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Ann Thorac Surg 2003;76:18-26
© 2003 The Society of Thoracic Surgeons
a Department of Surgery, University of Hawaii School of Medicine, Honolulu, Hawaii, USA
b Department of Surgery, St. Francis Medical Center, Honolulu, Hawaii, USA
c Department of Nuclear Medicine, St. Francis Medical Center, Honolulu, Hawaii, USA
d Department of Neurology, St. Francis Medical Center, Honolulu, Hawaii, USA
e Department of Cardiology, St. Francis Medical Center, Honolulu, Hawaii, USA
f Department of Psychiatry and Psychology, Straub Clinic and Hospital, Honolulu, Hawaii, USA
g Pacific Health Research Institute, Honolulu, Hawaii, USA
* Address reprint requests to Dr Lee, University of Hawaii School of Medicine, 1329 Lusitana Street, Suite 109, Honolulu, HI 96813, USA.
e-mail: jdl{at}heartsurgery-hawaii.com
Presented at the Forty-ninth Annual Meeting of the Southern Thoracic Surgical Association, Miami Beach, FL, Nov 7–9, 2002.
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Abstract |
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METHODS: Sixty patients (30 CABG and 30 OPCAB) were prospectively randomized. Neurocognitive testing was performed before the operation and 2 weeks and 1 year after the operation. Neurologic testing to detect stroke and 99mTc-HMPAO whole-brain single photon emission computed tomography scanning to assess cerebral perfusion were performed before the operation and 3 days afterward. Bilateral middle cerebral artery transcranial Doppler scanning was performed intraoperatively to detect cerebral microemboli. All examiners were blinded to treatment group. Clinical morbidity and costs were compared.
RESULTS: Coronary artery bypass grafting was associated with more cerebral microemboli (575 ± 278.5 CABG versus 16.0 ± 19.5 OPCAB (median ± semiinterquartile range) and significantly reduced cerebral perfusion after the operation to the bilateral occipital, cerebellar, precunei, thalami, and left temporal lobes (p 
0.01). Cerebral perfusion with OPCAB was unchanged. Compared with base line, OPCAB patients performed better on the Rey Auditory Verbal Learning Test (total and recognition scores) at both 2 weeks and at 1 year (p 0.05), whereas CABG performance was statistically unchanged for all cognitive measures. Patients who underwent CABG had more chest tube drainage (1389 ± 1256 mL CABG versus 789 ± 586 mL OPCAB, p = 0.02) and required more blood (3.9 ± 5.8 U CABG versus 1.2 ± 2.2 U OPCAB, p = 0.02), fresh frozen plasma (3.0 ± 6.0 U CABG versus 0.5 ± 2.2 U OPCAB, p = 0.03), and hours of postoperative use of dopamine (16.3 ± 21.2 hours CABG versus 7.3 ± 9.7 hours OPCAB, p = 0.04). These differences culminated in higher costs for CABG ($23,053 ± $5,320 CABG versus $17,780 ± $4,390 OPCAB, p < 0.0001). One stroke occurred with CABG, compared with none with OPCAB (p = NS). One OPCAB patient died because of a pulmonary embolus (p = NS).
CONCLUSIONS: Compared with CABG, OPCAB may reduce neurologic and clinical morbidity as well as cost.
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Introduction |
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In a longitudinal study, neurocognitive decline was identified in 53% of CABG patients at discharge, 36% at 6 weeks, and 24% at 6 months. At 5 years, 42% had developed evidence of significant cognitive decline [2].
Cardiopulmonary bypass (CPB) has long been considered to be a major factor in the development of post-CABG morbidity [3]. Nonpulsatile low-pressure flow during CPB may induce cerebral edema and cortical cerebral oxygen desaturation [4, 5]. Manipulation of the elderly aorta may cause microembolization of atheromatous debris to the brain. Off-pump coronary artery bypass (OPCAB) avoids the use of CPB entirely. In this prospective randomized trial comparing OPCAB with CABG, we compared rates of cerebral microemboli, brain perfusion, neurologic and neurocognitive function, clinical morbidity, and cost.
