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


     

Ann Thorac Surg 2008;85:1988-1993. doi:10.1016/j.athoracsur.2008.02.024
© 2008 The Society of Thoracic Surgeons
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):
Joel Dunning
Simon W.H. Kendall
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 Dunning, J.
Right arrow Articles by Khan, K.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Dunning, J.
Right arrow Articles by Khan, K.
Related Collections
Right arrow Coronary disease

Original Articles: Adult Cardiac

Coronary Artery Bypass Grafting is Associated With Excellent Long-Term Survival and Quality of Life: A Prospective Cohort Study

Joel Dunning, PhDa,*, Julian R.L. Waller, MRCSa, Barbara Smithc, Sue Pitts, RGNc, Simon W.H. Kendall, FRCS(Cth)a, Khalid Khan, FCARCSIb

a Department of Cardiothoracic Surgery, James Cook University Hospital, Middlesbrough, United Kingdom
b Department of Cardiothoracic Anesthesia, James Cook University Hospital, Middlesbrough, United Kingdom
c Department of Cardiothoracic Audit, James Cook University Hospital, Middlesbrough, United Kingdom

Accepted for publication February 8, 2008.

* Address correspondence to Dr Dunning, Department of Cardiothoracic Surgery, James Cook University Hospital, Middlesbrough, United Kingdom (Email: joeldunning{at}doctors.org.uk).


   Abstract
Top
 Abstract
Introduction
 Material and Methods
 Results
 Comment
 Acknowledgments
 References
 
Background: We investigated the long-term outcome of coronary artery bypass grafting both in terms of survival and quality of life.

Methods: Ten-year postsurgery survival was collated on patients undergoing coronary artery bypass grafting from 1994 to 1996, and quality of life was assessed using EQ-5D and a quality-of-life thermometer. We analyzed data from 1,180 patients. Mean age was 61 years, and 79% had triple-vessel disease.

Results: Thirty-day mortality was 3.3% (1.8% elective). Mean time to censorship for survivors was 9.9 years (range, 8.1 to 12.3 years). Ten-year survival was 66% across all patients, 70% for elective patients. Ten-year cardiac survival was 82%. Percutaneous intervention was required in 25 patients in the subsequent 10 years (2%), and only 4 required redo coronary artery bypass grafting (0.3%); 59% of patients reported no angina, and 88% of patients had grade II angina or better. Of 621 patients who were assessed for quality of life at 10 years, 530 (85%) had a quality of life within a 95% confidence interval of the score found in the general population with similar age. Poor quality of life was reported in 91 patients (14.7%). Significant predictors of poor long-term quality of life were current smoking, Canadian Cardiovascular Society grade III or IV, redo operation, female sex, diabetes, peripheral vascular disease, more than 2 days in intensive care, and chronic obstructive pulmonary disease. Twenty-five percent of patients with poor EQ-5D outcome had grade IV angina. Interestingly, age did not correlate with poor outcome, and administration of blood, arterial revascularization, left mainstem disease, or cross-clamp fibrillation had no impact on survival or outcome.

Conclusions: Coronary artery bypass grafting is associated with excellent 10-year survival and quality of life.


   Introduction
Top
 Abstract
 Introduction
Material and Methods
 Results
 Comment
 Acknowledgments
 References
 
Surgical scoring systems such as Parsonnet and EuroSCORE are well established to predict mortality after cardiac surgery [1, 2]. Although mortality represents a hard end point after surgery that is useful to benchmark the quality of operative surgery, patients desire a good long-term quality of life from their operation rather than simply a short-term survival. In addition, as patients are increasingly offered the choice of coronary artery bypass grafting (CABG) or percutaneous intervention, it is of utmost importance that the surgical community can offer their patients accurate data on both long-term survival and also the likely long-term quality of life from surgery in the modern era. Previous studies have presented quality-of-life data at 6 months [3], 3 years [4], after prolonged intensive care stay [5], and in comparison to angioplasty [6]. We sought to provide comprehensive data on the 10-year quality of life and survival of a large continuous cohort of patients who underwent their surgery in the modern era.


