EJCTS Click here for details of sales representative
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Sotiris C. Stamou
Robert C. Lowery
Emmanouil I. Kapetanakis
Peter C. Hill
Paul J. Corso
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Frankel, T. L.
Right arrow Articles by Corso, P. J.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Frankel, T. L.
Right arrow Articles by Corso, P. J.
Related Collections
Right arrow Coronary disease
Right arrow Minimally invasive surgery

Eur J Cardiothorac Surg 2005;27:494-500
© 2005 Elsevier Science NL

Risk factors for hemorrhage-related reexploration and blood transfusion after conventional versus coronary revascularization without cardiopulmonary bypass

Timothy L. Frankela, Sotiris C. Stamoua,*, Robert C. Loweryb, Emmanouil I. Kapetanakisa, Peter C. Hilla, Elizabeth Hailec, Paul J. Corsoa

a Section of Cardiac Surgery, Washington Hospital Center, Washington, DC, USA
b Section of Cardiac Surgery, SUNY Downstate Health Science Center, Brooklyn, NY, USA
c MedStar Research Institute, Washington, DC, USA

Received 7 July 2004; received in revised form 11 November 2004; accepted 23 November 2004.

* Corresponding author. Address: 1201 South Eads Street, Apt 1909, Arlington, VA 22202, USA. Tel.: +1 202 361 2377. (E-mail: paul.j.corso{at}medstar.net).


   Abstract
Top
 Abstract
1. Introduction
 2. Methods
 3. Results
 4. Discussion
 References
 
Objective: The premise of coronary revascularization without cardiopulmonary bypass (off-pump CABG) proposes that patient morbidity and, potentially, mortality can be reduced without compromising the excellent results of conventional revascularization techniques (on-pump CABG). It is unknown, however, whether coronary artery bypass without cardiopulmonary bypass (off-pump CABG) is associated with similar hemorrhage related reexploration rates and blood transfusion requirements compared to the on-pump approach. Methods: Between January 1998 and June 2002, 3646 patients underwent off-pump CABG and were compared with a contemporaneous control group of 5197 on-pump CABG patients. A logistic regression model was used to test the difference in the postoperative hemorrhage related reexploration rates and need for postoperative blood transfusions between the groups, controlling for preoperative risk factors. The patients undergoing off-pump CABG were matched to on-pump patients by propensity score. Results: Hemorrhage related reexploration rates were comparable between the 2 groups (odds-ratio [OR]=0.80, 95% confidence intervals [CI]=0.55–1.09, P=0.15). Off-pump CABG was associated with a lower need for single and multiple unit postoperative blood transfusions (OR=0.30, CI=0.24–0.31, P<0.01 and OR=0.4, CI=0.36–0.51, P<0.01, respectively) compared to on-pump CABG patients. Conclusions: Off-pump CABG eliminates the risks of cardiopulmonary bypass and the systemic inflammatory response it elicits. A substantially lower need for postoperative blood transfusions and a comparable hemorrhage-related reexploration rate suggests that off-pump CABG may avoid the morbidity and mortality associated with excessive postoperative blood loss.

Key Words: Cardiac surgical procedures • Complications • Comparative study • Reexploration due to bleeding • Blood transfusions

Abbreviations: Off-pump CABG = coronary artery bypass without cardiopulmonary bypass • On-pump CABG = coronary artery bypass with cardiopulmonary bypass • IABP = intraaortic balloon counterpulsation • CABG = coronary artery bypass graft • OR = odds ratio • 95% CI = 95% confidence intervals • PTCA = percutaneous transcatheter coronary angioplasty


   1. Introduction
Top
 Abstract
 1. Introduction
2. Methods
 3. Results
 4. Discussion
 References
 
In the past three decades, Coronary Artery Bypass Grafting (CABG) with cardiopulmonary bypass (CPB) has become the standard surgical intervention for the treatment of coronary artery disease (CAD). Its safety, efficacy, and completeness of revascularization over medical therapy or percutaneous transluminal coronary angioplasty (PTCA) have been well established [1]. Despite its relative safety, however, CABG is still associated with significant postoperative complications such as renal failure, atrial fibrillation, and bleeding complications (i.e. reexploration due to bleeding and need for postoperative transfusions) [1]. Recent advances in surgical techniques and postoperative management have aimed at reducing postoperative morbidity and mortality. One such advance attempts to avoid the deleterious effects of extracorporeal circulation by performing CABG without CPB (off-pump CABG).