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Material and methods |
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2.0 mg/dL); they also had to be able to undergo either procedure safely in the opinion of the surgeon. Candidates for study inclusion were asked if they were interested in participating at the time of their initial evaluation. The study design was explained and informed written consent was obtained. Sealed envelope randomization to CABG or OPCAB was then performed on the day of surgery. The same two surgeons (J.D.L., C.R.D.), each of whom had performed more than 100 OPCAB procedures before the beginning of the study, performed all surgical procedures. All examiners were blinded to the procedure performed.
Neurologic testing
Patients were examined by the same board-certified neurologist before and 3 days after the operation. The presence or absence of a new clinical stroke was determined and scored using a modified National Institutes of Health stroke scale.
Neurocognitive testing
We used the recommended core neuropsychological battery according to the 1994 Conference on CNS Dysfunction After Cardiac Surgery [6] with some additional assessment instruments (Table 1).
Testing was administered before the operation and 2 weeks and 1 year after the operation.
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Whole-brain single photon emission computed tomography scanning
Whole-brain single photon emission computed tomography (SPECT) scans were performed with 20 mCi 99mTc-HMPAO (Ceretec, Nycomed Amersham, Princeton, NJ) before and 3 days after the operation. For the SPECT scan, patients were supine with eyes open in a quiet room. Sixty minutes after the injection the patient was scanned on a dual-head SPECT camera (Vertex, ADAC Laboratories, Milipitas, CA) using low-energy high-resolution collimators. Single photon emission computed tomography images were obtained for 30 seconds per angle for 128 total projections and a 128 x 128 matrix. Axial images were aligned with the canthomeatal line. The SPECT reconstruction was done with a filtered back projection and a Butterworth filter frequency cut-off of 0.25, and an order of 5. Attenuation correction was done by Chang’s method. In addition, rather than using a subjective region of interest method of analysis, an objective voxel-based computerized method of analysis was used, Statistical Parametric Mapping 96 for Windows (SPM96-Wellcome Department of Cognitive Neurology, London, England). Each scan was spatially normalized to a standard brain in three dimensions followed by smoothing. Each group’s preoperative and postoperative images were then compared using analysis of variance at each voxel, which produced statistical parametric maps. Voxels with significantly reduced postoperative SPECT activity (p 0.01) were displayed in the composite image for each group. Preoperative scans of both groups were also compared. Anatomic regions of significantly reduced cerebral blood flow were identified by use of Talairach mapping of the composite brain images [7].
Surgical technique and management
Coronary artery bypass grafting was performed using standard CPB technique with mild hypothermia. Cardiac arrest was achieved with both antegrade and retrograde cold blood potassium cardioplegia. An open perfusion circuit consisting of a Cobe blood pump and Cobe Duo membrane oxygenator with a 40-µm Cobe Century arterial line filter (Cobe Cardiovascular Inc, Arvada, CO) was used. Flow rates were maintained at 1.8 to 2.4 L · min-1 · m-2, with a mean perfusion pressure of 60 mm Hg. Perfusion pressure was maintained primarily by regulating pump flow. The proximal anastomoses were sewn after removal of the aortic cross-clamp using a partial occlusion clamp.
Off-pump coronary artery bypass was performed through median sternotomy. Distal anastomoses were performed utilizing a Guidant Access Ultima stabilizer (Guidant Corporation, Santa Clara, CA). Proximal anastomoses were sewn to the aorta using a partial occlusion clamp. Anesthesia was provided in a consistent manner for both CABG and OPCAB patients as described previously [8]. All patients were "fast tracked" and extubation in the operating suite was attempted on all patients. Blood and blood products were transfused using uniform transfusion criteria. Transfusion of blood was allowed only when the serum hematocrit dropped below 25%. Fresh frozen plasma transfusion required documented abnormal coagulation measurements (>1.5 times control) and clinical bleeding. Chest tube drainage and hours of postoperative use of dopamine were compared as well.
