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Ann Thorac Surg 2009;88:1433-1439. doi:10.1016/j.athoracsur.2009.06.059
© 2009 The Society of Thoracic Surgeons
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Original Articles: Adult Cardiac

A Three-Group Model to Predict Mortality in Emergent Coronary Artery Bypass Graft Surgery

Bernhard C. Danner, MD*, Vassilios N. Didilis, MD, PhD, Tomislav Stojanovic, MD, Aron Popov, MD, Marius Grossmann, MD, Ralf Seipelt, MD, Friedrich A. Schöndube, MD, PhD

Department of Thoracic and Cardiovascular Surgery, University of Göttingen, Göttingen, Germany

Accepted for publication June 19, 2009.

Abbreviations and Acronyms CABG = coronary artery bypass graft surgery; CK-MB = creatine kinase-myocardial band; CI = confidence interval; EuroSCORE = European System for Cardiac Operative Risk Evaluation; IABP = intra-aortic balloon pump counterpulsation; NSTEMI = non–ST-segment elevation myocardial infarction; NYHA = New York Heart Association; OR = odds ratio; STEMI = ST-segment elevation myocardial infarction

* Address correspondence to Dr Danner, Department of Thoracic and Cardiovascular Surgery, University of Göttingen, Robert-Koch-Str 40, Göttingen, 37075, Germany (Email: drdanner{at}arcor.de).


   Abstract
Top
 Abstract
Introduction
 Material and Methods
 Results
 Comment
 References
 
Background: Emergent coronary artery bypass graft surgery (CABG) for acute myocardial infarction is associated with an increased operative risk. For estimation of mortality risk, the European System for Cardiac Operative Risk Evaluation (EuroSCORE) is appropriate up to a medium risk score (<6 points). To predict mortality risk more accurately in cases of higher EuroSCORE, additional cardiac data can be helpful.

Methods: Over a 3-year period, patient data including acute myocardial infarction and emergent CABG were retrospectively reviewed. Univariate and multivariate analysis for in-hospital mortality was performed. The EuroSCORE analysis and follow-up was investigated.

Results: Overall in-hospital mortality was 18.3%. Preoperative cardiac related predictors for in-hospital mortality were cardiogenic shock (p < 0.001), very poor left ventricular function (p = 0.001), and ST-segment elevation (p = 0.012). In multivariate regression analysis, age, cardiogenic shock, and pulmonary hypertension were independent preoperative risk factors. According to the EuroSCORE, we could define three statistically different groups: intermediate-risk, high-risk, and very high risk, with an observed mortality of 3.3%, 20.0%, and 63.2%, respectively. The EuroSCORE correlates with but overestimates the mortality risk. In subgroup analysis, the creatine kinase-myocardial band/hour ratio for the intermediate-risk group and ST-segment elevation for the high-risk group were additional cardiac risk factors.

Conclusions: Patients with an acute myocardial infarction and emergency aortocoronary CABG have an elevated operative risk. Logistic EuroSCORE overestimates the mortality rate. Three different risk groups can be defined, in which creatine kinase-MB/h-ratio and ST-segment elevation can more accurately predict operative risk.


   Introduction
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 Abstract
 Introduction
Material and Methods
 Results
 Comment
 References
 
Acute myocardial infarction is defined as necrosis of myocardial cells with elevation of myocardial biomarkers such as creatine kinase-myocardial band (CK-MB) and troponin T. It is categorized either as non–ST-segment elevation myocardial infarction (NSTEMI) or ST-segment elevation myocardial infarction (STEMI), and is associated with a high mortality rate [1, 2]. Standard treatment of acute myocardial infarction includes anti-ischemic agents, antithrombin therapy, antiplatelet agents, fibrinolytic agents, and coronary revascularization [1]. Studies showed a positive impact on survival if early revascularization is done, but performing coronary artery bypass graft surgery (CABG) is mostly delayed for several days [1, 3–5]. If surgical revascularization is necessary with ongoing myocardial infarction during the first hours, emergent CABG therapy has an increased mortality risk that reaches as high as 24% to 31% [6–8].

