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): Christian Detter Hermann Reichenspurner Dieter H. Boehm Bruno Reichart Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Detter, C. Articles by Reichart, B. Search for Related Content PubMed PubMed Citation Articles by Detter, C. Articles by Reichart, B. Related Collections Minimally invasive surgery

Eur J Cardiothorac Surg 2001;19:464-470
© 2001 Elsevier Science NL

Single vessel revascularization with beating heart techniques – minithoracotomy or sternotomy?

Department of Cardiac Surgery, University Hospital Grosshadern, Ludwig-Maximilian-University, Marchioninistrasse 15, D-81366 Munich, Germany

Received 30 October 2000; received in revised form 19 January 2001; accepted 7 February 2001.

Corresponding author. Tel.: +49-89-7095-3461, fax: +49-89-7095-3465
e-mail: cdetter{at}hch.med.uni-muenchen.de

	Abstract

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion Appendix A:. Conference... References

 
Objective: The purpose of the study was to evaluate the best surgical approach in off-pump single vessel revascularization of the left anterior descending coronary artery (LAD). Methods: In 256 patients a single left internal mammary artery (LIMA) to LAD bypass was performed with beating heart techniques through a left anterior minithoracotomy (minimally invasive direct coronary artery bypass (MIDCAB), n=129) or a full sternotomy (off-pump coronary artery bypass (OPCAB), n=127). Results: In the OPCAB group, significantly more severe comorbidities (P=0.001) and redo-operations were noted (P<0.001). Conversion to sternotomy or CPB was necessary in five MIDCAB patients and one OPCAB patient. No cerebrovascular accident was seen in both groups. There was no hospital death in MIDCAB- and two deaths in OPCAB procedures (P=ns). There was a significant reduction in time of surgery (P=0.028) and coronary occlusion (P=0.009) in the OPCAB group. No differences in postoperative ventilation time, ICU stay and length of hospital stay were recorded between groups. Wound infections occurred in six MIDCAB patients (4.7%) and one OPCAB patient (0.8%). Early postoperative reoperation due to graft failure was necessary in three patients after MIDCAB and two patients after OPCAB (P=ns). Confirmed by angiography, the early graft patency rate was 96 and 98%, respectively (P=ns). Conclusions: Both beating heart techniques showed good results with low hospital mortality, low early complications and comparable angiographic results. Nevertheless, MIDCAB is a challenging technique as demonstrated by the longer times of surgery and coronary occlusion with a tendency towards a higher risk of conversion and wound infection. Thus, this technique should only be performed in selected patients with favourable coronary anatomy. Through a sternotomy approach, single vessel revascularization can be performed safely off-pump even in high-risk patients.

Key Words: Coronary artery bypass grafting • Beating heart • Minimally invasive • Minimally invasive direct coronary artery bypass • Off-pump coronary artery bypass

	1. Introduction

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion Appendix A:. Conference... References

 
Coronary artery bypass grafting (CABG) with cardiopulmonary bypass (CPB) is still the most frequent cardiac surgical procedure. Nevertheless, the use of CPB has several adverse effects with inflammatory response and the systemic release of microthrombi, which can lead to an increase in postoperative morbidity [1,2]. Within the past few years, new minimally invasive surgical techniques without CPB on a beating heart have been introduced as an alternative to standard CABG in selected patients [3–5]. With the development of different cardiac stabilizers and exposure techniques, all coronary vessels could be exposed with off-pump coronary artery bypass (OPCAB) techniques and the safety of median sternotomy [6–8]. For single vessel revascularization of the left anterior descending coronary artery (LAD) using the left internal mammary artery (LIMA), the MIDCAB (minimally invasive direct coronary artery bypass) technique through a left anterior small thoracotomy has become widely employed [9–11]. This approach claims to preserve the chest stability and to reduce the surgical trauma with respect to the smaller chest incision by avoiding a median sternotomy. Despite widespread acceptance, concerns have been raised regarding the ability to perform an accurate coronary anastomosis on a beating heart, especially when the surgical access is limited. In addition, the limitations of adequate exposure of the heart via a left anterior minithoracotomy may account for an increase in operation time and perioperative complications. The advantages and disadvantages relative to median approach have not been defined.

The purpose of the study was to evaluate the best surgical approach in off-pump single vessel revascularization with different beating heart techniques.