   Material and Methods
Top
 Abstract
 Introduction
 Material and Methods
Results
 Comment
 Acknowledgments
 References
 
Study Population
Institutional ethical committee approval was obtained for this study, and the need for patient written consent was waived. A cohort of consecutive patients undergoing CABG between January 5, 1994, and January 2,1996, were studied. These patients had been prospectively entered into our institutional database, which collected a wide range of preoperative and perioperative variables. Patients of all ages and operative urgency were included, but patients were excluded if they had any cardiac, thoracic, aortic, or vascular procedures other than CABG. Patients were sent quality-of-life questionnaires in January 2003 and were finally censored for survival on February 1, 2005. All patients underwent surgery and were managed postoperatively in the Department of Cardiothoracic Surgery, James Cook University Hospital.

Surgery
Surgery was performed by three consultant cardiothoracic surgeons in the standard fashion with the use of cardiopulmonary bypass. The method of myocardial preservation and the use of arterial or venous conduits were determined by the attending surgeon. Myocardial preservation techniques included both cold blood and crystalloid cardioplegic solutions and intermittent cross-clamp fibrillation. All patients received the left internal mammary artery to left anterior descending coronary artery unless the left anterior descending artery was free from significant occlusive disease or occasionally if surgery was performed as an emergency procedure.

Data Collection
In-hospital data were collected prospectively in the patient administration system database, the theater operation database, and the cardiac intensive case unit database and cross checked with individual surgeons' databases. Data fields were compatible with the national database of the Society for Cardiothoracic Surgery (SCTS). Mortality tracking was performed with hospital records and the Office of National Statistics, which noted both time and cause of death as recorded on the issued death certificate. All surviving patients were contacted by mail or telephone and asked to complete a questionnaire.

Preoperative data
Preoperative variables included sex, age at operation, body mass index, dyspnea status (New York Heart Association grade), angina status (Canadian Cardiovascular Society grade), hypertension, hypercholesterolemia, diabetes, peripheral vascular disease, smoking status, renal dysfunction, previous myocardial infarction, myocardial infarction in preceding 30 days before surgery, extent of coronary artery disease (including presence of left mainstem disease), and left ventricular function. Surgical priority was defined as elective, urgent (operation as an inpatient after angiography), emergency (requiring operation within 24 hours), and salvage (immediate operation).

Operative data
Methods of myocardial preservation included cold crystalloid and blood cardioplegia and intermittent cross-clamp fibrillation was also used. Total cardiopulmonary bypass time and number of bypasses were recorded.

Postoperative data
Duration of ventilation, use of inotropic agents and intraaortic balloon pump, hemofiltration, total length of intensive care unit stay, 30-day postoperative data, and long-term survival were recorded.

Quality of life data
Data were collected from each patient by asking them to comment on their quality of life in five categories: mobility, self-care, usual activity, pain or discomfort, and anxiety or depression were all assessed, and their EQ-5D score calculated. In addition each patient was asked to rate their self-perceived health status on a scale of 0 to 100 to create the health thermometer score [7]. This score, which is simply the patient's self-perceived health status using a single number assigned by the patient, has been used previously, and again in our own study, to provide a measure of validity for the EQ-5D score.

Statistical Analysis
An EQ-5D poor outcome was defined as being a score below the 95% confidence interval of published EQ-5D for people in the general population of the same mean age of our patient group in the United Kingdom at censorship [8]. This was 0.78 (95% lower confidence interval [CI] is 0.28) for 484 people questioned across the United Kingdom in 1993. Univariate analysis was first used to explore the relationships between EQ-5D poor outcome and variables on our database. Dichotomous variables were analyzed using Fisher's exact test, and the remaining categorical data were analyzed with the {chi}2 test with a continuity correction as appropriate. Continuous data were compared using the Student's t test if a normal distribution could be demonstrated by the Kolmogorov-Smirnov test and alternatively the Mann-Whitney U test. Dichotomous variables were also analyzed for survival, and the thermometer scores for each group were also given. Survival between groups was assessed using the log-rank test.

Variables that significantly predicted poor outcome (EQ-5D score at 10 years) with a probability value of 0.20 or below were entered into multivariate analysis using logistic regression. Predictive factors for mortality were analyzed using Cox regression.


   Results
Top
 Abstract
 Introduction
 Material and Methods
 Results
Comment
 Acknowledgments
 References
 
A total of 1,180 consecutive patients underwent CABG during the study period. Preoperative and in-hospital data were complete for all patients.