Early studies suggest that off-pump CABG is associated with lower rates of postoperative atrial fibrillation [2], stroke [3], and a decreased overall mortality [4] compared to on-pump CABG. Other studies, however, have failed to reproduce these results [5]. It is largely unknown whether off-pump CABG may yield similar improvements in the hemorrhage related reexploration rates and transfusion requirements after CABG. The aim of this study was to compare hemorrhage-related reexploration rates and blood transfusion requirements after off-pump CABG with a matched set of patients undergoing on-pump CABG.


   2. Methods
Top
 Abstract
 1. Introduction
 2. Methods
3. Results
 4. Discussion
 References
 
2.1. Patients
The computerized database of the Section of Cardiac Surgery of the Washington Hospital Center was used to identify all patients who underwent CABG between January 1998 and June 2002 (N=8843). Of these patients, 5197 underwent on-pump CABG and 3646 had off-pump CABG. Patients who underwent emergent or salvage operations, who had a mini-lateral thoracotomy or a mini-sternotomy (MIDCAB) or had other cardiac or vascular surgical procedures were excluded from the study (N=143). Patients with >6 grafts (N=40), and those who received preoperative thrombolytics (N=7) were also excluded from this study. Baseline demographics, procedural data, and perioperative outcomes on 8843 patients were recorded and entered into a prespecified database by a dedicated data coordinating center.

2.2. Operative technique and selection criteria
Standard anesthesia and surgical techniques, extracorporeal circulation, and myocardial protection methods were used with on-pump CABG. Off-pump CABG was performed using the standard median sternotomy. Indications for off-pump CABG included patients who were considered high risk for on-pump CABG because of medical comorbidities such as renal failure, diffuse cerebrovascular and peripheral vascular disease, aortic atherosclerosis, chronic obstructive pulmonary disease, and religious convictions that precluded blood transfusions and also included surgeon's preference [3].

Contraindications for off-pump CABG included inadequate exposure and intramyocardial vessels.

2.3. Definitions
Previous cerebrovascular accident was defined as history of central neurologic deficit persisting for more than 24h. Chronic renal insufficiency was defined as a serum creatinine value≥2.0mg/dl. Diabetes was defined as a history of diabetes mellitus, regardless of duration of disease or need for oral agents or insulin. Preoperative anti-platelet agents included aspirin, adenosine diphosphate (ADP)-receptor antagonists and GPIIb/IIIa receptor antagonists. Single unit blood transfusion indicates the patient received no more than one 350ml unit of blood from a single donor either intraoperatively or postoperatively. Multiple unit blood transfusion indicates the patient received more than one 350ml unit of blood from one or multiple donors either intraoperatively, postoperatively, or both. The study's primary end point was the incidence of hemorrhage-related reexploration exclusive of any other cardiac or non-cardiac cause. Hemorrhage-related reexploration was indicated when chest tube drainage exceeded 500ml in the first hour, 400ml per hour in the first 2h, 300ml per hour in the first 3h, 200ml per hour in the first 4h, or in the case of cardiac tamponade.

Persistent intra-operative bleeding was controlled by first addressing all surgical causes, reversing heparin with protamine in an attempt to normalize the ACT, and then initiating PRBC transfusion as required. Aminocaproic acid was administered in all patients having on-pump CABG, but aprotinin, factor VII or other agents were not routinely used.

Operative blood loss plus intra- and postoperative transfusion rates and amounts were recorded for the principal blood product types, including packed red blood cells (PRBC), platelets and fresh frozen plasma (FFP). Clinical practice guidelines recommended PRBC transfusion at a hematocrit of <22 for patients younger than 65 years old or <24 for patients 65 years old or older. The need for additional blood product transfusions remained at the discretion of the individual surgeon, anesthesiologist or intensivist. Postoperative prophylactic unfractionated or low molecular weight heparin was not routinely used in the postoperative setting.