	2. Material and methods

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion Appendix A:. Conference... References

 
2.1. Patient selection
Between May 1997 and May 2000, a total of 430 patients underwent coronary artery bypass grafting without CPB at the University of Munich. Out of these, 256 patients had single vessel revascularization with a LIMA-to-LAD grafting with beating heart techniques. The indication for single vessel revascularization was derived from the individual cardiac findings or the extent and severity of comorbidity. Thus, indications for surgery in patients with isolated LAD stenosis were: (1) complete LAD occlusion; (2) complex lesions not considered feasible for percutaneous coronary angioplasty (PTCA) or stenting; (3) restenosis after previous PTCA or stenting; (4) the patient asked for a minimally invasive surgical procedure. If the LAD and a major diagonal branch was affected, both vessels were revascularized (n=83 patients). In the present study, however, all these patients were excluded. In 18 patients, a small diagonal branch had a significant stenosis, but was considered to small for revascularization. These patients remained in the study.

The patient selection was carried out according to the anatomical topography, coronary artery morphology, and the severity of comorbidities, and patients were carefully selected to either procedure. To detect potential technical difficulties and facilitate the decision for the best approach, since 1998 all patients with single vessel disease underwent electron beam computed tomography (EBCT) for preoperative visualization of the topographical structures and relationship between the LIMA, LAD and the bony thorax [12]. Thus, single vessel revascularization (LIMA-to-LAD grafting) was performed through a left anterior minithoracotomy (MIDCAB procedure) in 129 patients or through a median sternotomy (OPCAB technique) in 127 patients.

The patients in this study were operated by four surgeons, who are involved in our minimal invasive surgery program. These surgeons performed similar numbers of MIDCAB and OPCAB procedures. All patients were operated under comparable conditions after adequate stabilizers became commercially available.

2.2. Anesthesiological management
The procedures were performed under general endotracheal anaesthesia with a double-lumen endotracheal tube to allow right single-lung ventilation in MIDCAB procedures and regular single-lumen intubation in OPCAB surgery. The patients were positioned on a water-heated mattress in the operation room. A two-channel electrocardiograph (ECG) was applied and continuously monitored for ST-segment changes. Monitoring included continuous mixed venous saturation, a Swan-Ganz catheter for hemodynamic measurements and a transesophageal echocardiography (TEE) for detection of changes in regional wall motion. Intravenous heparin was given with a dose of 100 IU/kg body weight prior to the division of the internal mammary artery (IMA) to accomplish an activated coagulation time of greater than 250 s in all cases. Half of the amount of heparin was reversed with protamine after completion of the anastomoses.

2.3. Surgical access and beating heart technique
2.3.1. Minimally invasive direct coronary artery bypass grafting (MIDCAB) through an anterior minithoracotomy
The patient was placed in a supine position with the left shoulder being elevated about 30°. A left anterior minithoracotomy (5–8 cm) was performed and the fourth or fifth intercostal space was entered without resecting a rib. The LIMA was harvested under direct vision in all cases using the ThoraLift retractor (US Surgical Corp, Norwalk, CT). The LAD was examined and surrounded proximally and distally to the region of the anastomosis with 4-0 or 5-0 polypropylene sutures (Ethicon, Somerville, NJ) that were snared over a piece of pledget for temporary interruption of blood flow. After initial occlusion of the LAD, the ECG and regional wall motion controlled by TEE were checked for signs of major myocardial ischemia. In case of ischemia, preconditioning was performed with 5 min of occlusion, followed by a 5-min period of reperfusion. The CTS (CardioThoracic Systems Inc, Cupertino, CA) or the Genzyme stabilizer (Genzyme Surgical Products, Fall River, MA) was employed to achieve local immobilization of the target vessel. For an improved visualization of the vessel a humidified carbon dioxide blower (Medtronic DLP, Grand Rapids, MI) was used. The anastomosis between the LIMA and the LAD was performed on the beating heart with a single 7-0 or 8-0 polypropylene running suture.

In three patients (2.7%), the procedure was converted to a Port-Access CABG (Heartport Inc., Redwood City, CA) including femoral arterial and venous access for CPB and the use of transfemoral endoaortic occlusion catheter for aortic occlusion, root venting, and application of antegrade cardioplegia. This technique allows CABG to be done through the same left anterior minithoracotomy with extracorporeal circulation and cardioplegic arrest.

