ATS
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Massimo A. Mariani
Jan G. Grandjean
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Mariani, M. A.
Right arrow Articles by Grandjean, J. G.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Mariani, M. A.
Right arrow Articles by Grandjean, J. G.
Related Collections
Right arrow Coronary disease

Ann Thorac Surg 2004;78:1591-1597
© 2004 The Society of Thoracic Surgeons

Original article: cardiovascular

Total Arterial Off-Pump Coronary Surgery: Time to Change Our Habits?

Massimo A. Mariani, MD, PhDa,*, Alessandro D'Alfonso, MDa, Jan G. Grandjean, MD, PhDa

a Department of Cardiothoracic Surgery, University Hospital of Pisa, Pisa, Italy

Accepted for publication April 21, 2004.

* Address reprint requests to Dr Mariani, Department of Cardiothoracic Surgery, Ospedale Cisanello, Via Paradisa, 2, I-56124 Pisa, Italy
massimo_mariani{at}hotmail.com


   Abstract
Top
 Abstract
Introduction
 Patients and Methods
 Results
 Comment
 Appendix 1
 References
 
BACKGROUND: This was a single-institutional study about total arterial myocardial off-pump coronary artery bypass grafting (OPCAB) surgery.

METHODS: We studied 569 multivessel coronary artery bypass patients who underwent total arterial OPCAB (42.7% of total OPCAB and 42.4% of total coronary artery bypass grafting operations) between June 2000 and June 2003. Risk profile was moderate to high, with a mean logistic EuroSCORE of 6.2 ± 5.1. Univariate and multivariate analysis were used to find determinants of in-hospital death, neurologic events, and cardiac-related events at follow-up. Overall survival was determined by the Kaplan-Meier method. Linearized complication rates at follow-up are reported.

RESULTS: In-hospital mortality was 2.3%. At univariate analysis, significant determinants of in-hospital mortality were age, logistic EuroSCORE greater than 15, diabetes, extracardiac arteriopathy, New York Heart Association class IV, ejection fraction less than 30%, and intraaortic balloon pump. At multivariate analysis, extracardiac arteriopathy and New York Heart Association class IV were the independent predictors for in-hospital mortality. Neurologic events were 1.1%. At univariate analysis, significant determinants of neurologic events were age, logistic EuroSCORE greater than 15, and extracardiac arteriopathy. At multivariate analysis no independent factor for neurologic events was found. Survival at 36 months was 95.6% ± 0.9%, and freedom from cardiac-related events at follow-up was 91.6% ± 1.7%. Linearized rates of cardiac-related events during follow-up were as follows: recurrence of angina, 1.1% ± 0.3%/y; myocardial infarction, 0.6% ± 0.2%/y; congestive heart failure, 1.2% ± 0.3%/y; graft occlusion, 0.4% ± 0.2%/y; and re–coronary artery bypass grafting, 0.2% ± 0.1%/y.

CONCLUSIONS: Total arterial OPCAB has a safe outcome in terms of mortality and neurologic events and has a low linearized rate of cardiac-related events at follow-up, even for patients with a moderate- to high-risk profile.


   Introduction
Top
 Abstract
 Introduction
Patients and Methods
 Results
 Comment
 Appendix 1
 References
 
Coronary revascularization was first performed on beating hearts [1]. Later, the heart-lung machine facilitated widespread application of and allowed accurate anastomoses to be performed on a fibrillating or arrested heart [2]. However, beating-heart surgery (off-pump coronary artery bypass grafting; OPCAB) has enjoyed a recent resurgence in interest and technology [3, 4], and this has allowed surgeons to perform high-quality reproducible anastomoses and has established its place as a good method for multivessel coronary revascularization. Nowadays 25% to 30% of coronary revascularization operations are performed on a beating heart. In some countries this exceeds 50%, and in some units it even approaches 99% of unselected cases [5]. This evidence is found in more than 1,200 peer-reviewed articles.

Patient selection is related to the experience of the center and to the degree of reengineering that has taken place, but at present complete arterial revascularization is possible without patient selection [6]. Coronary surgery off-pump reduces, after adjustment for variability in risk, early mortality and some major morbidity events, such as neurocognitive dysfunction, stroke, and renal failure [7–10].