Patient demographics are listed in Table 1. Mean age was 61 years, and 77% were male. Seventy-nine percent had triple-vessel disease, and 16% had left mainstem disease. Mean body mass index was 26, 11% were diabetics, 16% were current smokers, and 85% were on antiplatelet agents, but only 9.8% were on statins at the time of surgery. Overall 30-day mortality was 3.3% (1.8% elective, 4.6% urgent, and 9.5% emergency). There were no deaths in the 3 patients receiving salvage procedures. Mean time to censorship for survivors was 9.9 years (range, 8.1 to 12.3 years). Ten-year survival was 66% across all patients (781 of 1,180), 70% for elective patients (505 of 717), 60% for urgent patients (234 of 389), and 57% for emergency patients (42 of 74). In total up to February 1, 2005, 399 patients had died. Of these deaths 41% (164 patients) were cardiac deaths, 18% (71 patients) were cancer deaths, and 5% (19 patients) were deaths attributable to respiratory causes (13% were attributable to other noncardiac causes). Cause of death was unknown in 23% of patients (90 patients); thus if half of these unknown deaths were cardiac, the 10-year freedom from cardiac mortality was 82% across the whole database [1 – (164 + 45)/1,180]. Twenty-five patients required percutaneous intervention in the 10 years after surgery (2%), and 4 required repeat CABG (0.3%).


View this table:
[in this window]
[in a new window]

  		Table 1 Demographics and Relationship to EQ-5D Poor Outcome and Survival a
 
Nine hundred eleven patients survived to receive a questionnaire, and of these, 621 successfully completed a quality-of-life questionnaire, giving a completion rate of 68%. The mean EQ-5D score in our database was 0.70 and the standard deviation was 0.307. This compares with the published mean EQ-5D score for the general population of 65- to 74-year-olds in the United kingdom of 0.78 with a standard deviation of 0.26 (Fig 1). Of 621 patients who were assessed for quality of life, 530 (85%) had a quality of life within a 95% CI of the score of the general population. Ninety-one patients (14.7%) reported a poor quality of life. Mean thermometer score for a patient with good outcome was 71 whereas for patients with a poor quality of life the mean score was 39. The correlation coefficient between EQ-5D and thermometer score was 0.672, which was highly significant and increases our confidence in the reliability of both scores. With regard to angina, at censorship 59% of patients reported no angina and 88% of patients had grade II angina or better. Only 6% of patients censored had grade IV angina at 10 years. An EQ-5D poor quality of life was highly significantly related to worse angina. Twenty-five percent of patients with poor EQ-5D outcome had grade IV angina, 11% were grade III, and only 37% of patients with poor quality of life had no angina.


Figure 1
View larger version (21K):
[in this window]
[in a new window]

  		Fig 1. Distribution of EQ-5D score across the cohort.

 
We found that significant predictors of poor quality of life were current smoking (odds ratio [OR], 3.98; 95% CI, 2.1 to 7.3), Canadian Cardiovascular Society grade III or IV (OR, 4.7; 95% CI, 2.2 to 10.3), redo operation (OR, 6.2; 95% CI, 2.1 to 18.6), female sex (OR, 2.1; 95% CI, 1.1 to 3.8), diabetes of any type (OR, 2.5; 95% CI, 1.2 to 5.5), peripheral vascular disease (OR, 2.1; 95% CI, 1.1 to 4.0), more than 2 days in the intensive care unit (OR, 2.32; 95% CI, 1.3 to 4.1), and chronic obstructive pulmonary disease (OR, 2.3; 95% CI, 1.0 to 5.1). Interestingly age did not correlate with poor quality of life, and neither administration of blood, endarterectomy, nor left mainstem disease had any impact on survival or poor quality of life. The full results are presented in Table 2.


View this table:
[in this window]
[in a new window]

  		Table 2 Multivariate Analysis for Poor Outcome by EQ-5D
 
Performing a multivariate analysis for survival revealed six factors that were significant predictors for survival. Age at operation (OR, 1.07; 95% CI, 1.05 to 1.09), chronic obstructive pulmonary disease or asthma (OR, 1.82; 95% CI, 1.27 to 2.61), redo operation (OR, 2.36; 95% CI, 1.33 to 4.18), intubation greater than 48 hours (OR, 1.72; 95% CI, 1.20 to 2.49), cardiogenic shock (OR, 5.03; 95% CI, 1.40 to 18.1), and performing three grafts or fewer (OR, 0.74; 95% CI, 0.56 to 0.98) was protective. Neither blood usage, endarterectomy, left mainstem disease, nor use of cross-clamp fibrillation had an adverse impact on long-term survival. Full results are presented in Table 3.