2.3.2. Off-pump coronary artery bypass grafting (OPCAB) and median sternotomy
OPCAB operation was carried out through a median sternotomy and the LIMA was harvested using standard techniques. Deep pericardial traction sutures were placed on the left side for exposure of the LAD. Stabilization of the vessel was initially accomplished with the Octopus^®1 suction stabilizer, since February 1999 with the Octopus^®2 stabilizer (Medtronic Inc, Minneapolis, MN), and more recently the Cohn platform (Genzyme Surgical Products, Fall River, MA) was used in addition. The distal coronary anastomosis was performed in the usual fashion as described above.

2.4. Quality control and assessment criteria
Graft patency and bypass flow rates were analyzed intraoperatively using a Doppler flow probe in all cases. Postoperative ECG was performed and serial samples of creatine kinase (CK), CK-MB, and cardiac troponin I were determined every 6 h up to 48 h in any patient. Myocardial infarction was defined as either an increase in CK-MB enzyme levels above 50 U/l or Q-wave in the postoperative ECG. An early postoperative control angiography was generally recommended, except for patients with renal insufficiency, and was always performed in patients with postoperative angina or increase CK-MB enzyme levels. Nevertheless, the majority of the patients denied to undergo subsequent angiography. Thus, postoperative angiography was only assessed in 56 MIDCAB patients (43%) and 47 OPCAB patients (37%). The average time interval between surgery and angiographic control was 7.4±5.8 days.

2.5. Statistical analysis
Values were expressed as mean±standard deviation or as median and range. Continuous data were analyzed using the Mann–Whitney U test or the unpaired Student's t-test, categorical data using the Chi-square test or Fisher's exact test as appropriate. Probability values (P) of less than 0.05 were considered significant. If a significance or a trend towards significance was found, the exact P-value was given, if no significance was found, n.s. was given. Statistical analysis was performed using the SPSS statistical software package 10.0 (SPSS Inc, Chicago, IL).

	3. Results

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion Appendix A:. Conference... References

 
Due to patient selection, the OPCAB patients were significantly older (P<0.001), had a higher CCS classification (P=0.021), a lower left ventricular ejection fraction (P=0.004), and a higher rate of unfavourable coronary anatomy (P<0.001) compared to MIDCAB patients. The preoperative demographics of the two groups are depicted in Table 1. In the OPCAB group, significantly more severe comorbidities including renal insufficiency, chronic obstructive pulmonary disease (COPD), peripheral vascular disease, and diabetes were noted (Table 2). Thus, multimorbid patients were more frequent in the OPCAB group with impairment of three or more different organ systems (P=0.001). In addition, there were a higher percentage of redo-operations in the OPCAB group (P<0.001).

View larger version (15K): [in this window] [in a new window]   Fig. 1. Graph showing mean with 95% confidence limits of creatine kinase (CK) concentrations comparing MIDCAB and OPCAB procedures up to 48 h postoperatively. The peak activity of CK was significantly higher in the MIDCAB group compared to the OPCAB technique (356±57 U/l vs. 159±27 U/l, P=0.009).

	4. Discussion

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion Appendix A:. Conference... References

This study was not randomized and the two groups were different in preoperative demographic data. Therefore, the results may have been influenced by selection bias. Nevertheless, we think that the MIDCAB procedure cannot be recommended for every patient with an isolated LAD disease. The patients were instead carefully selected to either procedure according to the anatomical topography, coronary morphology, the severity of comorbidities, and the preoperative EBCT. Thus, MIDCAB patients were significantly younger, had a lower CCS classification, and a higher left ventricular ejection fraction compared to OPCAB patients. In the OPCAB group, significantly more severe comorbidities and multimorbid patients as well as a higher rate of redo-operations were noted. However, both beating heart techniques showed good results with low hospital mortality and low early complications with no significant difference among groups. The early mortality rate was 0% in MIDCAB and 1.6% in OPCAB procedures and well comparable to other reports [8,14–18]. Both early deaths were not related to the occlusion of the LIMA-to-LAD graft. Thus, the early results appeared encouraging, especially in high-risk OPCAB patients regarding the increased surgical risk due to significantly more severe comorbidities and more complex cardiac findings. In fact, this patient group benefits the most from beating heart surgery compared to standard CPB [19].