The aim of this study was to investigate the incidence of in-hospital mortality and morbidity and to report early follow-up in terms of survival and cardiac-related events in total arterial off-pump coronary surgery.


   Patients and Methods
Top
 Abstract
 Introduction
 Patients and Methods
Results
 Comment
 Appendix 1
 References
 
Study Design
This study was a single-institutional retrospective study on consecutive patients. All patient data were prospectively collected by using our custom-made database (Microsoft Access; Microsoft Corp, Redmond, WA), which is used daily for clinical data management.

Study Population and Data Collection
A total of 1,342 consecutive adult patients underwent isolated coronary artery bypass grafting (CABG) between June 2000 and June 2003 in our department. Starting from June 2000 my colleagues and I began a comprehensive institutional policy for off-pump revascularization. At present (2003), 97% of coronary operations are performed off-pump at our institution. A total of 569 (42.4%) patients underwent total arterial OPCAB. The risk profile was moderate to high, with a mean standard EuroSCORE of 4.5 ± 2.2, a mean logistic EuroSCORE of 6.2 ± 5.1, and a mean age of 63 ± 8 years. Patient characteristics are displayed in Table 1.


View this table:
[in this window]
[in a new window]
  		Table 1. Preoperative Data

 
Preoperative and operative data were obtained by retrospective review of clinical and pathology reports from the database and were cross-checked with all medical charts. The data collected included the following: (1) demographics; (2) comorbidity risk factors; (3) operative data; (4) mortality; and (5) postoperative complications, defined as myocardial infarction (new Q wave or loss of R-wave progression across the chest leads or creatine kinase myocardial band enzyme > 10%), low cardiac output (a newly placed intraaortic balloon pump or the use of inotropic drugs for > 48 hours), malignant ventricular arrhythmias, bleeding requiring a rethoracotomy, respiratory insufficiency (mechanical ventilatory support > 48 hours), renal failure requiring dialysis, mediastinal infection, cerebrovascular accidents (CVA), and neurocognitive deficits (as determined by a staff neurologist).

Operative Technique
All procedures were performed through a median sternotomy. The internal thoracic arteries (ITAs) were harvested as pedicles, both for free and in situ grafting. The harvesting was performed with electrocautery. The radial artery (RA) was harvested as a pedicle through a skin incision in the left forearm starting 2 cm distal to the elbow and ending 3 cm proximal to the wrist. In all patients an Allen test was performed before operation, and the pressure of the RA stump was measured during the operation and recorded before the artery was divided. The gastroepiploic artery was harvested by opening the peritoneal cavity. All arterial conduits were distally divided after heparinization of the patient and were irrigated with 1% saline solution of papaverine.

Heparinization was achieved by giving heparin 150 IU/kg to obtain a target activated clotting time of more than 300 seconds. Protamine sulfate was generally used to reverse 50% of the heparin dose at the completion of the procedure [11].

To obtain a better visualization of the target coronary arteries during the distal anastomoses, a single 0-silk suture was placed on the posterior pericardium between the inferior vena cava and the left inferior pulmonary vein. A suction stabilizer (Axius Vacuum 2 Stabilizer System; Guidant, Santa Clara, CA, or Octopus 3; Medtronic, Minneapolis, MN) was used to stabilize the target coronary artery. All patients received postoperative low-molecular-weight heparin 5,000 IU twice daily until 15 days after the operation.

Follow-Up
Follow-up information on hospital survivors was collected by telephone interview during a 1-month interval ending in November 2003. The interview investigated survival, symptoms, long-term medical management, readmissions and reinterventions, and any operation-related complications. Unsuccessful attempts to trace patients were followed by contact with a family member or with the referring physician. Cardiac-related events during follow-up were defined as new episodes of angina or myocardial infarction, graft occlusion, re-CABG, and congestive heart failure requiring hospitalization or leading to death.

Statistical Analysis
Data are presented as mean ± standard deviation and percentages. All variables listed in the Appendix were investigated as independent determinants for in-hospital and late death and complications at univariate analysis. Student's t test or Wilcoxon's test for continuous data and {chi}2 or Fisher's exact tests for discrete variables were used as appropriate. All variables with a p value of less than 0.10 at univariate analysis were entered in the multivariate analysis: predictors of in-hospital mortality were identified by means of a stepwise logistic regression with forward selection and with a selection cutoff set at 0.05. Predictors of events during follow-up were identified by means of Cox's proportional hazards regression with a z value cutoff set at 2.0. Overall survival and freedom fromcardiac-related events during follow-up were determined by Kaplan-Meier actuarial analysis and expressed as the percentage of patients who were event free ± standard error. The linearized rate of follow-up complications was expressed as percentage per year ± standard error. Statistical analyses were performed with NCSS 2000 software (Statistical Solutions Ltd, Cork, Ireland).