The European System for Cardiac Operative Risk Evaluation (EuroSCORE) as a standardized risk score, not only in Europe, can predict the mortality risk [9, 10], but for patients with acute myocardial infarction, these predictors seem not to be accurate enough. We focused on these high-risk patients to find further preoperative risk factors that can be essential for decision making in the catheterization laboratory. Thus, the current study was undertaken to analyze factors for in-hospital mortality and for impact on the follow-up of patients undergoing operation on an emergent basis due to a myocardial infarction, either NSTEMI or STEMI.


   Material and Methods
Top
 Abstract
 Introduction
 Material and Methods
Results
 Comment
 References
 
Between 2003 and 2006, an emergent CABG was performed for 109 patients with an acute myocardial infarction (NSTEMI or STEMI) within the first 24 hours after coronary angiography. Immediate CABG was indicated when myocardial infarction was ongoing and (1) when percutaneous coronary intervention failed or was not technically feasible, (2) the patient had hemodynamic deterioration, or (3) the patient had persistent symptoms intractable to treatment by drugs or intra-aortic balloon pump (IABP). The combination of these factors indicates emergency status. When concomitant mitral valve repair was necessary, patients were excluded from analysis.

Hospital records of patients were reviewed to determine demographic, clinical, operative, and perioperative data. The maximum preoperative value of the myocardial biomarkers CK-MB (U · L–1) and troponin T (µg · L–1) were analyzed. Electrocardiogram abnormalities were categorized as STEMI or NSTEMI. Onset time of angina was given by the emergency records and was calculated as time span from onset of the symptoms to the beginning of the surgical intervention. For estimation of myocardial cell necrosis, the ratio of CK-MB and troponin T to this timespan was calculated, and is given as U/L–1 · h–1 or µg/L–1 · h–1, respectively. In-hospital mortality was defined as death during the periprocedural hospital stay; in our cohort, after the period of 100 days, either death occurred at the hospital or patients were discharged. Data were transformed to additive and logistic EuroSCORE values. The calculation was performed in accordance to the EuroSCORE definitions (available at: www.euroscore.org) [9]. Follow-up after discharge was given by medical records. The study was approved by the local Ethics Committee; patient consent was not necessary owing to the retrospective character of the study. No conflict of interest is declared.

Operative Procedure
All patients were operated on using standard cardiopulmonary bypass with ascending aortic and right atrial cannulation after median sternotomy. Mild hypothermia was applied, and cardiac arrest was induced either by cold crystalloid cardioplegia (Bretschneider) or antegrade and retrograde blood cardioplegia (Buckberg).

Statistical Analysis
Data are expressed for categorical variables as proportions (%) or number (n), and for continuous variables as mean ± SD. Differences in categorical variable were analyzed by Fisher's exact test, and for calculating the estimated odds ratio (OR), by the Mantel-Haenzel test. Differences in continuous variables were analyzed by independent Student t tests, controlled by the Levene test for equal variances. Results were considered significant if p values were less than 0.05; then, mean difference and confidence interval (CI) were given. Multivariate regression (likelihood function) analysis of preoperative factors was performed to identify independent factors for in-hospital mortality if p values were less than 0.05 in univariate analysis.

Kappa-means cluster analysis was performed to define groups, considering the predicted logistic EuroSCORE and observed mortality. After statistical definition of these groups, univariate risk factor analysis was performed to detect risk factors for in-hospital mortality in addition to EuroSCORE variables. Midterm survival (cardiac- and noncardiac-related deaths) was determined by the Kaplan-Meier method, and differences between groups were tested by the generalized Wilcoxon (Breslow) test.

Statistical modeling and testing were performed with SPSS statistical software (version 15.0.0; SPSS Inc, Chicago, IL).


   Results
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 Abstract
 Introduction
 Material and Methods
 Results
Comment
 References
 
Patients
Demographics and clinical characteristics of all patients are summarized in Table 1. Complete myocardial revascularization could be achieved in 98.2% (107 patients), with a mean of 3.6 distal coronary anastomoses; in 89%, the left internal thoracic artery was used. A coronary thrombendarterectomy was performed in 6.4% of patients. Aortic clamp time was 68 ± 25 minutes, and perfusion time was 139 ± 57 minutes. Postoperatively in 53 patients (48.6%), an IABP was installed; in 1 patient, extracorporeal membrane oxygenation therapy was used. In 45.9% of patients, prolonged intensive care unit stay (longer than 3 days; range 4 to 95; mean 15) was necessary; and in 34.9% of patients, prolonged ventilation time (longer than 48 hours; range, 2 to 92 days; mean 12.2) was necessary. Continuous hemofiltration was initiated in 24.8% of patients.


