HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Olivier Jegaden Armand Eker Pietro Montagna Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Jegaden, O. Articles by Mikaeloff, P. Search for Related Content PubMed PubMed Citation Articles by Jegaden, O. Articles by Mikaeloff, P.

Eur J Cardiothorac Surg 1998;14:353-359
© 1998 Elsevier Science NL

Does the extended used of arterial grafts compromise the myocardial recovery after coronary artery bypass grafting in left ventricular dysfunction?¹

Cl. Bernard University, INSERM 121, Cardiovascular Hospital, Lyons, France

Received 30 March 1998; received in revised form 27 July 1998; accepted 28 July 1998.

Corresponding author. Hopital Cardiologique, BP Lyon-Monchat 69394, Lyons cedex 03, France. Tel.: +33 4 72357530; fax: +33 4 72357532; e-mail: ojegaden@compuserve.com

	Abstract

Top Abstract Introduction Materials and methods Results Discussion Conclusion Appendix A. Conference... References

 
Objective: To assess the prognostic factors of myocardial recovery expected after coronary bypass surgery and the impact of surgical technique used, a prospective non-randomized study including a 1-year postoperative evaluation of left ventricular function was performed in patients with left ventricular dysfunction (left ventricular ejection fraction (LVEF)<0.40). Methods: From 1993 to 1996, 110 patients (mean age 61±11 years) were included in the study. The mean LVEF was 31±6%. All patients had preoperative radionuclide investigations based on the combination of stress/reinjection thallium single photon emission computed tomography (SPECT) and planar evaluation of LVEF; 88% of patients had reversible ischemic thallium defects. Two surgical technique were used: 53 patients received the left internal mammary artery with associated sequential vein graft, and 57 patients received only arterial grafts, internal mammary and gastroepiploic arteries. The mean number of distal anastomoses was 3.2±0.8 and 54% of patients had complete revascularization. At 1 year, all survivors had clinical evaluation and the same radionuclide investigations. Results: The early mortality was 2.7%. At 1 year, 100 patients were surviving; on average, NYHA class decreased 1.9±0.8 to 1.4±0.6 (P<0.01) and CCS class from 2.8±0.6 to 1±0.3 (P<0.01). The mean LVEF increase from 31±9 to 34±10% (P<0.01) and the mean LV end-diastolic volume decreased from 317±112 to 285±108 ml (n.s.). The postoperative improvement in LV function was higher in patients in NYHA class 3 or 4 before surgery (P<0.05), when associated sequential vein graft had been used (P<0.01), and in patients with low preoperative LVEF (P<0.01). The postoperative LVEF improvement observed was significantly correlated with the improvement in left ventricular end-diastolic (LVED) volume and the improvement in redistribution/reinjection thallium uptake. Multivariate analysis showed that the surgical technique used and the preoperative LVEF were independent prognostic factors of the postoperative myocardial function recovery, with a significant positive impact of the vein use. Conclusion: This study confirms the excellent clinical results of coronary artery bypass grafting (CABG) in patients with coronary artery disease and LV dysfunction; improvement in LV function can be documented objectively and is correlated with reperfusion of hibernating myocardium. However, the extended use of arterial grafts does not allow to achieve the significant myocardial recovery observed with the use of one internal mammary artery (IMA) and associated sequential vein graft; it seems to be related to the preoperative selection of patients, but a direct negative impact of arterial grafts was documented and leads to be cautious in patients with severe LV dysfunction.

Key Words: Coronary artery bypass grafting • Left ventricular dysfunction • Arterial grafts • Single photon emission computed tomography

	Introduction

Top Abstract Introduction Materials and methods Results Discussion Conclusion Appendix A. Conference... References

 
It is well established that myocardial revascularization improves the life expectancy in coronary patients with left ventricular (LV) dysfunction [1] [2]. However, the postoperative myocardial function recovery still remains uncertain and questionable because the underlying processes responsible for reversible contractile dysfunction are often difficult to ascertain in patients [3] [4]. Nevertheless, it is clear from multiple clinical series that there is an significant subset of patients with chronic coronary artery disease and LV dysfunction who show substantial improvement in LV function after myocardial revascularization [5] [6] [7]. However the impact of the surgical technique used for myocardial revascularization on the postoperative LV dysfunction outcome has never been determined, despite the extended use of arterial conduits in coronary artery bypass grafting (CABG) owing to their known excellent long-term patency.