2.4. Statistical analysis
Univariate comparisons of categorical preoperative, operative, and postoperative variables were performed between off-pump and on-pump CABG groups. Dichotomous variables were compared using a Chi-square test of general association or a Fisher's exact test for expected cell counts less than 5. Comparisons between continuous variables were performed using the Student t-test for normally distributed data or the Wilcoxon rank-sum test for non-parametric data. Ordinal data were compared using the Cochran-Armitage trend test. All tests were two-sided and P values≤0.05 were considered significant.

Logistic regression models were constructed using an unmatched sample to determine independent predictors of three outcomes; (1) hemorrhage-related reexploration, (2) rate of intraoperative and postoperative single unit blood transfusions, and (3) of those that received a blood transfusion, requirement of multiple unit intraoperative and postoperative blood transfusions. These models consisted of any preoperative risk factors that were deemed significant (P<0.15) in the univariate analysis of off-pump versus on-pump CABG, risk factors identified from the literature as being associated with postoperative hemorrhage-related reexploration [6] or need for transfusion [7], and variables from Parsonnet's risk score. Variables included are presented in Table 1. Model fit analysis was evaluated using the Homer and Lemeshow goodness-of-fit statistical and residual analysis. The c-statistic was reported as a measure of predictive power. The presence of linear dependencies or correlation among the independent variables was checked using diagnostics from ordinary logistic regression.


View this table:
[in this window]
[in a new window]
  		Table 1. Univariate analysis of preoperative patient characteristics
 
Propensity scores were computed for all patients and used to match patients from the off-pump CABG and on-pump CABG groups as previously described [8]. By matching on propensity score, a measure of the probability of being selected for either off-pump or on-pump CABG, each group will have nearly equal proportions of the preoperative variables [8,9]. Matching also controls for confounding variables. The general estimating method was then used in a logistic regression to test the difference in the rate of transfusion and hemorrhage-related reexploration between the off-pump and on-pump CABG groups, in the propensity score matched subpopulation.


   3. Results
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
4. Discussion
 References
 
3.1. Preoperative characteristics
Preoperative patient characteristics are presented in Table 1. Patients in the off-pump CABG group were more likely to be females (P<0.01), more likely to have received preoperative clopidogrel (P<0.01) or glycoprotein IIb/IIIa antagonists (P<0.01), were older (P<0.01) and their surgeries were performed more recently as compared to the patients who had on-pump CABG (P<0.01) (Table 1). Patients who underwent on-pump CABG were heavier (P<0.01), more likely to have diabetes (P<0.01), urgent/emergent or salvage surgery (P<0.01), lower preoperative ejection fraction (P<0.01), greater reoperative CABG rate (P<0.01), and more likely to have received preoperative heparin and/or warfarin (P<0.01), compared to the off-pump CABG group. Estimated blood loss was higher after on-pump compared to off-pump CABG (Table 1). There was no difference in core body temperature between the two groups on arrival in the ICU.

3.2. Hemorrhage-related reexploration
Hemorrhage-related reexploration rates for on-pump and off-pump CABG were 2.8% (N=146) and 2.1% (N=75), respectively, P=0.03. Results of the logistic regression model for the outcome hemorrhage-related reexploration are presented in Table 2. In multivariate logistic regression analysis of the unmatched sample, advanced age (P=0.02), weight (P<0.01), preoperative Clopidogrel (<0.01), left main stenosis (P=0.02), peripheral vascular disease (P=0.04), cardiogenic shock (P=0.02) and reoperative CABG (P<0.01) emerged as independent risk factors for hemorrhage-related reexploration (Table 2). Hemorrhage-related reexploration rates were similar between the off-pump and on-pump CABG patients [OR (odds ratio)=0.8, 95% CI (confidence intervals)=0.55–1.09, P=0.15].


View this table:
[in this window]
[in a new window]
  		Table 2. Multiple logistic regression of the unmatched group for the outcome reexploration due to hemorrhage (N=8843)
 
Following the logistic regression analysis, propensity scores were calculated for each patient and used to match patients receiving off-pump CABG to the contemporaneous on-pump CABG group. Matches were found for 59% of the off-pump CABG patients. A total of 4282 patients (2141 on-pump and 2141 off-pump CABG) were matched by propensity score. Patients were matched by age, gender, weight, african ancestry, reoperative CABG, hypertension, left main stenosis, peripheral vascular disease, cardiogenic shock, case priority, 4–6 vessels grafted (versus 1–3), diabetes, ejection fraction, preoperative hematocrit, preoperative administration of clopidogrel, aspirin, warfarin and/or heparin, glycoprotein IIb/IIIa inhibitors, other preoperative anti-platelet agents, date of surgery (2000–2001 versus 1998–1999), recent myocardial infarction (within 24h), cerebrovascular accident, failed PTCA, and hemodialysis. After matching by propensity (of being an off-pump patient) score, there was a comparable rate of hemorrhage related reexploration between the two groups [OR=0.8, 95% CI=0.53–1.24, P=0.34].