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  		Table 1 Demographics and Clinical Characteristics
 
Risk Factor Analysis
The overall in-hospital mortality rate was 18.3% (20 of 109 patients). In univariate analysis (see Table 2), significant preoperative risk factors for in-hospital mortality were age, STEMI, poor left ventricular ejection fraction, presence of cardiogenic shock, the need for IABP, pulmonary hypertonus, and high serum creatine level. Cardiogenic shock, the need for IABP or catecholamine, was subsumed under critical preoperative status. The additive EuroSCORE was significantly higher as was the logistic EuroSCORE in nonsurvivors. The other preoperative factors were not significantly different. Intraoperative factors such as number of graft anastomoses, the completeness of revascularization, aortic cross-clamp time, or cardioplegia were not different between survivors and nonsurvivors, whereas nonuse of the left internal artery and postoperative need for IABP were significant predictors of in-hospital mortality. In postoperative factor analysis, prolonged intensive care unit stay, ventilation time, and need for hemofiltration were significant predictors for in-hospital mortality. All data are shown in Table 2.


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  		Table 2 Univariate Analysis for In-Hospital Mortality
 
In multivariate analysis of preoperative factors, only age, cardiogenic shock, and pulmonary hypertonus reached significance as independent factors for in-hospital mortality prediction (Table 3).


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  		Table 3 Multivariate Logistic Regression Analysis for Preoperative Factors
 
STEMI versus NSTEMI
The in-hospital mortality rate was significantly higher among patients with STEMI than NSTEMI (OR 3.6, CI: 1.3 to 10.1, p = 0.012). Poor left ventricular function (OR 2.7, CI: 1.2 to 6.2, p = 0.023) and cardiogenic shock (OR 4.7, CI: 1.5 to 14.6, p = 0.006) were risk factors for in-hospital mortality in the STEMI group. The time between onset of symptoms and operative procedure was significantly shorter for patients with STEMI than for NSTEMI: 14.9 ± 12.6 hours versus 25.8 ± 18.4 hours, respectively (p = 0.001). The ratio of CK-MB per hour was significantly higher in patients with STEMI versus NSTEMI: 11.2 ± 14.5 U/L–1 · h–1 versus 4.3 ± 4.2 U/L–1 · h–1 (p = 0.015), respectively. Other preoperative factors were not significantly different; especially, there were no differences in additive or logistic EuroSCORE.

EuroSCORE Analysis
We could identify three statistically different groups related to the logistic EuroSCORE (additive EuroSCORE). In all three groups, the observed in-hospital mortality was lower than the predicted logistic EuroSCORE risk: intermediate group, 3.3% versus 17.5 ± 8.7% (additive 9.7 ± 2.0); high risk group, 20.0% versus 44.2 ± 11.2% (additive 13.9 ± 1.5); and very high risk group, 63.2% versus 74.5 ± 9.4% (additive 18.1 ± 1.8), respectively. Univariate analysis for preoperative risk factors beside the EuroSCORE variables for the three groups revealed additional predictors for mortality.

In the intermediate-risk group, the ratio of CK-MB per hour discriminates risk more accurately. Creatine kinase-MB was significantly lower (6.6 ± 5.5 versus 15.2 ± 1.9 U/L–1 · h–1, p = 0.036) in survivors versus nonsurvivors. The presence of STEMI, poor left ventricular function or cardiogenic shock, and other factors reached no statistical significance in this subgroup. In the high-risk group, the presence of STEMI was the only additional significant risk factor for in-hospital mortality (p = 0.005); in this group, no patient died in NSTEMI conditions. In the very high risk group, no further cardiac risk factor for in-hospital mortality was detected. All further preoperative factors (listed in Table 1) were not statistically different in this subgroup analysis for mortality. In all three groups, the EuroSCORE was not different between survivors and nonsurvivors. Disease characteristics for appropriate EuroSCORE calculations are listed in Table 4.