To test the hypothesis that the surgical technique used may influence the LV function recovery expected after CABG, in patients with LV dysfunction defined as LV ejection fraction (EF) less than 0.40, we have performed a prospective non-randomized study comparing the results of myocardium revascularization performed with either exclusive arterial grafts (internal mammary (IMA) and gastroepiploic (GEA) arteries) or one arterial graft (IMA) associated with a sequential vein graft. In this study, myocardial function and perfusion were determined by radionuclide investigations performed before surgery and one year after revascularization, with qualitative and quantitative analysis of thallium single photon emission computed tomography (SPECT) images.

	Materials and methods

Top Abstract Introduction Materials and methods Results Discussion Conclusion Appendix A. Conference... References

 
The study group consisted of a consecutive series of 110 patients who met three criteria: (1) an angiographic resting left ventricular ejection fraction (LVEF) less than 0.40, (2) preoperative radionuclide investigations using the classical combination of stress/reinjection thallium SPECT and planar evaluation of LVEF, and (3) CABG between 1993 and 1996. There was no exclusion. A prospective study of results 1 year after operation was conducted in surviving patients, based on functional assessment, myocardial function and perfusion analysis using the same radionuclide investigations as preoperatively, and angiographic control of bypass if patient accepted.

Coronary revascularization
All procedures were performed by the same surgeon; standard cardiopulmonary bypass techniques were applied using a membrane oxygenator with moderate hemodilution under mild hypothermia (34°C). For myocardial protection, slushed ice was used as topical cooling and an oxygenated cardioplegic solution was administered after aortic cross-clamping using the combined antegrade/retrograde perfusion. Two surgical techniques were performed: (1) in the arterial group, exclusive use was made of in situ arterial grafts, IMAs and GEA, according to the distribution of coronary stenoses; most often the left coronary network was revascularized by the both IMAs as sequential grafts if required, and the right coronary network by the GEA, (2) in the vein group, the left IMA was used to bypass the left anterior descending coronary artery (LAD) in all cases and it was associated with a sequential vein graft for the other coronary arteries. There was no randomization. The surgical technique was individually chosen in each case according to the state of the patient and the habits of the surgeon. As arterial grafting is technically more demanding, particularly in patients with LV dysfunction, the main idea was no increase in mortality and morbidity. Eventually vein grafts were most often used in the worse cases with heart dilation, severe LV dysfunction or heart failure signs, when immediate and maximal blood flow in the grafts seemed to be necessary. Complete myocardial revascularization was defined as bypass of all significant lesions defined as more than 70% stenosis.

Radionuclide investigations
Radionuclide studies were based on the combination of stress/reinjection thallium SPECT and planar evaluation of LVEF. Both the pre- and postoperative perfusion/viability studies were performed using a stress technique for the early thallium imaging followed by thallium reinjection and redistribution imaging. In all cases the stress was bicycle exercise, consisting of 2-min stages increments of 20 W. Thallium-201 injections were 111 MBq at maximal exercise and 37 MBq 3 h later as an additional injection. Stress SPECT were acquired starting less than 15 min after completion of the stress test and 1 h after the reinjection. After 3D reconstruction of the myocardium volume, tracer uptake was quantified and by comparison with a normal database, the size of the scintigraphic defect was quantified as a percentage of the total myocardium volume [8]. After completion of the perfusion/viability part of the study, the patient received an injection of technetium-99m for LVEF measurement.

Statistical analysis
Values of continuous variables are expressed as the mean±SD. Comparison of means was conducting using Student's t-test. Significance of differences in discrete variables was evaluated using ² analysis or Fischer's exact test. Linear regression analysis was employed to compare the correlation between continuous variables. The approximately normal distribution of the analysed continuous variables was verified. Multivariate analysis was performed by multiple logistic regression analysis, including the significant factors determined during the univariate analysis. Values of P<0.05 were considered statistically significant.

	Results

Top Abstract Introduction Materials and methods Results Discussion Conclusion Appendix A. Conference... References

 
Study subjects
The preoperative clinical characteristics of the 110 patients are shown in Table 1. As might be expected in a cohort of patients with severe coronary disease and abnormal LV function, the prevalence of male sex, prior myocardial infarction, three-vessel disease and heart failure signs was high. The mean LVEF was 31±6% (range 11–39%); it was less than 30% in 53 patients (48%). The two groups, defined according to the surgical technique used, were generally similar except that LVEF was more depressed, heart failure was more severe, LV was more dilated and number of anastomoses was higher in the vein group than in the arterial group (see Table 1); it confirms the inhomogeneous distribution of the patients between the two groups and that patients in vein group had a more severe ischemic cardiomyopathy preoperatively, despite the same prevalence of ischemic thallium defects in the both groups (see Table 1). In the arterial group, two arterial grafts were used in 32 patients and three arterial grafts in 25 patients; GEA was used to bypass the right coronary artery in 11 patients and the posterior descending coronary artery in 20 patients; there was no sequential GEA graft and 31% of patients had a sequential IMA graft.