Analysis of cost
All hospital costs from the date of surgery through the date of discharge were categorized by department, using the hospital computer database. Direct cost for each patient was calculated and included in the analysis. This cost included all patient services and supplies. Indirect hospital administration, building, and maintenance costs were excluded.
Statistical analysis
Statistical analysis was performed with the Statistical Package for the Social Sciences software (SPSS/PC+; Chicago, IL). All continuous variables are given as mean ± SD. Categorical variables are expressed as percent of those exhibiting the trait among all patients for whom data were available. All p values are two-tailed, and a p value 0.05 was considered statistically significant. Cognitive decline was assessed using two models. The 20:20 model used the presence of a 20% decline in 20% of the tests performed as one measure of cognitive decline. The multivariate analysis of variance used a repeated-measures model that compared within-subject differences between each time point, that is, preoperative versus 2 weeks postoperative versus 1 year postoperative for two groups (CABG and OPCAB). Cerebral microemboli are presented as median ± semiinterquartile range (SIR) unless otherwise specified.
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Results |
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Transcranial doppler
Bilateral monitoring was successful in 29 of 30 OPCAB patients (97%) and 28 of 30 CABG patients (93%). Inability to obtain a reliable bilateral signal was the reason for unilateral monitoring. Being nonparametric in nature, all cerebral microemboli data are presented as median ± SIR without a p value unless otherwise specified. A substantial reduction in discrete cerebral microemboli was seen in the OPCAB group (575 ± 278.5 CABG versus 16.0 ± 19.5 OPCAB) (Fig 1).
The pattern of microemboli release with CABG revealed the majority (473 ± 270, 82%) of cerebral microemboli were associated with the performance of CPB alone, without association to any surgical maneuver (Fig 2).
The second highest locus of emboli (46 ± 44.6, 8.0%) was with placement of the partial occlusion clamp onto the aorta. Other surgical events in order of mean frequency of microemboli release (expressed as mean ± SD or median ± SIR) were aortic cross-clamp release (14.8 ± 51.8 or 0 ± 1.4), termination of CPB (14.7 ± 53.5 or 0 ± 1.6), aortic cannulation (11.2 ± 20.5 or 6 ± 4.5), aortic partial occlusion clamp release (4.9 ± 12.7 or 1 ± 1.9), aortic decannulation (2.1 ± 7.7 or 0 ± 0), aortic cross-clamping (1.7 ± 4.1 or 0 ± 1), and inception of CPB (0.7 ± 1.5 or 0 ± 0.5). A slight left-sided predominance of microemboli was noted with CABG (left, 295.2 ± 173.5; right, 235 ± 128).
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Single photon emission computed tomography scanning
Twenty-nine patients in each group (97%) completed preoperative and postoperative brain scanning. One patient in each group declined repeat postoperative testing. The actual number of days for completion of the "3-day" follow-up was 4.3 ± 4.0 days for CABG patients compared with 3.4 ± 1.8 days for OPCAB patients (p = NS). Using a voxel-based computerized method of analysis of the two groups, no significant differences were found between the base line studies of the two groups. However, CABG postoperative brain perfusion was significantly reduced compared with base line, to the bilateral occipital and cerebellar lobes, both precunei and thalami, and the left temporal lobe (p 0.01) (Fig 3).
Individually, these brain perfusion deficits were observed to be both regional and scattered multifocal in distribution (Fig 4).
Conversely, OPCAB postoperative brain perfusion was statistically unchanged from base line. The OPCAB group specifically did not show the decreased posterior and left temporal brain SPECT activity pattern demonstrated by the CABG group (data not shown). Postoperatively, neither group had areas of significantly increased SPECT activity.
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0.05). Significant improvement was also observed in the Anxiety State scores in both groups at both testing intervals (p 0.05).