View this table:
[in this window]
[in a new window]

  		Table 3 Multivariate Analysis of Factors That Significantly Predict Mortality
 

   Comment
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
Acknowledgments
 References
 
Our study confirms the excellent long-term survival and quality of life at 10 years after cardiac surgery. The 10-year survival was 66%, and 85% of these patients had a quality of life at 10 years that was not significantly different from the population normal for people at a similar age in the United Kingdom. In addition, as more than a third of the deaths at 10 years were noncardiac, the 10-year cardiac survival was approximately 82%.

We have confirmed that risk factors such as current smoking, diabetes, chronic obstructive pulmonary disease, and peripheral vascular disease are significant predictors of poor long-term quality of life, but interestingly age was not a predictor of adverse quality of life.

Blood product usage has been cited by some studies as a predictor of poor long-term outcome [9–11]. Our study did not demonstrate any significant impact on either quality of life or survival. Care must be taken when adding blood product usage into logistic regression analysis models to predict outcomes such as long-term survival. If all other predictor variables are preoperative, then blood product usage, which is collected postoperatively, becomes a surrogate marker of the intraoperative and postoperative progress of the patient. We included other postoperative markers of progress, and thus blood product usage in our analysis did not impact on survival.

The method of myocardial protection was also not a significant factor in predicting long-term survival or quality of life. In particular we have moved to cross-clamp fibrillation owing to its ease of use, economics, and excellent clinical results, and 40% of patients in this study were operated on with this technique. This study supports its equivalence with cardioplegic techniques as do other studies [12–15].

The presence of left mainstem disease was not a predictor of adverse survival or quality of life. These patients therefore may expect the same excellent long-term quality of life and survival as any other patient with surgery, but because of their particular high risk of mortality without surgery, and the absence of equivalent long-term results with left mainstem stenting, surgery should certainly remain the first choice for these patients unless their surgical operative risk is prohibitively high.

Sixty-four patients underwent total arterial revascularization. However, their long-term survival and quality of life was equivalent to those undergoing revascularization with the left internal mammary artery and saphenous veins. This is in contrast to several cohort studies that suggest that additional arterial grafts may improve survival [16]. However, our results reflect increasing clinical experience that saphenous vein conduits are lasting much longer at 10 years than initial reports of vein graft patency [17–19]. This could be related to a range of factors, but factors could include more aggressive statin usage, diabetic control, and dietary and smoking prevention factors.

We found that prolonged ventilation greater than 48 hours was a significant predictor of long-term poor survival and quality of life. This confirms studies by other authors [20–23] that long-term survival is impaired by prolonged ventilation. Quality of life is impaired overall, although conversely there are many patients who do recover after prolonged ventilation or intensive care unit stay to have an acceptable quality of life.

With regard to other studies that have demonstrated similar results to our own, Bradshaw and coworkers [24] in 2006 performed a postal survey of 2,500 patients who had CABG from 6 to 20 years ago to look at their resulting quality of life. They found that 30% of patients had recurrence of angina or heart failure and this was associated with a lower quality of life, but in the remaining people, long-term quality of life was equivalent to the background population.

Gjeilo and associates [25] performed a quality-of-life assessment of 203 patients 3 years after CABG surgery. They found similar results to our own in that quality-of-life scores were equivalent to the background Norwegian population, including in older age groups. A study by Graham and colleagues [26], who looked specifically at quality of life in the elderly after coronary surgery, found that scores in patients older than 70 and older than 80 were actually superior to people of similar ages in the background population.

Hlatky and colleagues [6] followed up 934 patients who were entered into the Bypass Angioplasty Revascularization Investigation (BARI) trial from 1998 to 1991, in which patients were randomized to angioplasty or CABG. Coronary artery bypass grafting patients had an incidence of 18% of angina at 10 years, and a 12-year survival of only 61%, which is significantly lower than our own despite the average age of these patients being similar at 61 years old.

