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


     

Ann Thorac Surg 2009;87:757-765. doi:10.1016/j.athoracsur.2008.11.042
© 2009 The Society of Thoracic Surgeons
This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Correction (v87,p2008)
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 Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Feng, Z.-Z.
Right arrow Articles by Xu, Z.-F.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Feng, Z.-Z.
Right arrow Articles by Xu, Z.-F.
Related Collections
Right arrow Coronary disease

Original Articles: Adult Cardiac

Meta-Analysis of On-Pump and Off-Pump Coronary Arterial Revascularization

Zheng-Zhe Feng, MDa, Jian Shi, MDb, Xue-Wei Zhao, MDa,*, Zhi-Fei Xu, MDa

a Department of Thoracic Surgery, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, China
b Department of Gastroenterology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, China

Accepted for publication November 17, 2008.

* Address correspondence to Dr Zhao, Department of Thoracic Surgery, Shanghai Changzheng Hospital, Second Military Medical University, Fengyang Rd 415, Shanghai, 200003, China (Email: jimmy-rockingboy{at}163.com).


   Abstract
Top
 Abstract
Introduction
 Material and Methods
 Results
 Comment
 References
 
Background: There is no agreement whether off-pump coronary artery bypass (OPCAB) can reduce mortality, rates of stroke, myocardial infarction, or revascularization when compared with conventional coronary artery bypass (CCAB). We performed a meta-analysis comparing off-pump coronary artery bypass with conventional coronary artery bypass in randomized controlled trials.

Methods: We comprehensively retrieved randomized controlled studies according to predetermined criteria. We performed meta-analyses for each outcome and empirically determined whether potential biases that might result from differences in study design or patient characteristics actually biased the results of a study. We also conducted sensitivity analyses and tested for publication bias.

Results: We undertook a meta-analysis of ten randomized trials (2,018 patients) of OPCAB surgery versus CCAB surgery. No significant differences were found for 1-year mortality (odds ratio [OR], 1.00; 95% confidence interval [CI], 0.75 to 1.33), myocardial infarction (OR, 0.61; 95% CI, 0.44 to 0.84), stroke (OR, 0.56; 95% CI, 0.34 to 0.91), or revascularization (OR, 1.38; 95% CI, 1.00 to 1.92). Therefore, this meta-analysis demonstrates that mortality, stroke, myocardial infarction, and revascularization were not reduced in OPCAB.

Conclusions: In conclusion, OPCAB did not significantly reduce 1-year mortality, stroke, myocardial infarction, and revascularization compared with CCAB.


   Introduction
Top
 Abstract
 Introduction
Material and Methods
 Results
 Comment
 References
 
Coronary artery bypass grafting (CABG) is the most common surgical procedure in the world, benefiting a large number of patients [1]. According to the latest published statistics from the National Center for Health Statistics, 467,000 CABG procedures were performed in the United States in 2003. In high-risk patients, CABG has been shown to decrease mortality over a 10-year study period. Improvement in quality of life and relief of angina are also attributed to successful CABG surgery [2, 3].

Cardiopulmonary bypass (CPB) has allowed the establishment of CABG as a safe and effective treatment for patients with ischemic heart disease. However, concern has been raised that CPB may be responsible for CABG-related morbidity, and it has been suggested that CABG surgery itself would be safer without CPB. The development of commercially available cardiac stabilization devices resulted in several large, nonrandomized, retrospective case series demonstrating that CABG surgery can be performed safely without CPB (off-pump) and were suggestive of benefits when compared with conventional coronary artery bypass (CCAB).

The few randomized controlled studies published have been underpowered, and to date the advantages of OPCAB have yet to be demonstrated. We sought to determine, through systematic review with meta-analysis of all relevant randomized trials, whether OPCAB reduces 1-year mortality, rates of stroke, myocardial infarction, or revascularization when compared with CCAB.