The MIDCAB procedure offers an excellent cosmetic result to the patient with a significant lower rate of blood transfusions. Nevertheless, it is a challenging technique due to the limited approach as demonstrated by the longer time of surgery compared to a sternotomy approach. This is dedicated to the fact that the time for IMA harvesting, visualization and preparation of the LAD, as well as the coronary occlusion time was longer with a limited approach. In addition, MIDCAB tended to have a higher risk of conversion to CPB compared to OPCAB and was necessary in five MIDCAB and one OPCAB patients. In three MIDCAB patients the procedure was converted to a Port-Access CABG because of an intramyocardial LAD in two patients and an insufficient length of the LIMA in one case, conversion to sternotomy was necessary in two patients because of signs of ischemia in the ECG. In one OPCAB patient the procedure was converted to include cardiopulmonary bypass because of a small and intramyocardial LAD, which was even difficult to find with CPB. Nevertheless, 19% of the OPCAB patients had a small, calcified or intramyocardial vessel compared to 3.9% in MIDCAB patients. For this issue, the OPCAB technique is an easier approach because it allows the full exposure of the LAD and the detection of the optimal target area for the coronary anastomosis. Thus, single vessel revascularization on the beating heart it is even feasible in unfavourable coronary anatomy through a sternotomy approach.

The MIDCAB incision claims to reduce the surgical trauma and improves the cosmetic result. In fact, the need for blood transfusion was significant lower with respect to the limited incision compared to the OPCAB procedure. Nevertheless, anterior thoracotomy wound complications are not insignificant. Ng and associates [20] reported significantly higher wound complications in MIDCAB cases compared to a sternotomy approach (9.1% vs. 1.1%, P<0.005). In this study, no specific factor proved to predispose MIDCAB patients to wound problems. Pagni and colleagues suggested an increased wound infection risk associated with submammary incisions, reporting an incidence of 9%, particularly in morbidly obese patients [21]. In our study, serious wound infections occurred in six MIDCAB patients (4.7%) and one OPCAB patient (0.8%). Thus, our results showed a tendency towards a higher incidence of wound infections in the MIDCAB group. Although no risk factor could be defined, we think that the tension of the skin and the subcutaneous tissue, especially during IMA harvesting under direct vision through a minithoracotomy, may be a major risk factor predisposing for thoracotomy wound complications. The IMA retractor may contribute to fracture or avulsion of the costal cartilages. This might be a potential benefit of endoscopic IMA harvesting. Other factors that may also contribute to wound morbidity is the lack of collateral blood supply to the intercostal muscles and due to the trauma of the pectoralis muscle [20]. The muscle is divided and ischemia may occur. This is well described by the higher peak CK levels for the limited lateral incision. Nevertheless, CK-MB and troponin I levels were not different between both techniques, indicating no difference in myocardial injury and perioperative ischemia and no higher incidence of myocardial infarction.

Coronary artery bypass grafting on the beating heart is a more demanding procedure than conventional CABG. It is more difficult in terms of technical skills and requires more attention to the surgeon and the anaesthesiologist. Concerns have been raised regarding the ability to perform an accurate coronary anastomosis on a beating heart, especially with impaired visualization through a limited surgical access. In our study, the total patency rate of the LIMA-to-LAD anastomosis was not significantly different among groups. The graft patency rate was 96% through a limited incision and 98% through a full sternotomy and is well comparable with published series on the beating heart [14–18,22]. In addition, these results appear to be equivalent to conventional CABG with cardioplegic arrest. Mack and colleagues reported in a meta-analysis an early LIMA patency rate between 94.0 and 98.8% [22]. However, in this study a postoperative angiography was only assessed in 43% of the MIDCAB patients and 37% of the OPCAB patients. Although an early postoperative control angiography was generally recommended, the majority of the patients denied to undergo subsequent angiography. Thus the angiographic results may not be representative for the whole study group.

The surgical compromise between minimal incisions and best exposure is not easy to find. Proper patient selection remains the major key to a successful beating heart revascularization (Fig. 2) . If the coronary anatomy is favourable, the MIDCAB procedure can be performed in selected patients with good results. In high-risk multimorbid patients, the OPCAB procedure provides more safety, because conversion to CBP is fast and easy to perform. If an intramyocardial vessel or a small and diffuse calcified LAD is present, the MIDCAB procedure may be more difficult and conversion to sternotomy or to a Port-Access CABG with use of CPB may be necessary. A sternotomy approach is more helpful when performing revascularization on the beating heart, since the identification of the LAD and the localization of the optimal part of the vessel for the anastomosis is easier, making even revascularization of unfavourable coronary vessels feasible. Of 24 patients (19%) in the OPCAB group with unfavourable coronary anatomy, only one patient required conversion to CPB due to an intramyocardial LAD.