Our study has weaknesses. Our intraoperative and perioperative follow-up was excellent and survival follow-up was 100% complete, but the quality-of-life questionnaire was only 68% complete. This is a very good completion rate in our view 10 years after surgery; however, extrapolating our quality-of-life data to the whole database assumes that there is no systematic difference between those who completed the questionnaire and those who did not. We have no evidence that this assumption is valid. Many quality-of-life scales exist, and to ensure good compliance, we elected to use a relatively simple score. However, this does mean that direct comparison with some studies that may have used EuroQol, SF-36, [24], or other scores [27] is more difficult. However, our score is well validated and by using two scoring systems, this allowed us to determine good reliability in our study. Finally, we have found that there was no difference in patient groups receiving total arterial revascularization, blood usage, cross-clamp fibrillation, or left mainstem disease, and that the numbers in these groups were good. However, our study was not specifically powered to exclude a significant difference in these subgroups.

We conclude that CABG is associated with an excellent survival and quality of life in the modern era, and that neither method of myocardial protection, use of arterial conduits, blood usage, nor left mainstem disease impairs these outcomes. We further find that older patients can expect the same quality-of-life improvement postoperatively as their younger counterparts.


   Acknowledgments
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 Acknowledgments
References
 
The study was funded by the Purchaser Clinical Audit Group. The authors have no links financially or otherwise with this group.


   References
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 Acknowledgments
 References
 