3.3. Allogeneic-blood transfusion requirements
Multivariate logistic regression analyses for risk factors for postoperative single unit blood transfusion or multiple unit blood transfusion are listed in Tables 3 and 4, respectively. After matching, off-pump CABG was associated with a lower need for single unit intraoperative and/or postoperative blood transfusion (odds ratio=0.4, 95% confidence intervals=0.36–0.46, P<0.01). Matches were found for 69% of the off-pump CABG patients, of those who had received blood transfusions. A total of 2370 patients (1185 on-pump and 1185 off-pump CABG patients were matched by propensity score. Similarly, off-pump CABG was associated with a lower need of multiple units of intraoperative and/or postoperative blood transfusions (odds ratio=0.5, 95% confidence intervals=0.39–0.58, P<0.01). Thus, patients who underwent off-pump CABG have an almost 60% reduction in the odds of receiving single and 50% for receiving multiple unit blood transfusions intraoperatively and/or postoperatively, compared with patients who had on-pump CABG.


View this table:
[in this window]
[in a new window]
  		Table 3. Multiple logistic regression model of the unmatched group for single unit blood transfusion requirement (N=8843)
 
The median volume of blood received both intraoperatively and postoperatively was significantly greater in the on-pump group compared to the off-pump group with a median of 874ml (range 100–10,500ml) and 656ml (range 200–8500), respectively (P<0.01).


   4. Discussion
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
 4. Discussion
References
 
4.1. CPB, Systemic inflammatory respone and coagulopathy
Previous studies reported that on-pump CABG leads to coagulation disorders [10] and promotes a systemic inflammatory response [11]. CPB has been shown to induce complement activation, endotoxin release, leukocyte activation, the expression of adhesion molecules, and the release of many inflammatory mediators including oxygen-free radicals, arachidonic acid metabolites, cytokines, platelet-activating factor, nitric oxide, and endothelins. This inflammatory cascade may increase postoperative complications including respiratory and renal failure, multisystem organ failure, neurologic complications and bleeding disorders [11]. The possible pathophysiology of these postoperative coagulation disorders is likely multifactorial and includes hemodilution secondary to the pump priming solution [10,12], activation and degranulation of platelets [13], hyperfibrinolysis [14], and consumption of coagulation factors [10]. Elimination of CPB may attenuate postoperative coagulopathy resulting in a decreased need for blood transfusion requirements and hemorrhage-related reexploration [7,15]. A recent study by Casati et al. [16] comparing coagulation and fibrinolysis during on-pump versus off-pump CABG found that on-pump CABG patients experienced transient platelet consumption, and higher plasminogen activation, and D-dimer formation compared to those undergoing off-pump CABG. Although previous studies have investigated differences in postoperative hemorrhage-related complications between off-pump and on-pump CABG, they have been limited by small sample size and comparison of unmatched groups [15]. In our study, we compared hemorrhage-related reexploration and blood transfusion requirements in a large risk-adjusted group of patients undergoing off-pump versus on-pump CABG.

4.2. Hemorrhage-related reexploration
Coagulopathy during cardiac surgery with CPB results in impairment in hemostasis and subsequently higher morbidity and mortality. In our study, we compared hemorrhage-related reexploration rates between patients undergoing off-pump versus on-pump CABG. After matching by propensity score and adjusting for potential confounders, we found that off-pump CABG was associated with a comparable rate of hemorrhage-related reexploration. Previous authors have found a decreased rate of hemorrhage-related reexploration after off-pump compared to on-pump CABG [17]. A meta-analysis study on the early and mid-term results of off-pump compared to on-pump CABG confirmed a lower rate of hemorrhage-related reexploration after off-pump than on-pump CABG [18]. In ours and previous studies increasing age [6], diabetes, and reoperative CABG [19] emerged as independent predictors of hemorrhage-related reexploration. In addition to these previously described risk factors, weight, preoperative administration of clopidogrel, cardiogenic shock and reoperative CABG emerged as an independent risk factor for hemorrhage-related reexploration, echoing previous reports [20]. Presence of left main disease and peripheral vascular disease are gross indicators of the severity of atherosclerotic disease in these patients. Usually this subset of patients requires prolonged cardiopulmonary bypass times that can increase the risk for bleeding. However, delineation of the specific reasons why peripheral vascular disease and left main stenosis are associated with increased risk of postoperative bleeding was outside the scope of this study.