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Neurologic testing
A new minor stroke was detected in 1 CABG patient. This patient exhibited a new left-sided motor drift. The SPECT brain scan of this patient was not significantly different from that of other CABG patients. This deficit was considered to be consistent with a possible embolic or lacunar infarct. The patient was eventually discharged to a rehabilitation facility because of an overall debilitated state and did not complete neurocognitive follow-up at either 2 weeks or 1 year (declined follow-up). No strokes were identified in any OPCAB patient (p = NS).
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Comment |
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Despite blinded envelope randomization and no crossover participants, the OPCAB group had fewer grafts performed at surgery (3.1 ± 0.7 OPCAB versus 3.6 ± 0.9 CABG, p = 0.02), a finding that has been reported by others [8–11]. It is possible that participants selected for CABG had more severe coronary artery disease than participants selected for OPCAB by chance. Alternatively, OPCAB surgical technique might have had some degree of technical limitation. Nevertheless, circumflex distribution grafts were performed in 85% of CABG and 83% of OPCAB patients, respectively (p = NS). Subjectively, in the short-term, we have not observed any increase in recurrent angina or interval infarction with OPCAB. Objective longer-term data regarding these important end points will require further study.
The substantial reduction in cerebral microemboli observed with the OPCAB technique is an important finding. We had previously reported similar results in a nonrandomized sample of consecutive patients [8]. Although the nature of these cerebral microemboli remains undetermined, and may include air bubbles, calcific particles, fibroelastoma tissue, platelet fibrin, fat particles, or other atheromatous debris [11], the reduction in embolic load is clear and irrefutable in the OPCAB group.
Analysis of the pattern of microemboli release was interesting (Fig 2). Barbut and coworkers [12] performed intraoperative right-sided TCD in 20 CABG patients. In their experience, aortic cross-clamp release and aortic partial occlusion clamp release were responsible for 58% of total microemboli released. In contrast, using bilateral TCD monitoring, we found only 2.6% of microemboli were associated with these maneuvers. This stark difference may be partially explained by our current practice of vigorous air removal from the ascending aorta before clamp release. Although both studies were performed blinded to TCD findings, our previous experience [8] had clearly demonstrated that large numbers of microemboli were released when vigorous air removal was not performed. Therefore, we believe that when vigorous de-airing techniques are not utilized, many of the embolic signals associated with these maneuvers may be largely composed of air. In contrast, we detected the vast majority (473 ± 270, 82%) of microemboli without association to any surgical maneuver. These microemboli were associated with simply being on CPB.
What effect, if any, these particles may have on early postoperative brain perfusion and on early and late cognitive function remains undetermined. Since functional imaging may be more sensitive than structural imaging in the detection of organic brain dysfunction, we compared preoperative and postoperative whole-brain SPECT activity. 99mTc-HMPAO cerebral uptake is an indicator of regional physiologic activity. While Anderson and associates [4], using MRI, reported increased overall extracellular brain water and swelling after CPB with no focal structural changes, our findings in this functional study indicate that specific regions of the brain are significantly altered following CABG. Significantly reduced perfusion (p 0.01) to the bilateral occipital, cerebellar, precunei, thalami, and left temporal lobe was clearly evident (Fig 3). In contrast, no significant change in brain perfusion was detected in patients undergoing OPCAB.
Cerebral microemboli to watershed zones may be especially significant. The predominantly bilateral posterior involvement observed on 99mTc-HMPAO SPECT perfusion scans in CABG patients suggests an inherent special vulnerability of these regions to systemic hypotension and microemboli [13]. Pollanen [14] perfused the brains of cadavers with glass microspheres of 90 to 210 micron size and documented that larger particles of 150 to 210 micron size preferentially concentrate in watershed zones. Preferential pooling of larger embolic particles and relatively poorer perfusion of these watershed zones limiting the ability to clear these particles, may lead to regional zones of hypoperfusion [14]. Left unchecked, these areas may manifest as stroke. In one series of 19 CABG patients who suffered early postoperative stroke, 79% had bilateral cerebellar infarcts, 74% posterior cerebral infarcts, 53% posterior watershed infarcts, and 58% had middle cerebral artery infarcts [15]. No information is available on the microembolic burden delivered to the posterior brain, which is supplied by the vertebral basilar system.