View larger version (20K): [in this window] [in a new window]   Fig. 2. Patient selection for single vessel revascularization of the left anterior descending coronary artery. The selection of the right technique for the right patient remains the major key to a successful beating heart revascularization.

	Footnotes

 
Presented at the 14th Annual Meeting of the European Association for Cardio-thoracic Surgery, Frankfurt, Germany, October 7–11, 2000.

	Appendix A:. Conference discussion

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion Appendix A:. Conference... References

 
Dr V. Subramanian (New York, NY, USA): Being a very strong supporter of MIDCAB, I would like to defer in the method of analysis of your two groups. Obviously the MIDCAB was an evolving platform for OPCAB. OPCAB was never widely introduced until the middle of 1998. Perhaps if you excluded those early MIDCAB patients and looked at the later group of MIDCAB patients and OPCAB, you might have shown a little lesser operative and coronary occlusion time. Have you looked at it, first?

Dr Detter: We already excluded the earlier patients which were operated in Munich in 1996 with cardiopulmonary bypass on the beating heart. The longer time of operation compared to a sternotomy approach is due to the fact that this is a more demanding technique because of the limited approach.

Dr Subramanian: The second point is about the risk of conversion. We have not converted in the last 200 consecutive MIDCAB patients. As far as the position of the LAD, it depends on where you make your incision. So the MIDCAB becomes very difficult if you make an anterior incision on the lateral LAD. Have you considered making the MIDCAB incision somewhat lateral in a laterally placed LAD?

Dr Detter: Yes we did. Because technical difficulties may occur in patients with lateral position of the LAD, since 1998 all patients with single vessel disease underwent electron beam computed tomography. With this method, the topography and relationship of the LIMA and LAD can be visualized facilitating the decision for the best approach. Thus, a more lateral incision can be chosen, if necessary.

Dr B Messmer (Aachen, Germany): I am always surprised that with the MIDCAB technique and also in OPCAB surgery you have only one anastomosis on the anterior wall of the heart. In our cases of LAD revascularization we have in two-thirds of the patients at least one major diagonal branch to revascularize as well. Therefore my question: what are you doing with the major diagonal branches?

Dr Detter: You mean in MIDCAB?

Dr Messmer: Well, in OPCAB due to better vision you have the possibility to do the diagonal branch; in MIDCAB it is a little bit more difficult.

Dr Detter: When we have an affected LAD and a diagonal branch, we usually are choosing the OPCAB technique and try to graft both vessels, if there is a sufficient diameter of the diagonal branch. Nevertheless, this is a selected group of patients, who underwent single vessel revascularization with a LIMA to LAD graft with beating heart techniques.

	References

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion Appendix A:. Conference... References

 