   Material and Methods
Top
 Abstract
 Introduction
 Material and Methods
Results
 Comment
 References
 
Searching for Trials
This meta-analysis of randomized trials was performed in accordance with state-of-the-art methodologic recommendations, including the Quality of Reporting of Meta-analysis (Fig 1) Consensus Statement and Cochrane Collaboration recommendations [4, 5] and according to a protocol that prespecified outcomes, search strategies, inclusion criteria, and statistical analyses. A search was undertaken in accordance with Cochrane Collaboration recommendations to identify all published or unpublished randomized trials of OPCAB versus CCAB. English and non-English articles were included. The MEDLINE, Cochrane CENTRAL, EMBASE, Current Contents, DARE, NEED, and INAHTA databases were searched from the date of their inception to the end of April 2008. Search terms included variants of "off-pump," "beating heart," and "coronary artery bypass." Tangential electronic exploration of related articles and hand searches of bibliographies, scientific meeting abstracts, and related journals were also performed.


Figure 1
View larger version (27K):
[in this window]
[in a new window]

  		Fig 1. Identification of eligible trials. (RCTs = randomized controlled trials).

 
Inclusion Criteria
Studies were included if they met each of the following conditions: randomized allocation to OPCAB on the beating heart versus CCAB on the asystolic heart with cardiopulmonary bypass circuit; adult patients undergoing single or multiple vessel bypass; and reporting at least one pertinent clinical outcome. Blinded and unblinded studies were included. Hybrid (ie, OPCAB plus balloon angioplasty) and robotically assisted surgery studies were excluded.

Data Extraction
Two authors independently identified trials for inclusion and extracted information on demographics, interventions, and outcomes. Authors of included trials were contacted when necessary to clarify data and to identify multiple publications. When later publications added more information to original publications of randomized trials, the updated trial was included. Two reviewers independently assigned each trial a Jadad quality score that evaluates randomization, blinding, and completeness of follow-up (maximum score, 5) [6]. If there is disagreement, the trials included will be rescored by Zheng-Zhe Feng and Jian Shi together and disagreement will be resolved by consensus.

Endpoints
The primary outcome was defined as all-cause mortality, stroke, myocardial infarction, and revascularization at 1 year. Stroke was defined as a focal brain injury that persisted for more than 24 hours, combined with an increase in disability of at least one grade on the Rankin Scale for Acute Stroke [7]. Myocardial infarction was defined per study author definitions of new onset infarction using electrocardiogram or enzymatic criteria. Revascularization was defined as the need for repeat surgical coronary artery bypass grafting or the need for balloon angioplasty.

Statistical Analysis
Outcomes were analyzed as dichotomous variables. For dichotomous variables, odds ratios (OR) and 95% confidence intervals (CI) were calculated. Heterogeneity was explored using the Q statistic [8]. Recognizing that the Q test is often underpowered to detect statistically significant heterogeneity, particularly when there are few trials in the analysis, the relatively conservative threshold of p less than 0.10 was chosen to suggest statistically significant heterogeneity across trials. In addition to the Q statistic, the I2 was calculated to quantify the degree of heterogeneity across trials that could not be attributable to chance alone. As the I2 indicates the proportion of variability between trials that cannot be attributable to chance alone, it provides an improved measure of heterogeneity between trials and is not limited by power [4, 9, 10].

For each outcome, the fixed effect (Mantel-Haenszel for dichotomous variables and inverse variance for continuous variables) or random effects (DerSimonian and Laird for dichotomous and continuous variables) model was used when the Q statistic suggested lack or presence of heterogeneity, respectively. Pooled effect estimates and heterogeneity between studies were analyzed by use of Comprehensive Meta-Analysis (Biostat, 2002, Englewood, NJ) and Review Manager (RevMan for Windows, version 5.0.5, 2008, The Cochrane Collaboration, Oxford, England). Other than for the Q statistic, statistical significance was defined as p less than 0.05. All tests of statistical significance were two-sided. Whenever possible, data analysis was by intention-to-treat.

Subgroup analysis was planned to explore the potential effect of trial quality (Jadad Score ≥ 3), publication status (published versus unpublished), number of diseased vessels (no. ≥ 2), period of follow-up (years ≥ 2), and number of patients (no. ≥ 100). Publication bias was explored through visual inspection of funnel plots in which the inverse of the estimated variance of the natural logarithm of the adjusted relative risk was plotted against the natural logarithm of the adjusted relative risk for each outcome [11].


