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): John Pym Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Pym, J. Search for Related Content PubMed PubMed Citation Articles by Pym, J.

Eur J Cardiothorac Surg 1999;16:S88-S94
© 1999 Elsevier Science NL

Off-pump arterial grafting: 125 cases using the Medtronic-Utrecht Octopus

Queen's University, 102 Stuart Street, Kingston, Ontario K7L 2V6, Canada

	Abstract

Top Abstract 1. Introduction: 2. Materials and methods 3. Results 4. Discussion Appendix References

 
Objectives: The use of arterial grafts in coronary bypass surgery requires a high degree of cardiac stabilization, traditionally achieved with cardiopulmonary bypass and cardioplegic arrest. The Medtronic-Utrecht Octopus has recently been developed as an advanced cardiac stabilization device, based on its unique suction method for regional epicardial immobilization and retraction. The objective of this study was to investigate the feasibility of using this device to enable total arterial revascularization on the beating, working heart. Methods: From May 1997 to November 1998, off-pump coronary artery bypass using exclusively arterial grafts was performed in 125 selected patients (108 males), aged 2682 years (mean 61.1±10.5 years). Coronary artery immobilization was achieved with the Octopus, which uses local epicardial suction and avoids cardiac compression. Aortic anastomoses were avoided: both internal thoracic arteries and the right gastroepiploic artery were used as pedicle grafts in all but one case. All radial artery grafts and one right internal thoracic artery were used as Y-grafts from the left internal thoracic artery. There were four surgical approaches: sternotomy (98 patients), left anterior small thoracotomy (20 patients), anterolateral thoracotomy (six patients) and a subxiphoid approach in one patient. Results: Sternotomy: 187 grafts were performed in 98 patients (mean 1.9 grafts per patient). There were 99 grafts to anterior wall vessels, 47 grafts to posterior wall vessels and 41 grafts to lateral wall vessels. Left anterior thoracotomy: 20 patients had a single graft to the left anterior descending artery (LAD). Left anterolateral thoracotomy: three patients had a single graft to a circumflex branch, while three had composite grafts to the LAD and circumflex systems. Subxiphoid: one patient had a single graft to the posterior descending branch of the right coronary artery. There were no peri-operative deaths in any group. No patient required conversion to cardiopulmonary bypass. Three patients required conversion from a limited-access approach to sternotomy. There was one re-operation for bleeding. Postoperative stay was 27 days (mean 3.6±1.1; median 3 days) for anterior thoracotomy, 3–4 days (mean 3.5±0.6) for anterolateral thoracotomy, and 378 days (mean 6.6±8.7; median 4 days) for sternotomy. There were two late deaths in salvage patients; no patient has required cardiac intervention or re-operation. Conclusions: The Octopus maintains excellent local cardiac immobilization – enabling the routine use of arterial grafts in off-pump coronary surgery. It allows easy access to anterior wall vessels on the heart, and relatively straightforward access to the posterior wall. Circumflex branches are graftable with careful case selection and adjunctive technical maneuvers.

Key Words: Coronary bypass • Arterial graft • Internal thoracic artery • Gastroepiploic artery • Radial artery • Cardiopulmonary bypass

	1. Introduction:

Top Abstract 1. Introduction: 2. Materials and methods 3. Results 4. Discussion Appendix References

 
The superior medium-term and long-term patency of arterial grafts compared with saphenous vein has led to increasing interest in the concept of total arterial revascularization of the heart. However, arterial conduits, which are smaller and more delicate than saphenous vein, are technically more demanding to use. In particular, anastomosis of an arterial graft to a coronary artery requires a high degree of cardiac immobilization. This is traditionally achieved with cardiopulmonary bypass and cardioplegic arrest. Although the first reported internal thoracic to left anterior descending anastomosis was performed almost 35 years ago without the use of cardiopulmonary bypass [1], there had been little interest in this technique until the recent advent of left internal thoracic artery to left anterior descending anastomosis through a small left anterior thoracotomy [2]. With this technique, the heart is usually stabilized by a retractor-mounted compression device, which is reasonably effective on the anterior wall of the heart, but is less effective and less well tolerated haemodynamically when used on the posterior and lateral walls. The Medtronic-Utrecht Octopus is a recent advance in cardiac stabilization technology. It has rigid arms which are attached to the operating room table rails. They terminate in pods which use local epicardial suction to maintain coronary artery stability [2]. Early experience with this device has shown that it can be used to successfully stabilize coronary arteries on the posterior and lateral walls of the heart for bypass grafting using mostly arterial grafts [3]. The objective of this study was to investigate the feasibility of using the Octopus to enable total arterial revascularization of the heart without the use of cardiopulmonary bypass.