1. Kirklin J.K., Westaby S., Blackstone E.H., Kirklin J.W., Chenoweth D.E., Pacifico A.D. Complement and the damaging effects of cardiopulmonary bypass. J Thorac Cardiovasc Surg 1983;86:845-857.[Abstract]
2. Wan S., Izzat M.B., Lee T.W., Wan I.Y., Tang N.L., Yim A.P. Avoiding cardiopulmonary bypass in multivessel CABG reduces cytokine response and myocardial injury. Ann Thorac Surg 1999;68:52-57.[Abstract/Free Full Text]
3. Benetti F.J., Naselli G., Wood M., Geffner L. Direct myocardial revascularization without extracorporeal circulation. Experience in 700 patients. Chest 1991;100:312-316.[Abstract/Free Full Text]
4. Buffolo E., Andrade J.C., Branco J.N., Aguiar L.F., Ribeiro E.E., Jatene A.D. Myocardial revascularization without extracorporeal circulation. Seven-year experience in 593 cases. Eur J Cardio-thorac Surg 1990;4:504-508.[Abstract]
5. Pfister A.J., Zaki M.S., Garcia J.M., Mispireta L.A., Corso P.J., Qazi A.G., Boyce S.W., Coughlin T.R., Jr, Gurny P. Coronary artery bypass without cardiopulmonary bypass. Ann Thorac Surg 1992;54:1085-1092.[Abstract]
6. Buffolo E., de Andrade C.S., Branco J.N., Teles C.A., Aguiar L.F., Gomes W.J. Coronary artery bypass grafting without cardiopulmonary bypass. Ann Thorac Surg 1996;61:63-66.[Abstract/Free Full Text]
7. Jansen E.W., Grundeman P.F., Borst C., Eefting F., Diephuis J., Nierich A., Lahpor J.R., Bredee J.J. Less invasive off-pump CABG using a suction device for immobilization: the ‘Octopus’ method. Eur J Cardio-thorac Surg 1997;12:406-412.[Abstract]
8. Baumgartner F.J., Gheissari A., Capouya E.R., Panagiotides G.P., Katouzian A., Yokoyama T. Technical aspects of total revascularization in off-pump coronary bypass via sternotomy approach. Ann Thorac Surg 1999;67:1653-1658.[Abstract/Free Full Text]
9. Calafiore A.M., Giammarco G.D., 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;61:1658-1665.[Abstract/Free Full Text]
10. Subramanian V.A., Sani G., Benetti F.J., Calafiore A.M. Minimally invasive coronary bypass surgery: a multi-center report of preliminary clinical experience. Circulation 1995;92(Suppl. 1):645.
11. Acuff T.E., Landreneau R.J., Griffith B.P., Mack M.J. Minimally invasive coronary artery bypass grafting. Ann Thorac Surg 1996;61:135-137.[Abstract/Free Full Text]
12. Gulbins H., Reichenspurner H., Becker C., Boehm D.H., Knez A., Schmitz C., Bruening R., Haberl R., Reichart B. Preoperative 3D-reconstructions of Ultrafast-CT images for planning of minimally invasive direct coronary artery bypass operation (MIDCAB). Heart Surg Forum 1998;1:111-115.[Medline]
13. Loop F.D., Lytle B.W., Cosgrove D.M., Stewart R.W., Goormastic M., Williams G.W., Golding L.A., Gill C.C., Taylor P.C., Sheldon W.C., Proudfit W.L. Influence of the internal-mammary-artery graft on 10-year survival and other cardiac events. N Eng J Med 1986;314:1-6.[Abstract]
14. Jansen E.W., Borst C., Lahpor J.R., Grundeman P.F., Eefting F.D., Nierich A., Robles de Medina E.O., Bredee J.J. 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.[Abstract/Free Full Text]
15. Puskas J.D., Wright C.E., Ronson R.S., Brown W.M., 3rd, Gott J.P., Guyton R.A. Off-pump multivessel coronary bypass via sternotomy is safe and effective. Ann Thorac Surg 1998;66:1068-1072.[Abstract/Free Full Text]
16. Subramanian V.A., McCabe J.C., Geller C.M. Minimally invasive direct coronary artery bypass grafting: two-year clinical experience. Ann Thorac Surg 1997;64:1648-1655.[Abstract/Free Full Text]
17. Diegeler A., Falk V., Matin M., Battellini R., Walther T., Autschbach R., Mohr F.W. Minimally invasive coronary artery bypass grafting without cardiopulmonary bypass: early experience and follow-up. Ann Thorac Surg 1998;66:1022-1105.[Abstract/Free Full Text]
18. Cremer J.T., Wittwer T., Boning A., Anssar M.B., Kofidis T., Mugge A., Haverich A. Minimally invasive coronary artery revascularization on the beating heart. Ann Thorac Surg 2000;69:1787-1791.[Abstract/Free Full Text]
19. Arom K.V., Flavin T.F., Emery R.W., Kshettry V.R., Janey P.A., Petersen R.J. Safety and efficacy of off-pump coronary artery bypass grafting. Ann Thorac Surg 2000;69:704.[Abstract/Free Full Text]
20. Ng P.C., Chua A.N., Swanson M.S., Koutlas T.C., Chitwood W.R., Jr, Elbeery J.R. Anterior thoracotomy wound complications in minimally invasive direct coronary artery bypass. Ann Thorac Surg 2000;69:1338-1341.[Abstract/Free Full Text]
21. Pagni S., Salloum E.J., Tobin G.R., Van Himbergen D.J., Spence P.A. Serious wound infections after minimally invasive coronary bypass procedures. Ann Thorac Surg 1998;66:92-94.[Abstract/Free Full Text]
22. Mack M.J., Magovern J.A., Acuff T.A., Landreneau R.J., Tennison D.M., Tinnerman E.J., Osborne J.A. Results of graft patency by immediate angiography in minimally invasive coronary artery surgery. Ann Thorac Surg 1999;68:383-390.[Abstract/Free Full Text]
23. Becker C.R., Knez A., Ohnesorge B., Schoepf U.J., Flohr T., Bruening R., Haberl R., Reiser M.F. Visualization and quantification of coronary calcifications with electron beam and spiral computed tomography. Eur Radiol 2000;10:629-635.[Medline]