   Results
Top
 Abstract
 Introduction
 Patients and Methods
 Results
Comment
 Appendix 1
 References
 
In-Hospital Data
Among 569 patients, 131 (23%) had urgent or emergent procedures. According to the guidelines of the Italian Society for Cardiac Surgery, urgent operations are those performed within the same hospital admission because of anatomic or clinical signs or symptoms. Emergent operations are those performed within 6 hours of catheterization. There were 1,181 grafts placed and 1,640 anastomoses performed, with a mean of 2.9 ± 0.8 anastomoses per patient (range, 2 to 6). Grafts included 301 single ITA (53.0%), 266 double ITA (46.7%), 219 RA (38.5%), and 129 gastroepiploic artery (22.7%) grafts; there were 183 (32.2%) Y grafts to left ITA. Endarterectomy was performed in 18 patients (3.2%). No conversion to cardiopulmonary bypass was required, and reoperation for bleeding was necessary in 22 patients (3.9%).

The overall 30-day mortality was 2.3%. Dividing the group for risk classes [12], no mortality was recorded in patients at low risk (standard EuroSCORE from 0 to 2: expected mortality, 1.27 to 1.29), 0.7% was recorded in patients at medium risk (standard EuroSCORE from 3 to 5: expected mortality, 2.90 to 2.94), and 7.4% recorded in patients at high risk (standard EuroSCORE ≥ 6: expected mortality, 10.94 to 11.54). Causes of death were low cardiac output in 4 patients, myocardial infarction in 4 patients, and respiratory distress in 2 patients who could not be weaned from ventilation support; another 3 died of sepsis, ventricular fibrillation, and major wound infection (1 each). Fourteen patients (2.5%) had a perioperative myocardial infarction, and 16 patients (2.8%) had a low output syndrome. CVAs and neurocognitive deficits occurred in 6 (1.1%) and 11 (1.9%) patients, respectively. New renal failure, which was censored for preoperative renal failure and was defined as an increase in the postoperative serum creatinine level to greater than 2 mg/dL that required dialysis, occurred in 12 (2.1%) patients. Twelve patients (2.1%) needed a ventilation time longer than 96 hours. Atrial fibrillation occurred in 92 patients (16.2%), and ventricular fibrillation or tachycardia occurred in 6 patients (1.1%). Major wound infection (mediastinitis) requiring open treatment was recorded in 6 (1.1%) patients. In 10 (1.8%) patients minor wound infections of soft tissues were treated with surgical debridement and vacuum-assisted closure. Operation-to-discharge length of stay was 8.3 ± 5.3 days (range, 1 to 68 days).

Variables that significantly correlated with in-hospital mortality and complications on univariate and multivariate analysis are summarized in Table 2. On multivariate analysis significant predictors of in-hospital mortality were extracardiac arteriopathy and New York Heart Association (NYHA) class IV. Older age, a logistic EuroSCORE of 15 or more, preoperative renal disease, extracardiac arteriopathy, and intraaortic balloon pump were the significant predictors of low output syndrome; diabetes and preoperative renal disease (serum creatinine level > 2 mg/dL not requiring dialysis) were the significant predictors of wound infection and new postoperative renal failure requiring dialysis, respectively. A higher logistic EuroSCORE was the only significant predictor of myocardial infarction. At multivariate analysis no independent factor of major neurologic events was found. No significant difference was found in neurologic events between patients in whom the aorta was not touched and patients in whom proximal anastomoses were performed with a side clamp.


View this table:
[in this window]
[in a new window]
  		Table 2. Statistical Analysis for In-Hospital Deaths and Complicationsa

 
Follow-Up Data
Follow-up of hospital survivors (556 patients) was 99% complete; 5 patients were lost to follow-up. The cumulative follow-up was 1,125 patient-years, with a mean follow-up time of 2.1 ± 0.8 years (range, 32 days to 42 months). There were 7 late deaths: 3 patients died of myocardial infarction, 1 of congestive heart failure, 1 of malignancy, 1 of trauma, and 1 of unknown causes (sudden death). The linearized rate of overall death, including hospital deaths, was 1.8% ± 0.4%/y, with a survival of 95.6% ± 0.9% at 3 years (Fig 1).