The design and placement of the ascending aortic cannula used during CPB may cause preferential streaming of debris into the left brain, suggested by the predominance of left-sided hemispheric strokes after CABG [16]. Our finding of a greater number of microemboli going to the left brain (left 295.2 ± 173.5, right 235 ± 128) with reduced early perfusion to the left temporal lobe in CABG, may correlate with this left-sided clinical stroke predominance.
Van Dijk and associates [17] recently reported the cognitive outcomes of patients randomized to CABG and OPCAB. Using a categorical definition of cognitive decline as a 20% decline in 20% of neurocognitive tests performed, they found relatively similar declines at 3 months (29% CABG versus 21% OPCAB, p = NS) and 12 months (33.6% CABG versus 30.8% OPCAB, p = NS). Using the same criteria, our results were consistent with similar levels of cognitive decline in the 2 groups over time. At 2 weeks cognitive decline was present in 15.4% of CABG patients compared with 16.1% OPCAB patients (p = NS), and at 1 year 14.8% CABG versus 18.5% OPCAB (p = NS).
We believe, however, that a multivariate analysis of variance may offer a more sensitive method of analysis. Compared with base line, OPCAB patients obtained better RAVLT, Total and Recognition scores at both 2 weeks and 1 year postoperatively. Although the CABG group did not decline significantly in performance, they also did not show the same pattern of improved performance with repeated testing on the RAVLT. Improved performance with repeated testing may be attributable to learning [18]. One interpretation of these data may be that the lack of improved performance on the RAVLT over time, in the CABG group, may represent a relative cognitive decline or a deficit in the ability to learn the RAVLT. At base line, education levels in the two groups were comparable (13.0 ± 2.1 years of education CABG versus 11.7 ± 3.3 years of education OPCAB, p = NS) and do not explain this difference.
It should be emphasized that the statistically significant differences detected in cognitive performance between the two groups using a multivariate analysis were modest and the clinical significance of these small differences is unknown. While caution should be used in interpreting these data until they have been validated by larger prospective randomized trials, these results lead to some interesting speculations.
We have observed significantly reduced perfusion to the left temporal lobe and posterior brain in the CABG group (p 0.01) (Fig 3). As the (dominant) left temporal lobe is essential in processing auditory input, verbal learning, and memory [19], this brain region is important for managing tasks such as the RAVLT. This fact suggests a biologically plausible explanation for the subtle changes in cognitive function detected in the CABG group. Reduced left temporal lobe perfusion may underlie the relatively poorer performance on the RAVLT in those patients undergoing CABG. Further study in this area is warranted.
In summary, CABG is associated with several hundred cerebral microemboli, reduced early perfusion to the left temporal lobe and posterior brain, and relatively poorer performance on the RAVLT, Total and Recognition cognitive tests. The OPCAB group had few cerebral microemboli, preserved early brain perfusion, and improved performance on the RAVLT, Total and Recognition cognitive tests at both 2 weeks and 1 year. These findings lend support to the hypothesis that OPCAB may be less injurious to the neurologic system than CABG.
The importance of minimizing perioperative neurologic injury should not be underestimated. Among the 42% of CABG patients who developed late cognitive decline [2], the main risk factor associated with this condition was early cognitive decline. As perioperative injury likely plays a key role in early cognitive decline, reducing intraoperative cerebral microemboli and preserving brain perfusion in the immediate postoperative period may be important strategies for preserving brain function in the long term for patients requiring cardiac surgical procedures.
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Discussion |
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We have found that experimental animals exposed to cardiopulmonary bypass have decreased perfusion to the occipital lobes. I think the mechanisms are obscure for a global reduction of brain blood flow in this area. What are your thoughts about the mechanism for this global reduction of blood flow? We could understand that if you have a microembolus you might have a small area showing hypoperfusion.
I would like to ask you if phenylephine hydrochloride was used in the operating room to increase blood pressure and increase peripheral resistance? Could this strategy help?