Effects of operation on myocardial perfusion
During exercise testing, 18% of patients exhibited moderate ischemic thallium defects, reversible after redistribution, versus 88% preoperatively (P<0.01): anterior, five; inferior, 10; lateral, three. The rate of this silent residual ischemia detected by thallium scintigraphy was the same in both groups: from 85 to 15% in the vein group, from 87 to 21% in the arterial group. This postoperative improvement in myocardial perfusion was confirmed by the quantitative analysis of scintigraphic defects. The size of the stress thallium defects in % of the total myocardium volume, decreased from 35±13 to 27±10% (P<0.01), while there was no change in the size of redistribution/reinjection thallium defects: 27±11 preop versus 26±10% postop (n.s.). On the other hand, the significant preoperative ischemia defined as the difference between stress defects and redistribution/reinjection defects (35±13 vs. 27±11% P<0.01), disappeared after surgery: 27±11 versus 26±10% (n.s.). The same evolution was observed in both groups (see Table 3). The preoperative ischemia was 7±7% in arterial group and 7±6% in vein group, and 1±0.5% postoperatively in both groups. However, the postoperative improvement of stress thallium uptake (preop.–postop. values) was 6±7% in arterial group and 10±8% in vein group because the postoperative improvement in redistribution/reinjection thallium uptake (preop.–postop. values) was 4±8% in vein group and 0±4% in arterial group (P<0.05).

View larger version (12K): [in this window] [in a new window]   Fig. 1. Correlation between preoperative radionuclide left ventricular ejection fraction (LVEF) and the postoperative improvement in LVEF (D LVEF) defined as the difference between post- and preoperative values (P<0.05, r=0.41).

View larger version (15K): [in this window] [in a new window]   Fig. 2. Postoperative correlation between the LVEF improvement (D LVEF) defined as the difference between the post and the preoperative values, and the LVED volume improvement (D LVED Volume) defined as the difference between pre- and postoperative values (P<0.05, r=0.46).

View larger version (13K): [in this window] [in a new window]   Fig. 3. Postoperative correlation between the LVEF improvement (D LVEF) defined as the difference between the post and the preoperative values, and the improvement of redistribution/reinjection thallium defects (DTh uptake) defined as the difference between the pre and the postoperative values (P<0.05, r=0.48).

	Discussion

Top Abstract Introduction Materials and methods Results Discussion Conclusion Appendix A. Conference... References

 
The long-term benefit of CABG compared with medical therapy for coronary artery disease are more pronounced in patients with reduced LV function; myocardial revascularization is often performed to ameliorate ischemic symptoms, to prevent future ischemic events, and to improve survival [9] [10]. Successful revascularization can improve symptoms in the majority of these patients, even in the absence of significant improvement of objective measurements of cardiac output such as LVEF [11]. In this study, improvement in angina and heart failure symptoms occured in most patients after revascularization, regardless of the objective outcome as assessed by postoperative changes in LVEF. Patients with no significant postoperative improvement in LVEF can still potentially have improved heart failure symptoms and exercise tolerance due to resolution of ischemic LV dysfunction induced by exercise and improvement in diastolic function [3] [11]. The significant postoperative clinical improvement and decrease of ischemia during stress tests observed in this series have to be put together.

Improvement in LV function is not a universal finding after revascularization but it is not uncommon. The reversibility of LV dysfunction depends on factors including the presence and extent of stunned and hibernating myocardium, the surgeon's ability to completely revascularize hibernating tissue, perioperative myocardial infarction, and postoperative graft complications [3]. Studies have demonstrated that patients with the most severe preoperative dysfunction, and the highest resting ventricular volumes, showed the greatest postoperative improvement [7] [12] [13]. In this series the more depressed the LVEF was, the higher the LVEF improvement was. We have not observed the influence of the end-systolic LV volume index reported by Yamaguichi [13], of the extent of the reversible stress thallium defect reported by Chan [12], or of the LVED volume reported by Vanoverschelde [14]. In this series, the LV function improvement was significantly correlated with the decrease in LVED volume and improvement in redistribution/reinjection thallium uptake; it confirms that improvement in mechanical contraction is the result of recovery of hibernating myocardium due to increase in myocardial perfusion