	2. Materials and methods

Top Abstract 1. Introduction: 2. Materials and methods 3. Results 4. Discussion Appendix References

 
Between May 1997 and November 1998, 125 selected patients underwent coronary artery bypass using arterial grafts only, without the use of cardiopulmonary bypass. There were 108 males and 17 females, age 26–82 years (mean 61.1±10.5 years). All but four operations were performed by one surgeon. During this time, a further 187 patients in this surgeon's practice underwent isolated coronary bypass procedures using normothermic cardiopulmonary bypass and warm blood cardioplegic arrest. Total arterial revascularization (i.e. no venous grafts) was achieved in all but two patients in the on-pump group. The patients selected for off-pump surgery were a heterogeneous group and comprised both elective and urgent cases. There were also patients with intractable symptoms, who were deemed not to be candidates for conventional coronary bypass because of severe aortic or carotid atherosclerosis, poor renal function, or the fact that only very limited revascularization was possible. Initial selection was based on angiographic criteria – target vessel size (1.5 mm, relative freedom from distal coronary disease and the potential feasibility of exposure. Patients with significant cardiomegaly requiring grafts high on the circumflex system were not, at least initially, deemed suitable. The final decision in favor of an off-pump approach was based on intra-operative assessment. Vessel size and quality were assessed, and the heart manipulated to determine whether the target coronary artery could be exposed without significant haemodynamic compromise. Increasing experience with adjunctive technical maneuvers increased the frequency with which it was possible to graft patients off-pump. Cardiopulmonary bypass was readily available on stand-by for all cases: a dry (non-primed) bypass circuit was set up, and a perfusionist was available in the Operating Room Suite.

Four surgical approaches were used. A full or partial sternotomy was used in 98 patients (83 males, 15 females). A left anterior small thoracotomy (LAST) was used in 20 patients (18 males, two females), a left anterolateral thoracotomy in six patients (all male) and a subxiphoid approach in one male patient. Five patients, including the latter, had undergone previous coronary bypass surgery.

2.1 LAST approach
A small left anterior thoracotomy incision was made, centered on and just below the nipple. Costal cartilages were not excised or divided. The left ITA pedicle was mobilized as far as necessary to reach the left anterior descending artery (LAD) without tension or angulation and the left ITA-LAD anastomosis performed.

2.2 Left anterolateral thoracotomy approach
After harvesting a segment of radial artery, if more than one graft was needed, a left anterolateral thoracotomy incision was made from just below the nipple to the anterior border of latissimus dorsi. The left ITA pedicle was harvested up to the superior border of the first rib, and was capable of reaching distal circumflex branches with ease. For grafting both the LAD and circumflex systems, a composite graft was constructed with the radial to left ITA anastomosis at the level of the pulmonary artery. Differential pericardial traction was used to bring each artery under the surgical ‘window'. The left ITA-LAD anastomosis was performed first, followed by radial to circumflex anastomosis.

2.3 Subxiphoid approach
This was used in one patient who had previously undergone coronary artery bypass grafting and had three patent grafts, including an anteriorly situated left ITA-LAD graft. A small midline upper abdominal incision was performed, and the xiphoid process excised. After harvesting the right gastroepiploic pedicle, the central anterior attachments of the diaphragm were taken down, diaphragmatic pericardial adhesions mobilized and the posterior descending branch of the right coronary exposed.