I would like to hear you tell us about what measures you used to decrease aortic manipulation in your on-pump patients, what measures you used to reduce other forms of microembolism, such as fat and air; for example, reduction in the use of cardiotomy suction and absolute elimination of entrance of air into the venous circulation.
I want to congratulate you again on a fine presentation.
DR LEE: Thank you for your very important questions. We feel that the mechanisms underlying the predominantly posterior regional hypoperfusion may be related to two factors. The first is the cerebral microemboli observed during cardiopulmonary bypass. The second may be the fact that this area of the brain is partially a watershed zone, an area of reduced perfusion where the cerebral end arteries meet. We suspect these factors may have real clinical significance, since the majority of patients who develop a stroke after cardiac surgery have cerebellar and posterior cerebral infarcts.
This watershed region of the brain is known to be a vulnerable area and exposure to the relatively low-flow, low-pressure state during cardiopulmonary bypass could make clearing cerebral microemboli to the posterior brain especially difficult.
Regarding use of Neosynephrine, I do not have that data. Hopefully, these variables would be controlled for in a randomized prospective trial.
Regarding techniques to reduce cerebral microemboli, we have been able to use the data from this study to improve our current surgical methods significantly. We are now using a newer type of aortic cannula for on-pump procedures. This is a dispersion cannula. Early results showing less cerebral microemboli generated during surgery have been encouraging. In cases where the patient has significant atherosclerosis and needs to be placed on cardiopulmonary bypass, as in a valve procedure, we wrap the aortic cannula around the ascending aorta so that the flow of debris will tend to be downstream to the lower extremities rather than into the brain. Importantly, minimal use of cardiotomy suction has been shown by others to reduce cerebral microemboli to the brain.
DR JOHN H. CALHOON (San Antonio, TX): Doctor Lee, what a nice presentation with some really elegant slides and nice demonstration of your studies. I have a few concerns along the lines of Dr Hammon.
First, blood use in your cases was extremely high, in my opinion, with almost 4 units of red cells and 3 units of fresh frozen plasma in your on-pump patients. Let me again point out a concern with not only your study but every study that is published today about on-pump versus OPCAB, and that is, most articles do not specify how the bypass is performed. Also, as Dr Hammon discussed, what are you doing with the shed blood? Do you have a routine? Did all 30 patients who were on-pump undergo the cell-saving device, not using the cardiotomy sucker, possibly not using any of the blood at the time of the sternotomy? What type of filters are you using and how do you avoid aortic injuries? I would like to see some consensus for authors to make the same kind of effort to describe their on-pump techniques that you do to describe your off-pump techniques.
And finally, just as the quality of coronary revascularization is evaluated after the operation, I would like to see the same level of scrutiny applied at 5 years or 10 years to determine if the grafts performed off-pump are doing as good a job as grafts implanted on-pump.
Thank you again for an excellent study.
DR LEE: Thank you for your questions. The amounts of blood and FFP used in the CABG group are expressed as the mean number of units transfused. However, the percent of patients who received blood products (blood: CABG 53% versus OPCAB 36% and FFP: CABG 30% versus OPCAB 7%) is similar to rates of transfusions reported by others. Two factors may have affected the amount of blood products used in our patients. The patients were recruited from the clinical practices of two cardiothoracic surgeons: my partners’ and my own. Currently, almost all patients are referred on high doses of aspirin or Plavix, and often both. It is likely that although these agents were stopped prior to surgery they continued to have some effects on blood loss. Additionally, our patient population is predominantly Asian. Asians typically have a smaller body frame, lower body weight, and accordingly lower red cell volume.
We use a 40-micron filter and membrane oxygenators. In the manuscript, our complete cardiopulmonary bypass technique is fully described.
A study of the long-term quality of bypass grafts performed using the different techniques is an excellent idea. Our study was not designed to evaluate graft patency, but in our experience graft quality is excellent, and there have not been any significant clinical differences in long-term outcome between the two procedures.