This article has been cited by other articles:

				M. D. Giglio, A. Dell'Amore, T. Aquino, S. Calvi, M. Calli, C. Marri, F. Boni, and M. Lamarra Minimally invasive coronary artery bypass grafting using the inferior J-shaped ministernotomy in high-risk patients Interactive CardioVascular and Thoracic Surgery, June 1, 2008; 7(3): 402 - 405. [Abstract] [Full Text] [PDF]

				M. Argenziano, M. Katz, J. Bonatti, S. Srivastava, D. Murphy, R. Poirier, D. Loulmet, L. Siwek, U. Kreaden, D. Ligon, et al. Results of the prospective multicenter trial of robotically assisted totally endoscopic coronary artery bypass grafting. Ann. Thorac. Surg., May 1, 2006; 81(5): 1666 - 1675. [Abstract] [Full Text] [PDF]

				S. G. Raja Drug-Eluting Stents and the Future of Coronary Artery Bypass Surgery: Facts and Fiction. Ann. Thorac. Surg., March 1, 2006; 81(3): 1162 - 1171. [Abstract] [Full Text] [PDF]

				D. Glineur, P. Noirhomme, A. Poncelet, C. Hanet, P. Astarci, R. Verhelst, P. Y. Etienne, and G. El Khoury Gastroepiploic Artery Minimally Invasive Grafting in Reoperative Patients With Patent Mammaries Ann. Thorac. Surg., May 1, 2005; 79(5): 1606 - 1609. [Abstract] [Full Text] [PDF]

				H. Niinami, H. Ogasawara, Y. Suda, and Y. Takeuchi Single-Vessel Revascularization With Minimally Invasive Direct Coronary Artery Bypass: Minithoracotomy or Ministernotomy? Chest, January 1, 2005; 127(1): 47 - 52. [Abstract] [Full Text] [PDF]

				G. J. Murphy, A. J. Bryan, and G. D. Angelini Hybrid Coronary Revascularization in the Era of Drug-Eluting Stents Ann. Thorac. Surg., November 1, 2004; 78(5): 1861 - 1867. [Abstract] [Full Text] [PDF]

				H. M. Nathoe, E. Buskens, E. W.L. Jansen, W. J.L. Suyker, P. R. Stella, J. R. Lahpor, W.-J. van Boven, D. van Dijk, J. C. Diephuis, C. Borst, et al. Role of Coronary Collaterals in Off-Pump and On-Pump Coronary Bypass Surgery Circulation, September 28, 2004; 110(13): 1738 - 1742. [Abstract] [Full Text] [PDF]

				S. K. Singh, S. K. Mishra, D. Kumar, R. D. Yadave, and S. K. Sinha Multivessel Total Arterial Revascularization via Left Thoracotomy Asian Cardiovasc Thorac Ann, March 1, 2004; 12(1): 30 - 32. [Abstract] [Full Text] [PDF]

				R. K. Wolf, E. L. Alderman, M. P. Caskey, A. R. Raczkowski, M. K. Dullum, D. C. Lundell, A. C. Hill, N. Wang, and M. A. Daniel Clinical and six-month angiographic evaluation of coronary arterial graft interrupted anastomoses by use of a self-closing clip device: a multicenter prospective clinical trial J. Thorac. Cardiovasc. Surg., July 1, 2003; 126(1): 168 - 177. [Abstract] [Full Text] [PDF]

				C. Detter, T. Deuse, F. Christ, D. H. Boehm, H. Reichenspurner, and B. Reichart Comparison of two stabilizer concepts for off-pump coronary artery bypass grafting Ann. Thorac. Surg., August 1, 2002; 74(2): 497 - 501. [Abstract] [Full Text] [PDF]

				Z. S. Meharwal and N. Trehan Single vessel revascularization with beating heart techniques - minithoracotomy or sternotomy Eur. J. Cardiothorac. Surg., October 1, 2001; 20(4): 894 - 894. [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): Christian Detter Hermann Reichenspurner Dieter H. Boehm Bruno Reichart Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Detter, C. Articles by Reichart, B. Search for Related Content PubMed PubMed Citation Articles by Detter, C. Articles by Reichart, B. Related Collections Minimally invasive surgery