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  		Table 4 Patient Characteristics for EuroSCORE Calculation
 
Follow-Up
After discharge, 88 patients (98.9%) were in follow-up control. Overall estimated mean survival time was 35.3 ± 1.8 months (CI: 31.9 to 38.7; Fig 1). Late death occurred in 5 patients (5.3%) after a mean of 20.8 ± 8.5 months. In 4 of these 5 patients, death was due to a malignancy; in 1 patient, cause of death was unknown. Reintervention (percutaneous coronary intervention) was necessary in 1 patient; no patient had a reinfarction. New York Heart Association (NYHA) classification was a mean 1.9 ± 0.4. Four of 5 patients had NYHA classification 2 or less, and 6% had NYHA classification 3.


Figure 1
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  		Fig 1. Kaplan-Meier survival curve, all patients.

 
Midterm survival for the three groups (intermediate, high risk, and very high risk) was significantly different, with an estimated mean survival time of 41.4 ± 1.5, 35.2 ± 3.3, and 15.9 ± 4.6 months, respectively (Fig 2). Mean NYHA classification level increases from the intermediate group to the very high risk group: 1.8 ± 0.4, to 2.0 ± 0.5, to 2.5 ± 0.5 (p = 0.021 between intermediate and high-risk group; p = 0.009 between intermediate and very high risk group), respectively.


Figure 2
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  		Fig 2. Kaplan-Meier survival curves for intermediate-risk, high-risk, and very high risk groups (general Wilcoxon test between intermediate-risk and high-risk groups, p = 0.022; between high-risk and very high risk groups, p = 0.002).

 

   Comment
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
References
 
In recent years, the benefit to early and late mortality outcome with invasive therapeutic strategies in patients with acute coronary syndrome has been clearly demonstrated. In these studies, mostly percutaneous interventional procedures were performed, and surgical revascularization was delayed for more than 48 hours at least [1, 4, 5]. It is well known that patients with acute myocardial infarction have an elevated operative risk, as much as fourfold higher, and it correlates with the cardiac biomarker level in NSTEMI [11]; in patients with STEMI, mortality is as high as 24% in the first 24 hours [7].

The EuroSCORE adequately determines mortality rate for medium- and low-risk groups, but for the high-risk group, no further subgroups are established [9, 10]. In our opinion, preoperative variables such as type of myocardial infarction, time point of intervention, or critical preoperative status are not well determined by the EuroSCORE. In acute ongoing myocardial infarction with failure of percutaneous intervention, further factors are desired for the prediction of the mortality risk for these patients, and particularly, there were no differences of EuroSCORE levels in the subgroups. The EuroSCORE correlates with prediction of mortality risk even for this distinguished group of patients with ongoing acute myocardial infarction. As have we, other groups also revealed an overestimation of the mortality risk with the EuroSCORE [12]. With acute myocardial infarction, nearly all patients have a higher EuroSCORE than 6 points. In this retrospective analysis, the mortality risk increases with higher EuroSCORE, but as high as a 10-point (intermediate risk) mortality rate seems rather low for these patients. It is influenced additionally by the mass of myocardial necrosis, which is indicated by the CK-MB ratio [13]. This factor could indicate patients who should be refused an emergent CABG, and that needs to be evaluated in a larger series. A STEMI was an additional risk factor in the high-risk group (additive EuroSCORE 11 to 17) and raises the mortality risk 6.7-fold compared with that for NSTEMI patients. A STEMI was more often correlated with cardiogenic shock or poor left ventricular function, which is also considered in EuroSCORE, but was an additional factor in this group.

A greater portion of myocardial necrosis is indicated by a higher CK-MB per hour ratio in STEMI patients, but it reached no statistical significance. That could have an influence on intervention time, but the analysis of time dependency (data not shown) did not reveal a significant difference between time groups, for patients with STEMI or NSTEMI. Time interval differences were reported for STEMI patients operated on at 3 to 8 days versus the first 24 hours. In many studies, mortality associated with STEMI decreased the more the surgical intervention was delayed, but when focusing on patients operated on immediately, similar mortality rates as high as 24% were seen [7, 8, 14]. Appearance of cardiogenic shock raises the mortality rate in large studies as high as 46% to 51%, and with early percutaneous intervention and CABG is as high as 40% to 59%, respectively [16, 17]. In our patient cohort, the mortality rate of patients in cardiogenic shock was 55%. If sufficient coronary blood flow is not reached, outcome is much worse, with a very high mortality rate of 78% [16]. These patients can profit from aggressive surgical management including complete revascularization.