2.4 Sternotomy approach
A full median sternotomy was performed in 97 patients and a lower hemisternotomy in one. The incision was extended 5 cm inferiorly if right gastroepiploic harvesting was required. Internal thoracic arteries were harvested as pedicles. Y-grafts, if used, were constructed after systemic heparinization. Coronary arteries were grafted in order of increasing cardiac displacement, i.e. anterior wall vessels followed by posterior wall vessels and finally lateral wall vessels. This was done on the basis that maximum dispacement would be tolerated better by an almost completely revascularized heart.

Certain techniques were common to all surgical approaches. Systemic heparinization was carried out with 1.5 mg/kg, half the normal pump dose, and was half reversed after the final anastomosis. Proximal coronary occlusion was performed with a Teflon felt-cushioned 4/0 prolene snare for most anastomoses. A 5-min test occlusion was followed by a 2-min reperfusion. Local coronary occlusion with a soft intraluminal Flo-Rester^TM was used for all anastomoses. An intracoronary shunt (Rivetti-Levinson^TM) was used if ischaemic changes were seen on test occlusion. A typical set-up for anastomosis is seen in Fig. 1. The anastomotic field was kept clear of blood with a saline/gas blower-mister. Anastomoses were performed using a two-suture technique (continuous open sutures at heel and toe) with 7/0 prolene and using 4.5x magnification.

View larger version (120K): [in this window] [in a new window]   Fig. 1. Right ITA to LAD anastomosis showing two ‘offset right' Octopus pods attached to arms fixed to the operating table rails at the patient's right shoulder and left hip. An intracoronary shunt (Rivetti-LevinsonTM) is in place, and the proximal coronary snare has been released.

	3. Results

Top Abstract 1. Introduction: 2. Materials and methods 3. Results 4. Discussion Appendix References

3.2 Left anterolateral thoracotomy approach
A single left ITA to circumflex graft was performed in three patients. Two patients had left ITA-LAD graft with radial Y-graft to a circumflex marginal vessel. One patient had a left ITA-LAD graft with a radial sequential Y-graft to two circumflex branches.

3.3 Sub-xiphoid approach
One patient had a right gastroepiploic artery graft to the posterior descending branch of the right coronary artery. One other patient in whom this was attempted was converted to a sternotomy approach because of marked hepatomegaly, secondary to alcoholic liver disease.

3.4 Sternotomy approach
One hundred and eighty-seven grafts were performed in 98 patients (mean 1.9 grafts/patient). There were 30 single, 43 double, 19 triple and one quadruple graft. The left ITA was used in 93 patients, with five sequential grafts, and the right ITA in 33. There were 50 right gastroepiploic artery grafts and six radial artery composite grafts with the left ITA. Anterior wall vessels grafted were: LAD 90 (62 left ITA, 25 right ITA, three RGEA) and diagonal nine (three left ITA, five left ITA sequential, one right ITA). Posterior wall vessels grafted were: posterior descending artery 41 (39 RGEA, one radial Y-graft from left ITA), left ventricular branch two (one RGEA, one radial Y-graft from left ITA) and the main right coronary artery in four (four RGEA). There were 41 lateral wall vessels (circumflex branches) grafted (28 left ITA, five right ITA, four radial Y-grafts and one right ITA Y-graft from the left ITA, three RGEA).

Excellent cardiac immobilization was achieved with the Octopus. Apart from small subepicardial haematomas, no cardiac injury was seen from the suction cups. No patient required conversion to cardiopulmonary bypass. Elective Hemopump^TM support was used to decompress the heart in four patients. One patient required post-operative intra-aortic balloon pump support, which was also used electively in two patients and was placed after induction of anesthesia. There were no perioperative deaths. A perioperative myocardial infarct occurred in two patients (1.6%), in regions which were not revascularized because of diffuse coronary disease. One patient (0.8%) required thoracotomy for bleeding. A focal reversible neurological deficit was seen in one patient (0.8%), occurring on the third post-operative day. Median post-operative stay was 3 days (range 2–7, median 3.6±1.1) in the LAST group, 3 days in the anterolateral thoracotomy group (range 3–4, median 3.3±0.5) and 4 days in the sternotomy group (range 3–78, median 6.6±8.7). Long post-operative stays in the latter group were seen in ‘salvage' patients with multiple medical problems, many of whom would not have been offered conventional surgery. Such patients also accounted for the two late deaths in the series. No patient required repeat coronary angiography or an interventional procedure.