   Results
Top
 Abstract
 Introduction
 Material and Methods
 Results
Comment
 References
 
Clinical Outcomes
Figure 2 outlines primary outcomes. All-cause mortality at 1 year was not significantly reduced (OR, 1.00; 95% CI, 0.75 to 1.33). Similarly, stroke at 1 year was not significantly reduced (OR, 0.56; 95% CI, 0.34 to 0.91). Postoperative 1-year revascularization (OR, 1.38; 95% CI, 1.00 to 1.92) and acute myocardial infarction (OR, 0.61; 95% CI, 0.44 to 0.84) were not significantly reduced.


Figure 2
View larger version (43K):
[in this window]
[in a new window]

  		Fig 2. Forest plots: off-pump coronary artery bypass versus conventional coronary artery bypass. (CI = confidence integral; M-H = Mantel-Haenszel.)

 
Subgroup and Sensitivity Analysis
When subgroup analysis by number of patients was performed (Fig 3), no statistically significant differences in effect sizes were identified. The results do not change when subgroup analysis by time period of follow-up (Fig 4) or number of diseased vessels (Fig 5) was performed. As a result of insufficient data, subgroup analysis was not possible for age, renal dysfunction, pulmonary disease, and patients undergoing redo or urgent bypass. No unpublished trials were found; therefore, sensitivity analysis by publication status was unnecessary. Sensitivity analysis by Jadad score (Fig 6) showed no clear association between trial quality and outcome (test for interaction, p > 0.05 for each outcome).


Figure 3
View larger version (48K):
[in this window]
[in a new window]

  		Fig 3. Forest plots: off-pump coronary artery bypass versus conventional coronary artery bypass (number of patients ≥ 200). (CI = confidence integral; M-H = Mantel-Haenszel.) .

 

Figure 4
View larger version (35K):
[in this window]
[in a new window]

  		Fig 4. Forest plots: off-pump coronary artery bypass versus conventional coronary artery bypass (time period of follow-up ≥ 2 years). (CI = confidence integral; M-H = Mantel-Haenszel.)

 

Figure 5
View larger version (31K):
[in this window]
[in a new window]

  		Fig 5. Forest plots: off-pump coronary artery bypass versus conventional coronary artery bypass (numbers of diseased vessels ≥ 2). (CI = confidence integral; M-H = Mantel-Haenszel.)

 

Figure 6
View larger version (48K):
[in this window]
[in a new window]

  		Fig 6. Forest plots: off-pump coronary artery bypass versus conventional coronary artery bypass (Jadad score ≥ 3). (CI = confidence integral; M-H = Mantel-Haenszel.)

 

   Comment
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
References
 
Two previous meta-analyses have examined the effect of OPCAB versus CCAB in randomized and nonrandomized trials. The study by Reston and colleagues [12] suggested significant benefit for OPCAB versus CCAB for a number of clinical outcomes including death, myocardial infarction, stroke, and atrial fibrillation. However, these results were derived mainly from nonrandomized trials. Caution must be exercised in interpreting these results because of the selection bias inherent in nonrandomized trials. In addition, Reston and colleagues provide no information regarding baseline patient characteristics or number of grafts performed.

Parolari and colleagues [13] used a combined endpoint of stroke, myocardial infarction, and mortality from randomized trials, and concluded no clinical superiority of either surgical technique (OR, 0.48; 95% CI, 0.21 to 1.09). Although there was a trend that appeared to favor OPCAB versus CCAB for this composite outcome, the results needed to be interpreted with caution, as three of nine included trials were duplicated reports of the same population. A similar error including three duplicated reports of the same population occurred in the study by Reston and colleagues [12], which served to highlight the continued risk of inadvertent repeated publications contributing more than once to meta-analyses, even when care was taken to attempt to distinguish independent reports [14].

In a recent systematic review of OPCAB versus CCAB trials [15], all-cause mortality at 30 days was not significantly reduced (OR, 1.02; 95% CI, 0.58 to 1.80). Similarly, all-cause mortality at 1 to 2 years was not significantly reduced (OR, 0.88; 95% CI, 0.41 to 1.88) but was reported in only six trials. Postoperative 30-day stroke (OR, 0.68; 95% CI, 0.33 to 1.40) and acute myocardial infarction (OR, 0.77; 95% CI, 0.48 to 1.26) were not significantly reduced. Stroke at 1 to 2 years was not reduced (OR, 0.50; 95% CI, 0.15 to 1.70); however, clinically important differences cannot be ruled out because of the wide confidence intervals.