4.3. Allogeneic blood transfusion requirements
Exposure to non-autologous blood poses a risk for viral transmission, including hepatitis B,C, and HIV and transfusion reactions [21] previously found to be associated with increased postoperative morbidity and long-term mortality [22]. Multiple postoperative blood transfusions have also been associated with increased morbidity and mortality compared with single-unit blood transfusion [23]. Previous studies have suggested that off-pump CABG is associated with lower postoperative blood transfusion requirements [7], but no previous reports have investigated its effect on multiple blood unit transfusion requirements. In the current study, off-pump CABG was associated with a significantly lower need for both single and multiple unit blood transfusions. In multivariate analysis, advanced age, female gender, increased weight, African ancestry, chronic renal insufficiency, hemodialysis, left main stenosis, peripheral vascular disease, preoperative hematocrit and reoperative CABG emerged as independent risk factors for both single and multiple unit blood transfusion requirements. Previous studies [24] have suggested that the use of anti-platelet agents may not be associated with an increase in bleeding complications, however, in our study the preoperative administration of anti-platelet agents was an independent risk factor for both reexploration for hemorrhage and postoperative blood transfusion requirement, as previously reported [20].

4.4. Clinical implications
The historically poor postoperative course of patients requiring blood transfusions and hemorrhage-related reexploration illustrates the need for early recognition of risk factors that predispose patients to postoperative bleeding complications. We were able to create a statistically powerful model to adjust for potential imbalances between the two groups and identify risk factors for hemorrhage-related reexploration and allogeneic blood transfusion requirements. Patients deemed high-risk for postoperative bleeding complications may benefit from intraoperative administration of, {epsilon}-aminocaproic acid, tranexamic acid, aprotonin, or arginine vasopressin. Aprotinin acts as a serine protease inhinitor and has been shown in several randomized studies to reduce bleeding after CABG with or without cardiopulmonary bypass by about 50% without adverse effects in the patients studied [25,26]. E-aminocaproic acid and tranexamic acid are two other fibrinolytic agents that can be administered before, after or during cardiopulmonary bypass to reduce bleeding and the need for allogeneic blood transfusions [25]. Administration of corticosteroids and intraoperative ultrafiltration are already routine procedure during on-pump CABG in many cardiac surgery centers in an effort to decrease the systemic inflammatory response and coagulopathy associated with CPB [11].

Off-pump CABG, when indicated, may decrease the need for postoperative blood transfusion requirements. Patients with preoperative risk factors for postoperative bleeding complications such as advanced age, female gender, chronic renal insufficiency, hemodialysis, diabetes, reoperative CABG, or patients who received anti-platelet agents preoperatively may benefit from the decreased postoperative transfusion needs offered by off-pump CABG.

4.5. Study limitations
Limitations of our study include those inherent to a retrospective single-institution methodology. Furthermore, multivariate analysis may not adequately account for the inherent selection bias in non-randomized data. However, matching by propensity score has been shown to substantially decrease selection bias [8]. Furthermore, different criteria of reexploration in terms of blood loss/kg bodyweight/h may have led to a higher rate of reexploration. The long term outcomes after off-pump versus on-pump CABG remains to be ascertained. Furthermore the lack of comparative data on long-term outcomes emphasizes that these retrospective initial reports need to be validated by further studies. Thorough scientific analysis in a prospective randomized setting should ideally be performed for all surgical management paradigms.