	4. Discussion

Top Abstract 1. Introduction: 2. Materials and methods 3. Results 4. Discussion Appendix References

 
The morbidity of cardiopulmonary bypass is well known. Apart from the major neurological, hematological and athero-embolic complications, there is a total body inflammatory response [4] which can cause diffuse multi-organ injury. To some degree, this is universal, and undoubtedly delays post-operative recovery. Thus, if a cardiac surgical procedure can be safely performed without it, cardiopulmonary bypass should be avoided. Likewise, because of the well-known predisposition of saphenous vein grafts to accelerated atherosclerosis 7–10 years post-operatively, the use of saphenous vein grafts should be avoided, provided that total arterial revascularization can be safely performed. Are these two ideals compatible?

The ability to achieve total arterial revascularization of the heart depends on adequate surgical exposure, cardiac immobilization, the availability of appropriate conduits and their ability to reach target vessels.

4.1 Conduits
Our preference has been to use arterial grafts as pedicles, where possible, in order to avoid aortic anastomoses, and to avoid damage to the blood supply of the arterial wall. Grafts of choice have been the internal thoracic arteries, the right gastroepiploic artery and the radial arteries, in that order. In diabetics or those with significant risk factors for sternal wound problems, bilateral ITA harvesting can been avoided by the use of radial arteries to create composite or Y-grafts, usually with the left ITA. For off-pump bypass surgery, coronary anastomoses are frequently performed more distally than on pump, thus requiring longer grafts. Furthermore, the sequence of coronary grafting, choice of conduit and graft length have to take into account the effects of displacement of the full and beating heart during the procedure. Thus, whereas our normal practice is to place the left ITA to the LAD and the right ITA through the transverse sinus to proximal and mid circumflex branches, this is usually not possible off pump. Using the left ITA for the circumflex system and the right ITA for the LAD allows more distal coronary grafting and displacement of the heart without graft tension. An alternative strategy is to use a composite graft, with the left ITA placed to the LAD and a radial artery or right ITA Y-graft to the circumflex system. The right gastroepiploic artery is the graft of choice for the posterior wall of the heart. When brought through the diaphragm to the right of the midline opposite the atrioventricular groove, there is sufficient length to reach all posterior and posterolateral coronary arteries, and minimal change with cardiac elevation or rotation.