View larger version (16K):
[in this window]
[in a new window]
  		Fig 1. Survival analysis. (pts = patients.)

 
There were 544 survivors. Five hundred twenty-four (95%) of 551 patients available for follow-up were free from readmission for cardiac-related causes at the time of telephone survey. One hundred ninety-four (35.6%) patients were classified as being in NYHA class II, 45 (8.3%) in NYHA class III, and 4 (0.8%) in NYHA class IV.

Twenty-seven patients experienced cardiac-related events during follow-up (2.4% ± 0.5%/y; freedom from cardiac-related events at 3 years, 91.6% ± 1.7%): 12 had recurrence of angina (1.1% ± 0.3%/y; freedom from recurrence of angina at 3 years, 95.5% ± 1.3%), and 7 had myocardial infarctions (0.6% ± 0.2%/y; freedom from myocardial infarction at 3 years, 97.5% ± 1.1%), of which 3 were fatal (0.3% ± 0.2%). Episodes of congestive heart failure that required hospitalization occurred in 13 patients (1.2% ± 0.3%/y; freedom at 3 years, 96.8% ± 0.9%), of which 1 was fatal (0.1% ± 0.1%). Graft occlusion occurred in 4 patients (0.4% ± 0.2%/y; freedom from graft occlusion at 3 years, 98.0% ± 1.1%), and 2 had re-CABG (0.2% ± 0.1%/y; freedom at 3 years, 97.8% ± 0.9%). Kaplan-Meier analysis is shown in Figure 2.



View larger version (24K):
[in this window]
[in a new window]
  		Fig 2. Cardiac-related events: Kaplan-Meier analysis at 36 months. (AMI = acute myocardial infarction; CABG = coronary artery bypass graft; CHF = congestive heart failure.)

 
Variables significantly correlated with late mortality and cardiac-related events on univariate and multivariate analysis are summarized in Table 3. From proportional hazards regression analysis, significant predictors of late mortality were a preoperative ejection fraction less than 35% and postoperative low-output syndrome. A higher logistic EuroSCORE, preoperative NYHA class IV, and ejection fraction less than 35% were the significant predictors of cardiac-related events at follow-up.


View this table:
[in this window]
[in a new window]
  		Table 3. Statistical Analysis for Late Mortality and Cardiac Events at Follow-Upa

 

   Comment
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
Appendix 1
 References
 
The goal in CABG is to let the patient live as long as possible free from coronary events, angina, and reoperation. The use of arterial conduits has mid-term and long-term benefits in terms of recurrence of angina and myocardial infarction, percutaneous transluminal coronary angioplasty reinterventions, and higher graft patency rates compared with conventional left ITA on left anterior descending artery plus additional saphenous vein grafts [13–15]. Moreover, the use of arterial conduits alternative to the ITAs (RA and gastroepiploic artery) proved to overcome the anatomic limitations of in situ arterial grafts, allowing complete myocardial revascularization and extending the benefits of arterial revascularization to vessels other than the left anterior descending artery [16, 17].

The objective of our study was to evaluate whether total arterial myocardial revascularization could be safely and effectively performed with the OPCAB technique. The end points of the study were in-hospital death and complications and early outcome in terms of late mortality and cardiac-related events.

In our study the OPCAB technique was feasible for all patients. There was no conversion to on-pump surgery because of hemodynamic instability or major ventricular arrhythmia (ventricular fibrillation). Considering the proportion of patients with a high EuroSCORE (26.2% with EuroSCORE ≥ 6 and 47.6% with EuroSCORE between 3 and 5), our rate of in-hospital mortality (2.3%) compares favorably with those reported by others for either on-pump or off-pump operations [6–9, 18].