The impact of the surgical technique on the LV function recovery that we have observed in this series was a surprising result. As we have explained, there was no randomization, and it is the main limitation of the study. The association of one IMA and vein graft was used in the worst patients with heart failure signs and low LVEF to avoid increasing the operative risk; the concern has been that in such patients, compared with a sequential vein graft, arterial grafts may not provide as much early flow and may be more susceptible to spasm, especially with inotropic support [15]. On the other hand, the known long-term patency advantages of arterial grafts, especially IMAs [16] [17], led us to perform myocardial revascularization using only arterial grafts in patients with moderate LV dysfunction when angina was in the foreground, in order to improve late results and to prevent the mid-term worsening of the ischemic cardiomyopathy due to saphenous graft occlusion [7] [18]. So there was a high bias in this series between both groups, and the interpretation of the differences in results is difficult. The first hypothesis may be that in the vein group, we had selected patients with more hibernating myocardium and more capability of LV function recovery; the second hypothesis may be that the myocardial perfusion offered by arterial grafts was not enough to allow a recovery of the myocardial contractility and function, despite the same postoperative improvement in myocardial ischemia and the same rate of silent residual ischemia in both groups. The results of the multivariate analysis showed that both hypotheses may be adopted because the postoperative LVEF improvement was dependent on the preoperative LVEF and the use or not of vein graft; according to the analysis, with the same preoperative LVEF, the postoperative LVEF improvement expected is 3.4% more if vein graft was used. Low flow in arterial grafts had already been reported, especially concerning the GEA [15], and their negative impact on LV function recovery after CABG in patients with LV dysfunction was documented in this series and remains a subject of concern.

In patients who accepted angiographic control, the graft patency was satisfactory: 89% in vein grafts and 93% in arterial grafts. The alteration of GEA anastomoses had already been reported when using GEAs of small diameter [15] [19], and may contribute to the low LV function recovery in the arterial group, but angiographic control was performed in only 43% of patients and we have not observed a impact of grafts failure on postoperative LV function outcome.

	Conclusion

Top Abstract Introduction Materials and methods Results Discussion Conclusion Appendix A. Conference... References

 
This study confirms that in patients with coronary artery disease and LV dysfunction, CABG can be performed relatively safety, quality of life is improved and improvement in LV function can be documented objectively after bypass grafting and is correlated with reperfusion of hibernating myocardium. However, the extended use of arterial grafts does not allow to achieve the significant myocardial recovery observed with the use of one IMA and associated sequential vein graft; it seems to be related to the preoperative selection of patients, but a direct negative impact of arterial grafts was documented and leads to be cautious in patients with severe LV dysfunction.

	Footnotes

 
Presented at the 11th Annual Meeting of the European Association for Cardio-thoracic Surgery, Copenhagen, Denmark, September 28 – October 1, 1997.

	Appendix A. Conference discussion

Top Abstract Introduction Materials and methods Results Discussion Conclusion Appendix A. Conference... References

 
Dr A. Mazzucco (Verona, Italy): I think I totally agree with the clinical material you have presented. It is exactly the same as that which we have in our ongoing investigation of the effects of myocardial revascularization in cases of left ventricular dysfunction. I must say, however, from your presentation, I understand that the single identified variable conditioning the late result is actually the amount of viable hibernated myocardium in the two groups. So keeping in mind the presentation by Paul Sergeant today, together with your results, what is the plan for the future for treating the patients with a large amount of hibernating myocardium? Would you do exclusive arterial revascularization or a combined arterial end vein grafting?

Dr Jegaden: It is difficult to answer because we can be tempted to change our selection of patients and the surgical process that is used in patients, according to the results of his and our study. Most often, patients with a large amount of hibernating myocardium have a depressed myocardial contraction and function. In such patients we have to find a balance between the operative risk that should be controlled and the long-term results that should be optimal. Combined arterial and vein grafting offered a low operative risk in the worst patients, and exclusive arterial revascularization may prevent mid-term worsening of ischemic cardiomyopathy due to vein graft failure. The second objective of our study is to analyse the impact of graft occlusion at 5 years, and we have decided not to change our strategy in patients until the results of this 5-year study are completed.