4.2 Surgical exposure
If cardiopulmonary bypass is not used, unimpaired visibility and surgical access to appropriate anastomotic sites must be achieved without haemodynamic compromise. The LAD and its branches are easily displayed, usually by elevating the heart on a sponge. However, even this may be undesirable in a relatively unstable patient whose heart is in a transverse position. Strong retraction of the diaphragm inferiorly with, for example, a table-based Omni^TM retractor, allows the heart to rotate into a more vertical orientation, allowing easy exposure without direct cardiac manipulation. The easily accessible main right coronary artery is usually not ideal for using arterial grafts because of wall thickness and mural atherosclerosis. Furthermore, temporary occlusion of the main right coronary artery may result in A–V block. For these reasons, anastomoses are usually performed to the posterior descending artery (Fig. 2). Vertical displacement of the heart (apex to ceiling) is usually well tolerated: any haemodynamic compromise is immediately reversed by mild Trendelenburg positioning (head-down tilt). Diaphragmatic retraction (as above) gives more working space and prevents the diaphragm and abdominal contents from moving cephalad if the patient is tilted. The heart can be moved into a relatively vertical position without direct manipulation by one or two pericardial retraction sutures placed directly posteriorly or posterolaterally, 2–5 cm above the diaphragm. Access to circumflex branches remains the major challenge in off-pump coronary bypass surgery. The haemodynamic changes with left to right cardiac displacement to access circumflex marginal branches are largely due to right ventricular dysfunction [5], and are often corrected by Trendelenburg positioning. However, in relatively unstable patients with large hearts, adequate exposure may not be possible. Much can be achieved with differential pericardial retraction. Left-sided retraction sutures are placed posterior to the left phrenic nerve, while the pericardium is released on the right. Strong retraction on a suture placed just inferior to the left inferior pulmonary vein rotates the heart so that intermediate or high obtuse marginal vessels are exposed. For more lateral branches, more inferiorly placed retraction sutures are used. It is important to take advantage of gravity: it has been our clinical observation that the heart tolerates displacement by gravity, much more than by direct manipulation – confirming an observation in the animal model by Grundeman (P.F. Grundeman, Personal Communication). To this end, the patient can be tilted markedly to the right, as well as in Trendelenburg (Fig. 3). If the operating table is incapable of a 45° tilt, a bolster should be placed under the left hemithorax pre-operatively, and the table tilted leftwards to level the patient. It is important to give the heart space to fall into, without compression. This is achieved by diaphragmatic retraction and by right-sided pericardial release, allowing the heart to fall into this space. In patients with a large retrosternal space, the cardiac apex can be encouraged to fall into the right pleural cavity. A Chaux^TM retractor can also be used to raise the right hemi-sternum to achieve this (J.C. Hart, pers comm). With a combination of these methods, remarkably good exposure of lateral circumflex branches can be obtained (Fig. 4).

View larger version (115K): [in this window] [in a new window]   Fig. 2. Right gastroepiploic to PDA anastomosis prior to fixation of the pedicle. ‘Preformed right' and ‘straight left' Octopus pods on the left and right of the picture respectively are attached to arms in the same position as in Fig. 1.

View larger version (132K): [in this window] [in a new window]   Fig. 3. In preparation for circumflex grafting, the patient has been placed in Trendelenburg position and tilted 45° to the right. In this picture, a mesh placed behind the heart is used to gently encourage it to fall to the right. The diaphragm is retracted inferiorly.

View larger version (116K): [in this window] [in a new window]   Fig. 4. Left ITA to circumflex marginal graft, showing two ‘offset right' Octopus pods. The mesh support has been cut to expose the coronary artery. The left atrial appendage is seen at the left of the picture. The obtuse marginal vessel has been rotated to an anterior position.

There is a definite surgical learning curve, particularly with the approach to circumflex branches, and a progression of the degree of comfort with the procedure. While this series of off-pump cases represents almost 60% of one surgeon's coronary practice in the study period, Octopus use rose from 40% of coronary bypass procedures in the first 3 months to 70% in the last 3 months. The ultimate place of off-pump coronary bypass surgery will depend on long-term results and whether arterial grafts can be performed with the same degree of precision as on pump with an arrested heart. While we believe that this is the case, late angiography is needed before a final judgement can be made. In this series, it has not been possible to perform angiographic follow-up in the absence of clinical indications. No patient has required repeat angiography or an interventional procedure. Clinical follow-up is also short, and long-term follow-up will be required to confirm the early advantages of this surgical approach.

In summary, the Octopus maintains excellent local cardiac immobilization, sufficient to allow the routine use of arterial grafts in off-pump coronary surgery. Because of its unique mechanism of action – epicardial suction rather than compression – it provides superior support and retraction of the heart in all positions, and minimizes deleterious haemodynamic effects. Stability and exposure of anterior wall vessels are uniformly excellent. Posterior wall vessels can be reliably accessed and stabilized with minor and easily correctable haemodynamic changes, if any. Circumflex branches are graftable with careful case selection and adjunctive technical maneuvers. The Medtronic-Utrecht Octopus is a major advance in cardiac stabilization technology.