The perioperative incidence of myocardial infarction (2.5%) confirmed the report by Bouchard and Cartier [19] that despite cardiac elevation and transient hypotensive episodes, a beating-heart operation can provide adequate myocardial protection compared with cardioplegic arrest. The database used in this study does not characterize coronary anatomy; therefore, it could not be determined whether what might be considered difficult revascularization—eg, diffuse, small, calcified vessel disease—would influence the incidence of myocardial infarction. This characteristic is not incorporated into the risk stratification model either; therefore, it is difficult to determine the effect, if any, that this may have on outcome.

OPCAB has been associated with decreased stroke and neurocognitive deficit rates [20], and our study demonstrated an improved clinical outcome and a low CVA rate after OPCAB (1.1%). Stamou and colleagues [21] reported that among 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. The mortality rate was 6%, compared with 3% in the 70- to 79-year-old patients and 0.3% in the 60- to 69-year-old patients. In this study, however, patients had minimally invasive direct CABG, and the mean number of grafts was fewer than 2.

A possible limitation of our study is the underestimation of neurocognitive deficits. In fact, because much of the neurocognitive impairment is subtle, extensive preoperative neurocognitive testing is required to detect a postoperative incidence. Because we did not perform tests, our study might have underestimated the incidence of neurocognitive deficits after OPCAB.

Sternal wound infection is a concern, especially in bilateral ITA grafting, with reported incidences of up to 7% [16]. Kouchoukos and colleagues [22] found bilateral ITA harvesting to be the strongest predictor of a sternal complication, especially in diabetic patients. To reduce this problem, we used bilateral ITA grafting in only 31% of diabetic patients, and the incidence of mediastinitis in this at-risk group was 4.1%, which was not significantly different from the incidence in diabetic patients with single ITA grafting (1.8%). Moreover, the overall incidence of major wound infection in our study (1.1%) compares favorably with those reported by others [6], probably because off-pump surgery reduces the systemic inflammatory response when compared with on-pump surgery [23].

Larger retrospective studies [8, 24, 25] did demonstrate significantly less perioperative renal dysfunction for off-pump compared with on-pump operations. Conversely, evaluating patients with preoperative creatinine greater than 1.5 mg/dL, Cleveland and associates [8] from the large Society of Thoracic Surgeons National Database analysis did not show a statistical difference in renal dysfunction between the on-pump and off-pump groups. Our study demonstrated an incidence of 2.1% for new postoperative renal failure requiring dialysis and revealed at multivariate analysis that preoperative renal disease without dialysis is a predictor of postoperative renal failure requiring dialysis. In agreement with Puskas and colleagues [6], we observed a low incidence of atrial fibrillation (16.2%), and 3 large studies have demonstrated a decrease of atrial fibrillation in off-pump operations when compared with on-pump operations [21, 23, 26, 27].

Early results showed a substantially low rate of in-hospital mortality and complications, with only 4 in-hospital deaths related to myocardial infarction and with low-output syndrome in 16 patients (2.8%). The independent risk factors for mortality on multivariate logistic regression were older age, preoperative comorbidities (renal disease and extracardiac arteriopathy), and a high logistic EuroSCORE.

Survival at 3 years was good (95.6% ± 0.9%), and a significant clinical improvement was observed in the vast majority of patients; moreover, freedom from cardiac-related events was more than 90%, a value that compared very favorably to that reported by Muneretto and colleagues [18] at a shorter follow-up. Preoperative left ventricular dysfunction seemed to be the independent risk factor on proportional hazards regression at 3 years of follow-up.

Because the early outcome complications seem low in this study, graft patency will ultimately determine the out-of-hospital long-term relief of angina, as well as quality of life and survival. Graft patency is difficult to interpret because many factors (severity of coronary artery disease, quality of conduit, and so on), as well as the technical quality of the anastomosis, affect graft patency. Large prospective, randomized trials with a high percentage of angiographic follow-up need to be performed to account for all these variables.

In conclusion, and within the limitations of a single-institutional retrospective study, total arterial OPCAB can be safely performed with low in-hospital mortality and complication rates. Clinical outcome and survival free of cardiac-related events at 3 years of follow-up confirmed the effectiveness of total arterial OPCAB.