In our meta-analysis, we attempted to exclude all repeated data by contacting the authors of included studies. The rigor of this meta-analysis, as evidenced by comprehensive searches or randomized trials of all relevant outcomes and comparisons in any language, and the adherence to "Quality of Reports of Meta-Analyses" recommendations [5] serve to increase confidence that this represents a complete summary of the best available evidence. Although the median Jadad quality score was 2 of 5, this is common for meta-analysis of randomized trials [16, 17] and does not necessarily mean the trials were of low quality but rather that key methodologic details simply were not reported. Indeed, in this meta-analysis, tests for interaction found no significant association between effect size and study quality. Because blinding requires considerable effort in this type of trial, the most common reason for Jadad quality scores of 3 or less was the lack of blinding.

In our study, meta-analysis of the original ten randomized controlled trials (RCTs) did not show any significant differences between the two groups. In the sensitivity analyses, which included long-term studies (≥ 2 years), or large-size studies (total number of patients ≥ 200), we all found no significant differences in effect sizes; whereas a long-term original RCT with a mean follow-up of 1 year included in our analysis was not found to have any demonstrable prior effect on the long-term outcomes of OPCAB and did not improve the survival of OPCAB patients. Moreover, the method of blinding was not described in the RCT. Therefore, these shortcomings may harm the quality of the RCT, which might lead to the disappointing results.

Description of the Selected Studies
Figure 1 outlines the search results. Of more than 1,020 citations screened, 96 apparently relevant randomized trials were identified. Of these, 39 were excluded during online screening of the abstracts for the following reasons: nonrandom comparison, combined procedure, robotic procedure, or no direct comparison of OPCAB and CCAB. A total of 57 potentially relevant randomized trials were retrieved for evaluation. On further examination of these retrieved papers, 29 were subsequently excluded for the following reasons: nonrandom design, combined procedure, no conventional revascularization group, no relevant outcomes reported, and no extractable data reported. Of the remaining reports, we identified ten independent randomized trials. No unpublished trials were found. Therefore, a total of 2,018 patients in ten original trials provided data for this meta-analysis (Table 1).


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

  		Table 1 Numbers of Clinical Events in the Original Trials Included in Meta-Analysis
 
Although most studies stated that they excluded high-risk patients (Table 2), one study included only high-risk patients, defined as the following: left-ventricular ejection fraction of less than 0.30; had recent myocardial infarction within 1 month; had a history of supraventricular arrhythmia; had had previous CABG; had renal or respiratory impairment; or had had previous stroke, transient ischemic attack, or coagulopathy. The median Jadad score was 3 (range, 2 to 5) and only one of the included trials was scored 5. In some trials, only a few patients were included, as in the studies by Czerny and colleagues [19] and Lee and colleagues [20], so their research paper gave a relatively low statistical power.


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

  		Table 2 Characteristics of Included Trials
 
Limitations
Although the baseline demographics suggest that trials, on average, included relatively young and healthy patients, some recent trials included higher risk patients with multiple vessel disease. Nevertheless, some high-risk groups (age >70, renal dysfunction, pulmonary disease, aortic disease, ongoing ischemia) were underrepresented. This is notable, as it is precisely these patients that are purported to benefit from OPCAB.

Conclusion
In conclusion, at 12-months follow-up, off-pump coronary artery bypass surgery in our study did not differ from on-pump surgery with regard to mortality, rates of stroke, myocardial infarction, or revascularization.