View this table:
[in this window]
[in a new window]
  		Table 4. Multivariate analysis of the unmatched group for multiple unit blood transfusion requirement (N=5336)
 

   References
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
 4. Discussion
 References
 
  1. Yusuf S, Zucker D, Peduzzi P, Fisher LD, Takaro T, Kennedy JW, Davis K, Killip T, Passamani E, Norris R. Effect of coronary artery bypass graft surgery on survival: overview of 10-year results from randomized trials by the Coronary Artery Bypass Graft Surgery Trialists Collaboration. Lancet 1994;344:563-570.[CrossRef][Medline]
  2. Stamou SC, Dangas G, Hill PC, Pfister AJ, Dullum MK, Boyce SW, Bafi AS, Garcia JM, Corso PJ. Atrial fibrillation after beating heart surgery. Am J Cardiol 2000;86:64-67.[CrossRef][Medline]
  3. Stamou SC, Hill PC, Dangas G, Pfister AJ, Boyce SW, Dullum MK, Bafi AS, Corso PJ. Stroke after coronary artery bypass: incidence, predictors, and clinical outcome. Stroke 2001;32:1508-1513.[Abstract/Free Full Text]
  4. Magee MJ, Jablonski KA, Stamou SC, Pfister AJ, Dewey TM, Dullum MK, Edgerton JR, Prince SL, Acuff TE, Corso PJ, Mack MJ. Elimination of cardiopulmonary bypass improves early survival for multivessel coronary artery bypass patients. Ann Thorac Surg 2002;73(4):1196-1202.[Abstract/Free Full Text]
  5. van Dijk D, Nierich AP, Eefting FD, Buskens E, Nathoe HM, Jansen EW, Borst C, Knape JT, Bredee JJ, Robles de Medina EO, Grobbee DE, Diephuis JC, de Jaegere PP, Octopus Study Group. Early outcome after off-pump versus on-pump coronary bypass surgery: results from a randomized study. Circulation 2001;104(15):1761-1766.[Abstract/Free Full Text]
  6. Dacey LJ, Munoz JJ, Baribeau YR, Johnson ER, Lahey SJ, Leavitt BJ, Quinn RD, Nugent WC, Birkmeyer JD, O'Connor GT. Reexploration for hemorrhage following coronary artery bypass grafting: incidence and risk factors. Northern New England Cardiovascular Disease Study Group. Arch Surg 1998;133(4):442-447.[Abstract/Free Full Text]
  7. Ascione R, Williams S, Lloyd CT, Sundaramoorthi T, Pitsis AA, Angelini GD. Reduced postoperative blood loss and transfusion requirement after beating-heart coronary operations: a prospective randomized study. J Thorac Cardiovasc Surg 2001;121:689-696.[Abstract/Free Full Text]
  8. Grunkemeier GL, Payne N, Jin R, Handy Jr JR. Propensity score analysis of stroke after off-pump coronary artery bypass grafting. Ann Thorac Surg 2002;74(2):301-305.[Free Full Text]
  9. Allison P. Logistic regression using the SAS system, theory and application. SAS Institute; 1999pp. 197–206.
  10. Rinder CS. Hematologic effects of cardiopulmonary bypass. In: Gravlee GP, Davis RF, Kurusz M, Utley JR, editors. Cardiopulmonary bypass: principles and practice. Baltimore, MD: Lippincott, Williams and Wilkins; 2000. pp. 492-505.
  11. Wan S, LeClerc JL, Vincent JL. Inflammatory response to cardiopulmonary bypass: mechanisms involved and possible therapeutic stratagies. Chest 1997;112:676-692.[Abstract/Free Full Text]
  12. Cormack JE, Forest RJ, Groom RC, Morton J. Size makes a difference: use of a low-prime cardiopulmonary bypass circuit and autologous priming in small adults. Perfusion 2000;15:129-135.[Abstract/Free Full Text]
  13. Rinder CS, Bohnert J, Rinder HM, Mitchell J, Ault K, Hillman R. Platelet activation and aggregation during cardiopulmonary bypass. Anesthesiology 1991;75:388-393.[Medline]
  14. Giuliani R, Szwarcer E, Martinez Aquino E, Palumbo G. Fibrin-dependent fibrinolytic activity during extracorporeal circulation. Thromb Res 1991;61:369-373.[CrossRef][Medline]