Dr U. Althaus (Bern, Switzerland): I have a short comment concerning your classification of clinical symptoms according to the New York Heart Association and the Canadian Cardiac Society. To my knowledge, in both classification systems the optimal category is class 1. So a patient who has no symptoms has to be allocated to class 1. There is no class 0. It you really succeeded to bring some of your patients into class 0, then I would say you have been able to transform them into immortal beings. I think you should review your classification policy.

Dr T. Kaul (Birmingham, AL, USA): I am glad that you have established the reversibilility of ischemia before operation as well as after the operation. This is a very important step in this group of patients. Please remember that thallium scan has its limitations and also has a false-negative rate which may be reduced by performing delayed thallium scanning. The second thing is you can supplement this information in select cases, by performing a dobutamine stress test. The gold standard for establishment of reversibility of ischaemia is PET scan, which is not always available, but that is the most reliable test. But I am glad that you have used these methods because I have used and recommended this approach when I published my paper on this subject. (J Thorac Cardiovasc Surg 1996;111:1001–1012).

Dr Jegaden: I totally agree with you; but as you know PET scan is very expensive and it is difficult to perform such an investigation in 100 patients. On the other hand, the aim of this study was not to identify myocardium viability before surgery or to select patients for myocardial revascularization, but to analyse factors of postoperative myocardial function recovery. Maybe, the regional study of the myocardial viability and contractility could help us to assess the revascularization impact of vein graft and arterial graft.

Dr Mazzucco: I think the concept of using PET tomography is rather expensive and cannot be a routine investigation. But the combination of a routine investigation. But I think the combination of a thallium scan and a dobutamine stress test gives practically the same amount of information on myocardial viability.

Dr A. Takriti (Damascus, Syria): I would like to know if you refuse to operate a patient depending on left ventricular and gastric pressure? If yes, what is your limit?

Dr Jegaden: No, we have really no contraindication factors in patients. In very severe cases, the indication should be discussed according to each patient. I think that there is no absolute and isolated criteria of no indication, each one should be discussed: the left ejection fraction, the end-diastolic pressure, the pulmonary pressure, the state of coronary network, and so on. I think that the decision should be very careful only in one case, i.e. if the patient shows signs of right heart failure because there is no more myocardial reserve.

Dr Takriti: If you have a patient of end diastolic pressure 30, do you operate this patient or not?

Dr Jegaden: In such difficult cases, it is a good indication to perform a PET scan or a dobutamine stress test with echo or MRI to assess the myocardial viability. If the patient has myocardial viability, he is a good candidate for myocardial revascularization with a strong probability of myocardial function recovery.

	References

Top Abstract Introduction Materials and methods Results Discussion Conclusion Appendix A. Conference... References

 