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 A. J. Rastan, J. I. Eckenstein, B. Hentschel, A. K. Funkat, J. F. Gummert, N. Doll, T. Walther, V. Falk, and F. W. Mohr Emergency Coronary Artery Bypass Graft Surgery for Acute Coronary Syndrome: Beating Heart Versus Conventional Cardioplegic Cardiac Arrest Strategies Circulation, July 4, 2006; 114(1_suppl): I-477 - I-485. [Abstract] [Full Text] [PDF]
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B. O. Jensen, P. Hughes, L. S. Rasmussen, P. U. Pedersen, and D. A. Steinbruchel Cognitive Outcomes in Elderly High-Risk Patients After Off-Pump Versus Conventional Coronary Artery Bypass Grafting: A Randomized Trial Circulation, June 20, 2006; 113(24): 2790 - 2795. [Abstract] [Full Text] [PDF]
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 S. Al-Ruzzeh, S. George, M. Bustami, J. Wray, C. Ilsley, T. Athanasiou, and M. Amrani Effect of off-pump coronary artery bypass surgery on clinical, angiographic, neurocognitive, and quality of life outcomes: randomised controlled trial BMJ, June 10, 2006; 332(7554): 1365. [Abstract] [Full Text] [PDF]
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 G. N. Djaiani Aortic arch atheroma: stroke reduction in cardiac surgical patients. Seminars in Cardiothoracic and Vascular Anesthesia, June 1, 2006; 10(2): 143 - 157. [Abstract] [PDF]
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C. S. Ernest, M. U.C. Worcester, J. Tatoulis, P. C. Elliott, B. M. Murphy, R. O. Higgins, M. R. Le Grande, and A. J. Goble Neurocognitive Outcomes in Off-Pump Versus On-Pump Bypass Surgery: A Randomized Controlled Trial Ann. Thorac. Surg., June 1, 2006; 81(6): 2105 - 2114. [Abstract] [Full Text] [PDF]
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J. M. Brown, R. S. Poston, J. S. Gammie, M. G. Cardarelli, K. Schwartz, J. A. H. Sikora, S. Yi, R. N. Pierson III, and B. P. Griffith Off-Pump Versus On-Pump Coronary Artery Bypass Grafting in Consecutive Patients: Decision-Making Algorithm and Outcomes Ann. Thorac. Surg., February 1, 2006; 81(2): 555 - 561. [Abstract] [Full Text] [PDF]
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V. L. Babikian and P. A. Wolf Retinal and Cerebral Microembolism During On-Pump and Off-Pump Coronary Artery Bypass Graft Surgery Circulation, December 20, 2005; 112(25): 3816 - 3817. [Full Text] [PDF]
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C. Lund, K. Sundet, B. Tennoe, P. K. Hol, K. A. Rein, E. Fosse, and D. Russell Cerebral Ischemic Injury and Cognitive Impairment After Off-Pump and On-Pump Coronary Artery Bypass Grafting Surgery Ann. Thorac. Surg., December 1, 2005; 80(6): 2126 - 2131. [Abstract] [Full Text] [PDF]
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V. Tomic, S. Russwurm, E. Moller, R.A. Claus, M. Blaess, F. Brunkhorst, M. Bruegel, K. Bode, F. Bloos, J. Wippermann, et al. Transcriptomic and Proteomic Patterns of Systemic Inflammation in On-Pump and Off-Pump Coronary Artery Bypass Grafting Circulation, November 8, 2005; 112(19): 2912 - 2920. [Abstract] [Full Text] [PDF]
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 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]
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F. W. Sellke, J. M. DiMaio, L. R. Caplan, T. B. Ferguson, T. J. Gardner, L. F. Hiratzka, E. M. Isselbacher, B. W. Lytle, M. J. Mack, J. M. Murkin, et al. Comparing On-Pump and Off-Pump Coronary Artery Bypass Grafting: Numerous Studies but Few Conclusions: A Scientific Statement From the American Heart Association Council on Cardiovascular Surgery and Anesthesia in Collaboration With the Interdisciplinary Working Group on Quality of Care and Outcomes Research Circulation, May 31, 2005; 111(21): 2858 - 2864. [Abstract] [Full Text] [PDF]
