa, F. Yasuda, and Y. Miyake Usefulness of preoperative intraaortic balloon pump therapy during off-pump coronary artery bypass grafting in high-risk patients Ann. Thorac. Surg., June 1, 2004; 77(6): 2056 - 2059. [Abstract] [Full Text] [PDF]

				T. Athanasiou, O. Aziz, O. Mangoush, A. Weerasinghe, S. Al-Ruzzeh, S. Purkayastha, J. Pepper, M. Amrani, B. Glenville, and R. Casula Do off-pump techniques reduce the incidence of postoperative atrial fibrillation in elderly patients undergoing coronary artery bypass grafting? Ann. Thorac. Surg., May 1, 2004; 77(5): 1567 - 1574. [Abstract] [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): Daniel J. Goldstein Frederic F. Sardari Ravindra Karanam Paul G. Burns Craig R. Saunders Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Beauford, R. B. Articles by Saunders, C. R. Search for Related Content PubMed PubMed Citation Articles by Beauford, R. B. Articles by Saunders, C. R. Related Collections Coronary disease