   Appendix 1
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 Appendix 1
References
 
Patient Variables Considered in Analyses
Demographic Variables Age, sex, height, weight, body-surface area, body mass index Symptoms Functional class (highest angina or New York Heart Association functional class, I–IV) Left ventricular function Left ventricular dysfunction grade (none or mildly, moderately, or severely impaired), history of myocardial infarction, chronic heart failure Cardiac comorbidity Atrial fibrillation, ventricular tachycardia, use of intraaortic balloon counterpulsation Noncardiac comorbidity Smoking history, carotid artery disease, history of stroke, peripheral vascular disease, hypertension, diabetes (insulin treated or oral hypoglycemic treated), history of renal disease, chronic obstructive pulmonary disease Coronary disease Degree of stenosis in left main trunk, number of diseased systems, unstable angina Operation risk Logistic EuroSCORE Revascularization Urgent or emergent procedures; use of 1 internal thoracic artery, 2 internal thoracic arteries, radial artery, gastroepiploic artery; arterial Y graft; number of peripheral anastomoses per patient; thromboendarterectomy


   References
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 Appendix 1
 References
 

  1. Kolessov VI. Mammary artery–coronary artery anastomosis as a method of treatment for angina pectoris. J Thorac Cardiovasc Surg. 1967;54:535–544[Medline]
  2. Garrett HE, Dennis EW, DeBakey ME. Aortocoronary bypass with saphenous vein grafts: seven-year follow-up. JAMA. 1973;223:792–794[Abstract/Free Full Text]
  3. Benetti FJ. Direct coronary surgery with saphenous vein bypass without either cardiopulmonary bypass or cardiac rest. J Cardiovasc Surg. 1985;26:217–222[Medline]
  4. Buffolo E, de Andrade JC, Branco JN, Teles CA, Aguiar LF, Gomes WJ. Coronary artery bypass grafting without cardiopulmonary bypass. Ann Thorac Surg. 1996;61:63–66[Abstract/Free Full Text]
  5. Outcome evidence after OPCAB surgery. September 2003. Available at: http://www.ctsnet.org/file/OPCABLitReviewSlide_Spring2004_Final_PDF.pdf. Accessed: February 2, 2004
  6. Puskas JD, Williams WH, Duke PG, et al. Off-pump coronary artery bypass grafting provides complete revascularization with reduced myocardial injury, transfusion requirements and length of stay: a prospective randomized comparison of two hundred unselected patients undergoing off-pump versus conventional coronary artery bypass grafting. J Thorac Cardiovasc Surg. 2003;125:797–808[Abstract/Free Full Text]
  7. Plomondon ME, Cleveland JC, Ludwig ST, et al. Off-pump coronary artery bypass is associated with improved risk-adjusted outcomes. Ann Thorac Surg. 2001;72:114–119[Abstract/Free Full Text]
  8. Cleveland J, Shroyer A, Chen A, et al. Off-pump coronary artery bypass grafting decreases risk-adjusted mortality and morbidity. Ann Thorac Surg. 2001;72:1282–1289[Abstract/Free Full Text]
  9. Magee M, Jablonski K, Stamaou S, et al. Elimination of cardiopulmonary bypass improves early survival for multivessel coronary artery bypass patients. Ann Thorac Surg. 2002;73:1196–1203[Abstract/Free Full Text]
  10. Ascione R, Lloyd CT, Underwood MJ, et al. On-pump versus off-pump coronary revascularization: evaluation of renal function. Ann Thorac Surg. 1999;68:493–498[Abstract/Free Full Text]
  11. Mariani MA, Gu YJ, Boonstra PW, Grandjean JG, van Oeveren W, Ebels T. Procoagulant activity after off-pump coronary operation: is the current anticoagulation adequate? Ann Thorac Surg. 1999;67:1370–1375[Abstract/Free Full Text]
  12. Nashef SAM, Roques F, Michel P, Gauducheau E, Lemeshow S, Salamon R. European system for cardiac operative risk evaluation (EuroSCORE). Eur J Cardiothorac Surg. 1999;16:9–13[Medline]
  13. Pick AW, Orszulak TA, Anderson BJ, Schaff HV. Single versus bilateral internal mammary artery graft: 10 year outcome analysis. Ann Thorac Surg. 1997;64:599–605[Abstract/Free Full Text]
  14. Lytle BW, Blackstone EH, Loop FD, et al. Two internal thoracic artery grafts are better than one. J Thorac Cardiovasc Surg. 1999;117:855–872[Abstract/Free Full Text]
  15. Muneretto C, Negri A, Manfredi J, et al. Safety and usefulness of composite grafts for total arterial myocardial revascularization: a prospective randomized evaluation. J Thorac Cardiovasc Surg. 2003;125:826–835[Abstract/Free Full Text]
  16. Tector AJ, Amundsen S, Schmahl TM, Kress DC, Peter M. Total revascularization with T grafts. Ann Thorac Surg. 1994;57:33–39[Abstract]
  17. Royse A, Royse CF, Raman JS. Exclusive Y-graft operation for multi-vessel coronary revascularization. Ann Thorac Surg. 1999;68:1612–1618[Abstract/Free Full Text]
  18. Muneretto C, Bisleri G, Negri A, et al. Off-pump coronary artery bypass surgery technique for total arterial myocardial revascularization: a prospective randomized study. Ann Thorac Surg. 2003;76:778–783[Abstract/Free Full Text]
  19. Bouchard D, Cartier R. Off-pump revascularization of multivessel coronary artery disease has a decreased myocardial infarction rate. Eur J Cardiothorac Surg. 1998;14(Suppl 1):20–24
  20. Bhasker Rao B, Van Himbergen D, Edmonds HL Jr, et al. Evidence for improved cerebral function after minimally invasive bypass surgery. J Card Surg. 1998;13:27–31[Medline]
  21. Stamou SC, Dangas G, Dullum MKC, 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. Kouchoukos NT, Wareing TH, Murphy SF, Pelate C, Marshall WG Jr. Risk of bilateral internal mammary artery bypass grafting. Ann Thorac Surg. 1990;49:210–219[Abstract]
  23. Gu YJ, Mariani MA, van Oeveren W, Grandjean JG, Boonstra PW. Reduction of the inflammatory response in patients undergoing minimally invasive coronary artery bypass grafting. Ann Thorac Surg. 1998;65:420–424[Abstract/Free Full Text]
  24. Mack MJ, Bachand D, Acuff T, et al. Improved outcomes in coronary artery bypass grafting with beating heart techniques. J Thorac Cardiovasc Surg. 2002;124:598–607[Abstract/Free Full Text]
  25. Sabik JF, Gillinov AM, Blackstone EH, et al. Does off-pump coronary surgery reduce morbidity and mortality? J Thorac Cardiovasc Surg. 2002;124:698–703[Abstract/Free Full Text]
  26. Angelini GD, Taylor FC, Reeves BC, et al. Early and midterm outcomes after off-pump and on-pump surgery in Beating Heart Against Cardioplegic Arrest Studies (BHAGAS 1 and 2): a pooled analysis of two randomized controlled trials. Lancet. 2002;359:1194–1199[Medline]
  27. Hernandez F, Cohn WE, Baribeau YR, et al. In hospital outcomes of off-pump versus on-pump coronary artery bypass procedures: a multicenter experience. Ann Thorac Surg. 2001;72:1528–1534[Abstract/Free Full Text]