There are several studies in which off-pump or beating-heart technique revealed decreased mortality rate, with significantly less bypass grafting, especially for the circumflex and right coronary artery, resulting in incomplete revascularization [15, 18]. Complete revascularization is an essential factor for long-term survival, and we reached a complete revascularization in 98% of patients [19, 20]. Our standard surgical approach is operation with cardiac arrest with cardioplegia. In most cases, we used antegrade and retrograde blood cardioplegia—which is superior to crystalloid cardioplegia [21–23]—but we found no statistically significant difference for in-hospital mortality rate.

Nonuse of the left internal thoracic artery was mostly in elderly patients and in those without left anterior descending artery stenosis, but in all these patients, revascularization was complete. Because the nonuse of left internal thoracic artery interfered with age, it was not an independent factor in multivariate analysis. The use of left internal thoracic artery is an important factor for late survival, and we used it in 90% of patients younger than 75 years [20].

After discharge from hospital, the follow-up was without relevant major cardiac adverse events, and the functional capacity of the patients compares mostly with NYHA class II or even less. That indicates high surgical performance and is probably based on complete revascularization and the consequent use of the left internal artery even in emergent circumstances. In our renewed high-risk groups (intermediate, high, and very high risk), we observed statistically different midterm survival rates, which were based on the in-hospital mortality rate. The slope of survival in the intermediate group is caused by the incidence of malignant neoplasm.

Limitations of the study were the retrospective setting of the study and the single-center database, but CABG emergently performed is in most studies a small subgroup [7, 19, 24], so a multicenter prospective protocol should be initiated. The three-group analysis is based on a rather low number of patients, and has to be validated in a prospective investigation.

In conclusion, patients with ongoing acute myocardial infarction and emergent need for CABG had a significantly higher in-hospital mortality risk that is correlated with but overestimated by the EuroSCORE. We could define three groups of intermediate risk, high risk, and very high risk, which had different additional cofactors for mortality prediction.