  1. Parsonnet V, Dean D, Bernstein AD. A method of uniform stratification of risk for evaluating the results of surgery in acquired adult heart disease Circulation 1989;79:1-12.[Abstract/Free Full Text]
  2. Roques F, Nashef SA, Michel P, et al. Risk factors and outcome in European cardiac surgery: analysis of the EuroSCORE multinational database of 19030 patients Eur J Cardiothorac Surg 1999;15:816-822.[Abstract/Free Full Text]
  3. Panagopoulou E, Montgomery A, Benos A. Quality of life after coronary artery bypass grafting: evaluating the influence of preoperative physical and psychosocial functioning J Psychosom Res 2006;60:639-644.[Medline]
  4. Myles PS, Viira D, Hunt JO. Quality of life at three years after cardiac surgery: relationship with preoperative status and quality of recovery Anaesth Intensive Care 2006;34:176-183.[Medline]
  5. Ryan TA, Rady MY, Bashour CA, Leventhal M, Lytle B, Starr NJ. Predictors of outcome in cardiac surgical patients with prolonged intensive care stay Chest 1997;112:1035-1042.[Medline]
  6. Hlatky MA, Boothroyd DB, Melsop KA, et al. Medical costs and quality of life 10 to 12 years after randomization to angioplasty or bypass surgery for multivessel coronary artery disease Circulation 2004;110:1960-1966.[Abstract/Free Full Text]
  7. Brooks R, Rabin R, de Charro F. The measurement and valuation of health status using EQ-5D: a European perspective: evidence from the EuroQol BIO MED Research Programme 2003The Publication Office, Centre for Health Economics, University of York, York.
  8. Kind P, Hardman G, Macran S. UK population norms for EQ-5DYork, UK: University of York Centre for Health Economics; 1999.
  9. Engoren MC, Habib RH, Zacharias A, Schwann TA, Riordan CJ, Durham SJ. Effect of blood transfusion on long-term survival after cardiac operation Ann Thorac Surg 2002;74:1180-1186.[Abstract/Free Full Text]
  10. Spiess BD. Transfusion of blood products affects outcome in cardiac surgery Semin Cardiothorac Vasc Anesth 2004;8:267-281.[Abstract/Free Full Text]
  11. Koch CG, Khandwala F, Li L, Estafanous FG, Loop FD, Blackstone EH. Persistent effect of red cell transfusion on health-related quality of life after cardiac surgery Ann Thorac Surg 2006;82:13-20.[Abstract/Free Full Text]
  12. Raco L, Mills E, Millner RJ. Isolated myocardial revascularization with intermittent aortic cross-clamping: experience with 800 cases Ann Thorac Surg 2005;73:1436-1440.
  13. Korbmacher B, Simic O, Schulte HD, Sons H, Schipke JD. Intermittent aortic cross-clamping for coronary artery bypass grafting: a review of a safe, fast simple and successful technique J Cardiovasc Surg 2004;45:535-543.[Medline]
  14. Liu Z, Valencia O, Treasure T, et al. Cold blood cardioplegia or intermittent cross-clamping in coronary artery bypass grafting? Ann Thorac Surg 1998;66:462-465.[Abstract/Free Full Text]
  15. Alhan HC, Karabulut H, Tosun R, et al. Intermittent aortic cross-clamping and cold crystalloid cardioplegia for low-risk coronary patients Ann Thorac Surg 1996;61:834-839.[Abstract/Free Full Text]
  16. Taggart DP, D'Amico R, Altman DG. Effect of arterial revascularisation on survival: a systematic review of studies comparing bilateral and single internal mammary arteries[see comment] Lancet 2001;358:870-875.[Medline]
  17. Goldman S, Copeland J, Moritz T, et al. Saphenous vein graft patency 1 year after coronary artery bypass surgery and effects of antiplatelet therapy. Results of a Veterans Administration Cooperative Study. Circulation 1989;80:1190-1197.[Abstract/Free Full Text]
  18. Goldman S, Copeland J, Moritz T, et al. Improvement in early saphenous vein graft patency after coronary artery bypass surgery with antiplatelet therapy: results of a Veterans Administration Cooperative Study Circulation 1988;77:1324-1332.[Abstract/Free Full Text]
  19. Chesebro JH, Clements IP, Fuster V, et al. A platelet-inhibitor-drug trial in coronary-artery bypass operations: benefit of perioperative dipyridamole and aspirin therapy on early postoperative vein-graft patency N Engl J Med 1982;307:73-78.[Abstract]
  20. Pappalardo F, Franco A, Landoni G, Cardano P, Zangrillo A, Alfieri O. Long-term outcome and quality of life of patients requiring prolonged mechanical ventilation after cardiac surgery Eur J Cardiothorac Surg 2004;25:548-552.[Abstract/Free Full Text]
  21. Wahl GW, Swinburne AJ, Fedullo AJ, Lee DK, Bixby K. Long-term outcome when major complications follow coronary artery bypass graft surgery: recovery after complicated coronary artery bypass graft surgery Chest 1996;110:1394-1398.[Medline]
  22. Bashour CA, Yared JP, Ryan TA, et al. Long-term survival and functional capacity in cardiac surgery patients after prolonged intensive care[see comment] Crit Care Med 2000;28:3847-3853.[Medline]
  23. Combes A, Costa MA, et al. Morbidity, mortality, and quality-of-life outcomes of patients requiring >or=14 days of mechanical ventilation Crit Care Med 2003;31:1373-1381.[Medline]
  24. Bradshaw PJ, Jamrozik KD, Gilfillan IS, Thompson PL. Asymptomatic long-term survivors of coronary artery bypass surgery enjoy a quality of life equal to the general population Am Heart J 2006;151:537-544.[Medline]
  25. Gjeilo KH, Wahba A, Klepstad P, Lydersen S, Stenseth R. Health-related quality of life three years after coronary surgery: a comparison with the general population Scand Cardiovasc J 2006;40:29-36.[Medline]
  26. Graham MM, Norris CM, Galbraith PD, Knudtson ML, Ghali WA. PPROACH I. Quality of life after coronary revascularization in the elderly. [See comment] Eur Heart J 2006;27:1690-1698.[Abstract/Free Full Text]
  27. Phillips-Bute B, Mathew JP, Blumenthal JA, et al. Association of neurocognitive function and quality of life 1 year after coronary artery bypass graft (CABG) surgery Psychosom Med 2006;68:369-375.[Abstract/Free Full Text]



This article has been cited by other articles:


Home page
 Eur. J. Cardiothorac. Surg.Home page
C. Naughton, R. O. Feneck, and J. Roxburgh
Early and late predictors of mortality following on-pump coronary artery bypass graft surgery in the elderly as compared to a younger population
Eur. J. Cardiothorac. Surg., October 1, 2009; 36(4): 621 - 627.
[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):
Joel Dunning
Simon W.H. Kendall
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 Dunning, J.
Right arrow Articles by Khan, K.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Dunning, J.
Right arrow Articles by Khan, K.
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