	Appendix

Top Abstract 1. Introduction: 2. Materials and methods 3. Results 4. Discussion Appendix References

 
Invited commentary

Eugene KW Sim, Robert T Grignani

Division Cardiothoracic Surgery, Cardiac Department, National University Hospital, Singapore

We congratulate Dr Pym on his excellent and large series of patients in whom off-pump coronary artery bypass grafting was performed using the octopus stabiliser. Total arterial grafting was attempted in all patients. There was no mortality and extremely low morbidity, with a short length of hospital stay. It also should be noted that Dr Pym is not a stockholder in Medtronic, nor does Medtronic employ him as a consultant. This paper together with papers by Jansen [1] and Spooner [2] adds to the available literature on off-pump coronary artery bypass using the octopus stabiliser.

Like the previous two papers, the total number of vessels grafted is lower than that we would normally expect. However, probably a large number actually had single vessel coronary artery bypass grafting. In the previous two series, the majority of the patients had good ventricular functions, which is not mentioned in Dr Pym's paper. Another unique feature of this paper is that the hemopump (Medtronic, Inc., Minneapolis, MN) was used in four patients to provide cardiac support during the procedure as compared to the previous papers where cardiopulmonary bypass was used in two and six patients respectively.

Unfortunately, angiography was not available. This is a significant and important shortcoming of this paper as we know that many patients have survived off pump coronary artery bypass grafting, however whether the grafts are patent is of essential importance [3]. In Dr Jansen's paper, 86 of 100 patients were studied with 95% patency rate [1].

Off-pump coronary artery bypass grafting is not new. Beneffi and Buffalo have reported large series of patients in the 1980s. The resurgence of interest is primarily to do with the clinical successes of minimally invasive coronary artery bypass grafting (MIDCAB) and the theoretical advantage is that adverse effects of cardiopulmonary bypass and cardioplegic arrest are eliminated [4,5].

Before we can embrace this technique unreservedly, we must remember that in the early series of MIDCAB when angiography was performed routinely, the incidence of unsatisfactory results was unacceptably high [6–8]. However, it is becoming apparent that with the use of stabilisers, graft patency has improved [1,2,8,9].

This excellent report shows that multi-vessels arterial grafting with the octopus stabiliser is possible with good clinical results. However, many questions remained unanswered, for example identifying and targeting difficult vessels such as small vessels, intra-myocardium vessels or calcified vessels. Because angiography was not performed, this study cannot confirm our belief that beating heart surgery provides technically equivalent or superior results to conventional coronary artery bypass grafting.

References[1] Jansen EWL, Borst C, Lahpor JR, Gruendemann PF, Eefting FD, Nierich A, De Medina EOR, Bredee JJ. Coronary artery bypass grafting without cardiopulmonary bypass using the octopus method: results in the first one hundred patients. J Thorac Cardiovasc Surg 1998;116:60–67.[2] Spooner TH, Dyrud PE, Monson BK, Dixon GE, Robinson LD. Coronary artery bypass on the beating heart with the octopus: a North American experience. Ann Thorac Surg 1998;66:1032–1035.[3] Izzat MB, Yim APC. MIDCABG: lessons learned from routine ‘on-table' angiography. Ann Thorac Surg 1997;64:1872–1874.[4] Sim EKW, Goh JJ, Cheng A, Tan HC, Lim YT. Minimally invasive direct coronary artery bypass. Singapore Med J (in press).[5] Sim E, Landreneau R, Goh PMY, Chew C, Ng WL. Minimally invasive coronary artery bypass surgery. Asian Cardiovasc Thorac Am 1996;4: 115–116.[6] Pagni S, Qaqish NK, Senior DG. Anastomotic complications in minimally invasive coronary artery bypass grafting. Ann Thorac Surg 1997;6:564–567.[7] Barstad RM, Fosse E, Vatne K, Anderson K, Tonnessen T-I, Sennevig JL, Geiran OR. Intraoperative angiography in minimally invasive direct coronary artery bypass grafting. Ann Thorac Surg 1997;64:1835–1839.[8] Possati G, Gaudino M, Allessandrini F, Zimarino M, Glieca F, Luciani N. Systematic clinical and angiographic follow-up of patients undergoing minimally invasive coronary artery bypass. J Thorac Cardiovasc Surg 1998;115:785–790.[9] Calafiore AM, Teodori G, Di Giammarco G, Vitolla G, Iacò A, Iovino T, Cirmeni S, Bosco G, Scipioni G, Gallina S. Minimally invasive coronary artery bypass grafting on a beating heart. Ann Thorac Surg 1997;63:572–575.