   References
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 References
 

  1. Thom T, Haase N, Rosamond W, et al. Heart disease and stroke statistics–2006 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee Circulation 2006;113:e85-e151.[Free Full Text]
  2. Yusuf S, Zucker D, Peduzzi P, et al. Effect of coronary artery bypass graft surgery on survival: overview of 10-year results from randomized trials by the Coronary Artery Bypass Graft Surgery Trialists Collaboration Lancet 1994;344:563-570.[Medline]
  3. Eagle KA, Guyton RA, Davidoff R, et al. ACC/AHA 2004 guideline update for coronary artery bypass graft surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines 2004.
  4. Alderson P, Green S, Higgins J. Cochrane Reviewers' Handbook 4.2.1, [updated December 2003]Chichester, UK: John Wiley & Sons, Ltd; 2004.
  5. Moher D, Cook DJ, Eastwood S, Olkin I, Rennie D, Stroup DF. Improving the quality of reports of meta-analyses of randomised controlled trials: the QUOROM statement. Quality of Reporting of Meta-analyses. Lancet 1999;354:1896-1900.[Medline]
  6. Jadad AR, Moore RA, Carroll D, et al. Assessing the quality of reports of randomized clinical trials: is blinding necessary? Control Clin Trials 1996;17:1-12.[Medline]
  7. van Swieten JC, Koudstaal PJ, Visser MC, Schouten HJ, van Gijn J. Interobserver agreement for the assessment of handicap in stroke patients Stroke 1988;19:604-607.[Abstract/Free Full Text]
  8. Paul SR, Donner A. Small sample performance of tests of homogeneity of odds ratios in K 2 x 2 tables Stat Med 1992;11:159-165.[Medline]
  9. Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses BMJ 2003;327:557-560.[Free Full Text]
  10. Higgins JP, Thompson SG. Quantifying heterogeneity in a meta-analysis Stat Med 2002;21:1539-1558.[Medline]
  11. Egger M, Davey Smith G, Schneider M, Minder C. Bias in meta-analysis detected by a simple, graphical test BMJ 1997;315:629-634.[Abstract/Free Full Text]
  12. Reston JT, Tregear SJ, Turkelson CM. Meta-analysis of short-term and mid-term outcomes following off-pump coronary artery bypass grafting Ann Thorac Surg 2003;76:1510-1515.[Abstract/Free Full Text]
  13. Parolari A, Alamanni F, Cannata A, et al. Off-pump versus on-pump coronary artery bypass: meta-analysis of currently available randomized trials Ann Thorac Surg 2003;76:37-40.[Abstract/Free Full Text]
  14. Tramèr MR, Reynolds DJ, Moore RA, McQuay HJ. Impact of covert duplicate publication on meta-analysis: a case study BMJ 1997;315:635-640.[Abstract/Free Full Text]
  15. Cheng DC, Bainbridge D, Martin JE. Does off-pump coronary artery bypass reduce mortality, morbidity, and resource utilization when compared with conventional coronary artery bypass?. A meta-analysis of randomized trials. Anesthesiology 2005;102:188-203.[Medline]
  16. Moher D, Jones A, Lepage L, CONSORT Group (Consolitdated Standards for Reporting of Trials) Use of the CONSORT statement and quality of reports of randomized trials: a comparative before-and-after evaluation JAMA 2001;285:1992-1995.[Abstract/Free Full Text]
  17. Choi PT, Halpern SH, Malik N, Jadad AR, Tramèr MR, Walder B. Examining the evidence in anesthesia literature: a critical appraisal of systematic reviews Anesth Analg 2001;92:700-709.[Abstract/Free Full Text]
  18. Karolak W, Hirsch G, Buth K, Légaré JF. Medium-term outcomes of coronary artery bypass graft surgery on pump versus off pump: Results from a randomized controlled trial Am Heart J 2007;153:689-695.[Medline]
  19. Czerny M, Baumer H, Kilo J, et al. Complete revascularization in coronary artery bypass grafting with and without cardiopulmonary bypass Ann Thorac Surg 2001;71:165-169.[Abstract/Free Full Text]
  20. Lee JD, Lee SJ, Tsushima WT, et al. Benefits of off-pump bypass on neurologic and clinical morbidity: a prospective randomized trial Ann Thorac Surg 2003;76:18-26.[Abstract/Free Full Text]
  21. 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]
  22. Lingaas PS, Hol PK, Lundblad R, et al. Clinical and radiologic outcome of off-pump coronary surgery at 12 months follow-up: a prospective randomized trial Ann Thorac Surg 2006;81:2089-2095.[Abstract/Free Full Text]
  23. Widimsky P, Straka Z, Stros P, et al. One-year coronary bypass graft patency: a randomized comparison between off-pump and on-pump surgery angiographic results of the PRAGUE-4 trial Circulation 2004;110::3418-3423.[Abstract/Free Full Text]
  24. Puskas JD, Williams WH, Mahoney EM, 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 2004;291:1841-1849.[Abstract/Free Full Text]
  25. Angelini GD, Taylor FC, Reeves BC, Ascione R. Early and midterm outcome after off-pump and on-pump surgery in Beating Heart Against Cardioplegic Arrest Studies (BHACAS 1 and 2): a pooled analysis of two randomised controlled trials Lancet 2002;359:1194-1199.[Medline]
  26. Nathoe HM, van Dijk D, Jansen EW, et al. A comparison of on-pump and off-pump coronary bypass surgery in low-risk patients N Engl J Med 2003;348:394-402.[Medline]