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Y. Abu-Omar, P. M. Matthews, and D. P. Taggart Reply to the Editor J. Thorac. Cardiovasc. Surg., May 1, 2005; 129(5): 1194 - 1195. [Full Text] [PDF]
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O. A. Selnes Do Off-Pump Surgical Procedures Really Improve Memory? Ann. Thorac. Surg., April 1, 2005; 79(4): 1462 - 1462. [Full Text] [PDF]
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J. D. Lee, S. J. Lee, W. T. Tsushima, W. T. Lau, D. Johnson, H. Petrovitch, and C. R. Dang Do Off-Pump Surgical Procedures Really Improve Memory? Reply Ann. Thorac. Surg., April 1, 2005; 79(4): 1462 - 1462. [Full Text] [PDF]
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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]
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D. Bainbridge, J. Martin, and D. Cheng Off Pump Coronary Artery Bypass Graft Surgery Versus Conventional Coronary Artery Bypass Graft Surgery: A Systematic Review of the Literature Seminars in Cardiothoracic and Vascular Anesthesia, March 1, 2005; 9(1): 105 - 111. [Abstract] [PDF]
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P. Boivie, C. Edstrom, and K. G. Engstrom Side differences in cerebrovascular accidents after cardiac surgery: A statistical analysis of neurologic symptoms and possible implications for anatomic mechanisms of aortic particle embolization J. Thorac. Cardiovasc. Surg., March 1, 2005; 129(3): 591 - 598. [Abstract] [Full Text] [PDF]
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 T. M. Hemmerling, J.-F. Olivier, F. Basile, N. Le, and I. Prieto Bispectral Index as an Indicator of Cerebral Hypoperfusion During Off-Pump Coronary Artery Bypass Grafting Anesth. Analg., February 1, 2005; 100(2): 354 - 356. [Abstract] [Full Text] [PDF]
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S. G. Raja, A. A. Behranwala, and J. Dunning Does off-pump coronary artery surgery reduce the incidence of postoperative atrial fibrillation? Interactive CardioVascular and Thoracic Surgery, December 1, 2004; 3(4): 647 - 652. [Abstract] [Full Text] [PDF]
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W. T. Mahle, K. Lundine, K. R. Kanter, J. M. Forbess, P. Kirshbom, S. R. Tosone, and R. N. Vincent The short term effects of cardiopulmonary bypass on neurologic function in children and young adults Eur. J. Cardiothorac. Surg., November 1, 2004; 26(5): 920 - 925. [Abstract] [Full Text] [PDF]
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R. Motallebzadeh and M. Jahangiri Benefits of off-pump bypass on neurologic function Ann. Thorac. Surg., September 1, 2004; 78(3): 1131 - 1132. [Full Text] [PDF]
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G. J.M.G. van der Heijden, H. M. Nathoe, E. W.L. Jansen, and D. E. Grobbee Meta-analysis on the effect of off-pump coronary bypass surgery Eur. J. Cardiothorac. Surg., July 1, 2004; 26(1): 81 - 84. [Abstract] [Full Text] [PDF]
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 J. D. Puskas, W. H. Williams, E. M. Mahoney, P. R. Huber, P. C. Block, P. G. Duke, J. R. Staples, K. E. Glas, J. J. Marshall, M. E. Leimbach, et al. Off-Pump vs Conventional Coronary Artery Bypass Grafting: Early and 1-Year Graft Patency, Cost, and Quality-of-Life Outcomes: A Randomized Trial JAMA, April 21, 2004; 291(15): 1841 - 1849. [Abstract] [Full Text] [PDF]
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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]
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 K. G. Engstrom Contaminating fat in pericardial suction blood: a clinical, technical and scientific challenge Perfusion, January 1, 2004; 19(1_suppl): S21 - S31. [Abstract] [PDF]
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