	Footnotes

 
Presented at the 2nd MITSIG International Symposium: Controversies in Cardiothoracic Surgery, Hong Kong, November 20–21, 1998.

¹ Tel.: +1-613-549-3898; fax: +1-613-549-2902

	References

Top Abstract 1. Introduction: 2. Materials and methods 3. Results 4. Discussion Appendix References

 

1. Kolesov VI. Mammary artery-coronary artery anastomosis as a method of treatment for angina pectoris. J Thorac Cardiovasc Surg 1967;54:535-544.[Medline]
2. Calafiore AM, DiGiammarco G, Teodori G, Bosco G, D'Annunzio E, Barsotti A, Maddestra N, Paloscia L, Vitolla G, Sciarra A, Fino C, Contini M. Left anterior descending coronary artery grafting via left anterior small thoracotomy without cardiopulmonary bypass. Ann Thorac Surg 1996;61:1658-1685.[Abstract/Free Full Text]
3. Borst C, Jansen EWL, Tulleken CF, Grundeman PF. Mansveld Beck. H.J., van Dongen, J.W.F., Hodde, K.C., Bredee, J.J., Coronary artery bypass without cardiopulmonary bypass and without interruption of native coronary flow using a novel anastomosis site restraining device (‘Octopus'). J Am Coll Cardiol 1996;27:1356-1364.
4. Mayers I, Johnson D. The nonspecific inflammatory response to injury. Can J Anaesth 1998;45:871-879.[Abstract/Free Full Text]
5. Grundeman PF, Borst C, van Herwaarden JA. Mansvelt Beck. H.J., Jansen, E.W.L., Hemodynamic changes during displacement of the heart by the Utrecht ‘Octopus' method. Ann Thorac Surg 1997;63:S88-S92.

This article has been cited by other articles:

				N.A. Scott, J.L. Knight, B.P. Bidstrup, H. Wolfenden, R.N. Linacre, and G.J. Maddern Systematic review of beating heart surgery with the Octopus(R) Tissue Stabilizer Eur. J. Cardiothorac. Surg., May 1, 2002; 21(5): 804 - 817. [Abstract] [Full Text] [PDF]

				A. C. Anyanwu, S. Al-Ruzzeh, S. J. George, R. Patel, M. H. Yacoub, and M. Amrani Conversion to off-pump coronary bypass without increased morbidity or change in practice Ann. Thorac. Surg., March 1, 2002; 73(3): 798 - 802. [Abstract] [Full Text] [PDF]

				O. Chavanon, M. Durand, R. Hacini, H. Bouvaist, M. Noirclerc, T. Ayad, and D. Blin Coronary artery bypass grafting with left internal mammary artery and right gastroepiploic artery, with and without bypass Ann. Thorac. Surg., February 1, 2002; 73(2): 499 - 504. [Abstract] [Full Text] [PDF]

				H. Corbineau, J.-P. Verhoye, T. Langanay, P. Menestret, and A. Leguerrier Feasibility of the utilisation of the right internal thoracic artery in the transverse sinus in off pump coronary revascularisation: early angiographic results Eur. J. Cardiothorac. Surg., November 1, 2001; 20(5): 918 - 922. [Abstract] [Full Text] [PDF]

				D. Varghese, M. H. Yacoub, R. Trimlett, and M. Amrani Outcome of non-elective coronary artery bypass grafting without cardio-pulmonary bypass Eur. J. Cardiothorac. Surg., March 1, 2001; 19(3): 245 - 248. [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): John Pym Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Pym, J. Search for Related Content PubMed PubMed Citation Articles by Pym, J.