   References
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 References
 

  1. Anderson JL, Adams CD, Antman EM, et al. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non ST-segment elevation myocardial infarction. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing committee to revise the 2002 guidelines for the management of patients with unstable angina/non–ST-elevation myocardial infarction). Circulation 2007;116:e148-e304.[Free Full Text]
  2. Rosamond WD, Chambless LE, Folsom AR, et al. Trends in the incidence of myocardial infarction and in mortality due to coronary heart disease, 1987 to 1994 N Engl J Med 1998;339:861-867.[Medline]
  3. Van de WF, Ardissino D, Betriu A, et al. Management of acute myocardial infarction in patients presenting with ST-segment elevation. The task force on the management of acute myocardial infarction of the European Society of Cardiology. Eur Heart J 2003;24:28-66.[Free Full Text]
  4. FRagmin and Fast Revascularisation during InStability in Coronary artery disease Investigators Invasive compared with non-invasive treatment in unstable coronary-artery disease: FRISC II prospective randomised multicentre study Lancet 1999;354:708-715.[Medline]
  5. Cannon CP, Weintraub WS, Demopoulos LA, et al. Comparison of early invasive and conservative strategies in patients with unstable coronary syndromes treated with the glycoprotein IIb/IIIa inhibitor tirofiban N Engl J Med 2001;344:1879-1887.[Medline]
  6. 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 (committee to update the 1999 guidelines for coronary artery bypass graft surgery). Circulation 2004;110:e340-e437.[Free Full Text]
  7. Thielmann M, Neuhauser M, Marr A, et al. Predictors and outcomes of coronary artery bypass grafting in ST elevation myocardial infarction Ann Thorac Surg 2007;84:17-24.[Abstract/Free Full Text]
  8. Tomasco B, Cappiello A, Fiorilli R, et al. Surgical revascularization for acute coronary insufficiency: analysis of risk factors for hospital mortality Ann Thorac Surg 1997;64:678-683.[Abstract/Free Full Text]
  9. Nashef SA, 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.[Abstract/Free Full Text]
  10. Nashef SA, Roques F, Hammill BG, et al. Validation of European System for Cardiac Operative Risk Evaluation (EuroSCORE) in North American cardiac surgery Eur J Cardiothorac Surg 2002;22:101-105.[Abstract/Free Full Text]
  11. Thielmann M, Massoudy P, Neuhauser M, et al. Prognostic value of preoperative cardiac troponin I in patients with non-ST-segment elevation acute coronary syndromes undergoing coronary artery bypass surgery Chest 2005;128:3526-3536.[Abstract/Free Full Text]
  12. Toumpoulis IK, Anagnostopoulos CE, DeRose JJ, Swistel DG. European System for Cardiac Operative Risk Evaluation predicts long-term survival in patients with coronary artery bypass grafting Eur J Cardiothorac Surg 2004;25:51-58.[Abstract/Free Full Text]
  13. Tanasijevic MJ, Cannon CP, Antman EM, et al. Myoglobin, creatine-kinase-MB and cardiac troponin-I 60-minute ratios predict infarct-related artery patency after thrombolysis for acute myocardial infarction: results from the Thrombolysis in Myocardial Infarction study (TIMI) 10B J Am Coll Cardiol 1999;34:739-747.[Abstract/Free Full Text]
  14. Peacock WF, De Marco T, Fonarow GC, et al. Cardiac troponin and outcome in acute heart failure N Engl J Med 2008;358:2117-2126.[Medline]
  15. Locker C, Mohr R, Paz Y, et al. Myocardial revascularization for acute myocardial infarction: benefits and drawbacks of avoiding cardiopulmonary bypass Ann Thorac Surg 2003;76:771-776.[Abstract/Free Full Text]
  16. Zeymer U, Vogt A, Zahn R, et al. Predictors of in-hospital mortality in 1333 patients with acute myocardial infarction complicated by cardiogenic shock treated with primary percutaneous coronary intervention (PCI): results of the primary PCI registry of the Arbeitsgemeinschaft Leitende Kardiologische Krankenhausarzte (ALKK) Eur Heart J 2004;25:322-328.[Abstract/Free Full Text]
  17. Hochman JS, Sleeper LA, Webb JG, et al. Early revascularization in acute myocardial infarction complicated by cardiogenic shock. SHOCK Investigators: should we emergently revascularize occluded coronaries for cardiogenic shock. N Engl J Med 1999;341:625-634.[Medline]
  18. Rastan AJ, Eckenstein JI, Hentschel B, et al. Emergency coronary artery bypass graft surgery for acute coronary syndrome: beating heart versus conventional cardioplegic cardiac arrest strategies Circulation 2006;114:I477-I485.[Medline]
  19. Sergeant P, Blackstone E, Meyns B. Early and late outcome after CABG in patients with evolving myocardial infarction Eur J Cardiothorac Surg 1997;11:848-856.[Abstract/Free Full Text]
  20. Sergeant P, Blackstone E, Meyns B, Stockman B, Jashari R. First cardiological or cardiosurgical reintervention for ischemic heart disease after primary coronary artery bypass grafting Eur J Cardiothorac Surg 1998;14:480-487.[Abstract/Free Full Text]
  21. Pichon H, Chocron S, Alwan K, et al. Crystalloid versus cold blood cardioplegia and cardiac troponin I release Circulation 1997;96:316-320.[Medline]
  22. Elvenes OP, Korvald C, Myklebust R, Sorlie D. Warm retrograde blood cardioplegia saves more ischemic myocardium but may cause a functional impairment compared to cold crystalloid Eur J Cardiothorac Surg 2002;22:402-409.[Abstract/Free Full Text]
  23. Kamlot A, Bellows SD, Simkhovich BZ, et al. Is warm retrograde blood cardioplegia better than cold for myocardial protection? Ann Thorac Surg 1997;63:98-104.[Abstract/Free Full Text]
  24. Donatelli F, Benussi S, Triggiani M, Guarracino F, Marchetto G, Grossi A. Surgical treatment for life-threatening acute myocardial infarction: a prospective protocol Eur J Cardiothorac Surg 1997;11:228-233.[Abstract/Free Full Text]



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