1. Alderman E.L., Fischer L.D., Litwin P. Results of coronary artery surgery in patients with poor left ventricular function (CASS). Circulation 1983;68:785-795.[Abstract/Free Full Text]
2. Killip T., Passamani E., Davis K. Coronary artery surgery study (CASS): a randomized trial of coronary bypass surgery. Eight years follow-up and survival in patients with reduced ejection fraction. Circulation 1985;72:V102-V109.
3. Bonow R.O. Identification of viable myocardium. Circulation 1996;94:2674-2680.[Free Full Text]
4. Christian T.F., Miller T.D., Hodge D.O., Orszulak T.A., Gibbons R.J. An estimate of the prevalence of reversible left ventricular dysfunction in patients referred for coronary artery bypass surgery. J Nucl Cardiol 1997;4:140-146.[Medline]
5. Elefteriades J.A., Tolis G., Levi E., Mills K., Zaret B.L. Coronary artery bypass grafting in severe left ventricular dysfunction: excellent survival with improved ejection fraction and functional state. J Am Coll Cardiol 1993;22:1411-1417.[Abstract]
6. Dreyfus G.D., Duboc D., Blasco A., Vigoni F., Dubois C., Brodaty D., de Lentdecker P., Bachet J., Goudot B., Guilmet D. Myocardial viability assessment in ischemic cardiomyopathy: benefits of coronary revascularization. Ann Thorac Surg 1994;57:1402-1408.[Abstract]
7. Flameng W.J., Shilvalkar B., Spiessens B., Maes A., Nuyts J., Vanhaecke J., Mortelmans L. PET scan predicts recovery of left ventricular function after coronary artery bypass operation. Ann Thorac Surg 1997;64:1694-1701.[Abstract/Free Full Text]
8. Bontemps L., Nazzi M.B., Gabain M., Jegaden O., Felecan R., Itti R. A theoretical model for myocardial functional characterization: application to a group of patients evaluated before and after surgical revascularization. J Nucl Cardiol 1998;5:134-143.[Medline]
9. Milano C.A., White W.D., Smith R., Jones R.H., Lowe J.E., Smith P.K., van Trigt P. Coronary artery bypass in patients with severely depressed ventricular function. Ann Thorac Surg 1993;56:487-493.[Abstract]
10. Mickleborough, L.L., Maruyama, H., Takagi, Y., Mohamed, S., Sun, Z., Ebisuzaki, L. Results of revascularization in patients with severe left ventricular dysfunction. Circulation 1995;92:II73–II79.
11. DiCarli M.F., Asgarzadie F., Schelbert H.R., Brunken R.C., Laks H., Phelps M.E., Maddahi J. Quantitative relation between myocardial viability and improvement in heart failure symptoms after revascularization in patients with ischemic cardiomyopathy. Circulation 1995;92:3436-3444.[Abstract/Free Full Text]
12. Chan R.K.M., Raman J., Lee K.J., Rosalion A., Hicks R.J., Pornvilawan S., Sia B.S.T., Horowitz J.D., Tonkin A.M., Buxton B.F. Prediction of outcome after revascularization in patients with poor left ventricular function. Ann Thorac Surg 1996;61:1428-1434.[Abstract/Free Full Text]
13. Yamaguchi A., Ino T., Adachi H., Mizuhara A., Murata S., Kamio H. Left ventricular end-systolic volume index in patients with ischemic cardiomyopathy predicts postoperative ventricular function. Ann Thorac Surg 1995;60:1059-1062.[Abstract/Free Full Text]
14. Vanoverschelde, J.L.J., Gerber, B.L., D'Hondt, A.M., de Hock, M., Dion, R., Wijns, W., Melin, J.A. Preoperative selection of patients with severely impaired left ventricular function for coronary revascularization. Role of low-dose dobutamine echocardiography and exercise-redistribution-reinjection thallium SPECT. Circulation 1995;92:II37–II44.
15. Jegaden O., Eker A., Montagna P., Ossette J., de Gevigney G., Saint Pierre A., Revel D., Itti R., Mikaeloff P. Risk and results of bypass grafting using bilateral internal mammary and right gastroepiploic arteries. Ann Thorac Surg 1995;59:955-960.[Abstract/Free Full Text]
16. Schmidt S.E., Jones J.W., Thornby J.I., Miller C.C., Beall A.C. Improved survival with multiple left-sided bilateral internal thoracic artery grafts. Ann Thorac Surg 1997;64:9-15.[Abstract/Free Full Text]
17. Pick A.W., Orszulak T.A., Anderson B.J., Schaff H.V. Single versus bilateral internal mammary artery grafts: 10-year outcome analysis. Ann Thorac Surg 1997;64:599-605.[Abstract/Free Full Text]
18. Jegaden O., de Gevigney G., Montagna P., Delahaye F., Eker A., Ossette J., Mikaeloff P. Late survival up to 20 years after isolated coronary bypass surgery using internal mammary artery in patients with severe left ventricular dysfunction. J Cardiovasc Surg 1994;35:129-134.
19. Voutilainen S., Verkkala K., Järvinen A., Keto P. Angiographic 5-year follow-up study of right gastroepiploic artery grafts. Ann Thorac Surg 1996;62:501-505.[Abstract/Free Full Text]

This article has been cited by other articles:

				S. Al-Ruzzeh, S. George, M. Bustami, K. Nakamura, S. Khan, M. Yacoub, and M. Amrani The early clinical and angiographic outcome of sequential coronary artery bypass grafting with the off-pump technique J. Thorac. Cardiovasc. Surg., March 1, 2002; 123(3): 525 - 530. [Abstract] [Full Text] [PDF]

				R. Lorusso, G. La Canna, C. Ceconi, V. Borghetti, P. Totaro, G. Parrinello, G. Coletti, and G. Minzioni Long-term results of coronary artery bypass grafting procedure in the presence of left ventricular dysfunction and hibernating myocardium Eur. J. Cardiothorac. Surg., November 1, 2001; 20(5): 937 - 948. [Abstract] [Full Text] [PDF]

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Olivier Jegaden Armand Eker Pietro Montagna Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Jegaden, O. Articles by Mikaeloff, P. Search for Related Content PubMed PubMed Citation Articles by Jegaden, O. Articles by Mikaeloff, P.