This article has been cited by other articles:


Home page
 Ann. Thorac. Surg.Home page
W. B. Halbersma, S. C. Arrigoni, G. Mecozzi, J. G. Grandjean, A. P. Kappetein, J. van der Palen, F. Zijlstra, and M. A. Mariani
Four-year outcome of OPCAB no-touch with total arterial Y-graft: making the best treatment a daily practice.
Ann. Thorac. Surg., September 1, 2009; 88(3): 796 - 801.
[Abstract] [Full Text] [PDF]

Home page
 Ann. Thorac. Surg.Home page
D. Navia, M. Vrancic, G. Vaccarino, F. Piccinini, H. Raich, S. Florit, and J. Thierer
Total Arterial Off-Pump Coronary Revascularization Using Bilateral Internal Thoracic Arteries in Triple-Vessel Disease: Surgical Technique and Clinical Outcomes
Ann. Thorac. Surg., August 1, 2008; 86(2): 524 - 530.
[Abstract] [Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Massimo A. Mariani
Jan G. Grandjean
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Mariani, M. A.
Right arrow Articles by Grandjean, J. G.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Mariani, M. A.
Right arrow Articles by Grandjean, J. G.
Related Collections
Right arrow Coronary disease

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
ANN THORAC SURG ASIAN CARDIOVASC THORAC ANN EUR J CARDIOTHORAC SURG
J THORAC CARDIOVASC SURG ICVTS ALL CTSNet JOURNALS