This article has been cited by other articles:


Home page
 Eur J Cardiothorac SurgHome page
B. Yanagawa, K. D. Algarni, T. M. Yau, V. Rao, and S. J. Brister
Improving results for coronary artery bypass graft surgery in the elderly
Eur J Cardiothorac Surg, January 13, 2012; (2012) ezr300v1.
[Abstract] [Full Text] [PDF]

Home page
 Eur J Cardiothorac SurgHome page
N. N. Patel, E. Akowuah, and J. A. Hutter
Patient preference for coronary artery bypass graft surgery performed on the arrested or beating heart: a questionnaire study,
Eur J Cardiothorac Surg, December 1, 2011; 40(6): 1282 - 1284.
[Abstract] [Full Text] [PDF]

Home page
 Eur Heart JHome page
J. Afilalo, M. Rasti, S. M. Ohayon, A. Shimony, and M. J. Eisenberg
Off-pump vs. on-pump coronary artery bypass surgery: an updated meta-analysis and meta-regression of randomized trials
Eur. Heart J., October 10, 2011; (2011) ehr307v1.
[Abstract] [Full Text] [PDF]

Home page
 J. Thorac. Cardiovasc. Surg.Home page
H. Takagi, H. Manabe, and T. Umemoto
Late mortality in off-pump versus on-pump coronary artery bypass grafting: A meta-analysis of propensity score-adjusted studies.
J. Thorac. Cardiovasc. Surg., August 1, 2011; 142(2): 475 - 477.
[Full Text] [PDF]

Home page
 J. Thorac. Cardiovasc. Surg.Home page
H. Takagi, M. Matsui, and T. Umemoto
Conventional rather than off-pump coronary artery bypass grafting should be performed for non-high-risk patients.
J. Thorac. Cardiovasc. Surg., May 1, 2011; 141(5): 1330 - 1331.
[Full Text] [PDF]

Home page
 J. Thorac. Cardiovasc. Surg.Home page
N. N. Patel and G. D. Angelini
Off-pump coronary artery bypass grafting: For the many or the few?
J. Thorac. Cardiovasc. Surg., November 1, 2010; 140(5): 951 - 953.e1.
[Full Text] [PDF]

Home page
 J. Thorac. Cardiovasc. Surg.Home page
M. Misfeld, R. J. L. Brereton, E. A. Sweetman, and G. S. Doig
Neurologic complications after off-pump coronary artery bypass grafting with and without aortic manipulation: Meta-analysis of 11,398 cases from 8 studies
J. Thorac. Cardiovasc. Surg., August 1, 2010; 142(2): e11 - e17.
[Abstract] [Full Text] [PDF]

Home page
 Ann. Thorac. Surg.Home page
H. Takagi, M. Matsui, and T. Umemoto
Off-Pump Coronary Artery Bypass May Increase Late Mortality: A Meta-Analysis of Randomized Trials
Ann. Thorac. Surg., June 1, 2010; 89(6): 1881 - 1888.
[Abstract] [Full Text] [PDF]

Home page
 Interact CardioVasc Thorac SurgHome page
R. Jeganathan and G. Campalani
Have improvements in myocardial protection influenced a surgeon's choice of coronary artery bypass surgery?
Interact CardioVasc Thorac Surg, June 1, 2010; 10(6): 855 - 858.
[Abstract] [Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Correction (v87,p2008)
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 Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Feng, Z.-Z.
Right arrow Articles by Xu, Z.-F.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Feng, Z.-Z.
Right arrow Articles by Xu, Z.-F.
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