  15. Kshettry VR, Flavin TF, Emery RW, Nicoloff DM, Arom KV, Petersen RJ. Does multivessel, off-pump coronary artery bypass reduce postoperative morbidity?. Ann Thorac Surg 2000;69:1725-1730.[Abstract/Free Full Text]
  16. Casati V, Gerli C, Franco A, Della Valle P, Benussi S, Alfieri O, Torri G, D'Angelo A. Activation of coagulation and fibrinolysis during coronary surgery: on-pump versus off-pump techniques. Anesthesiology 2001;95:1103-1109.[CrossRef][Medline]
  17. Meharwal ZS, Mishra YK, Kohli V, Singh S, Bapna RK, Mehta Y, Trehan N. Multivessel off-pump coronary artery bypass: analysis of 4953 cases. Heart Surg Forum 2003;6:153-159.[Medline]
  18. Reston JT, Tregear SJ, Turkelson CM. Meta-analysis of short-term and mid-term outcomes following off-pump coronary artery bypass grafting. Ann Thorac Surg 2003;76:1510-1515.[Abstract/Free Full Text]
  19. Unsworth-White MJ, Herriot A, Valencia O, Poloniecki J, Smith EE, Murday AJ, Parker DJ. Resternotomy for bleeding after cardiac operation: a marker for increased morbidity and mortality. Ann Thorac Surg 1995;59:664-667.[Abstract/Free Full Text]
  20. Dullum MKC, Leiboff BO, Stamou SC, Hill PC, Boyce SW, Pfister AJ, Bafi AS, Lowery R, Qazi A, Garcia JM, Corso PJ. Clopidogrel for prevention of thrombotic complications after cardiac surgery: a word of caution. J Am Coll Cardiol 2001;37(Suppl):362A.
  21. Schreiber GB. The risk of transfusion-transmitted viral infections. N Engl J Med 1996;334:1685-1691.[Abstract/Free Full Text]
  22. Engoren MC, Habib RH, Zacharias A, Schwann TA, Riordan CJ, Durham SJ. Effect of blood transfusion on long-term survival after cardiac operation. Ann Thorac Surg 2002;74:1180-1186.[Abstract/Free Full Text]
  23. Baud O, Lacaze-Masmonteil T, Monsaingeon-Lion A, Chabernaud JL, Zupan V, Boithias C, Andre P, Gross E, Dehan M. Eur J Pediatr 1998;157:579-582.[CrossRef][Medline]
  24. Grubitzsch H, Wollert HG, Eckel L. Emergency coronary artery bypass grafting: does excessive preoperative anticoagulation increase bleeding complications and transfusion requirements?. Cardiovasc Surg 2001;9:510-516.[CrossRef][Medline]
  25. In: Koutsoukos NT, Blackstone EH, Doty DB, Hanley FL, Karp RB, editors. Hypothermia, circulatory arrest and cardiopulmonary bypass. 3rd ed. Kirklin/Barrat-Boyes cardiac surgery. Philadelphia, PA: Churchill Livingstone; 2003. pp. 66-130.
  26. Cartier R, Brann S, Dagenais F, Martineau R, Couturier A. Systematic off-pump coronary artery revascularization in multivessel disease: experience of three hundred cases. J Thorac Cardiovasc Surg 2000;119:221-229.[Abstract/Free Full Text]



This article has been cited by other articles:


Home page
 J. Thorac. Cardiovasc. Surg.Home page
P. C. Austin
Propensity-score matching in the cardiovascular surgery literature from 2004 to 2006: a systematic review and suggestions for improvement.
J. Thorac. Cardiovasc. Surg., November 1, 2007; 134(5): 1128 - 1135.
[Abstract] [Full Text] [PDF]

Home page
 J. Thorac. Cardiovasc. Surg.Home page
J. K. Shim, Y. S. Choi, Y. J. Oh, S. O. Bang, K. J. Yoo, and Y. L. Kwak
Effects of preoperative aspirin and clopidogrel therapy on perioperative blood loss and blood transfusion requirements in patients undergoing off-pump coronary artery bypass graft surgery
J. Thorac. Cardiovasc. Surg., July 1, 2007; 134(1): 59 - 64.
[Abstract] [Full Text] [PDF]

Home page
 ICVTSHome page
P. J. Robinson, B. Billah, K. Leder, C. M. Reid, and on behalf of the ASCTS Database Committee
Factors associated with deep sternal wound infection and haemorrhage following cardiac surgery in Victoria
Interactive CardioVascular and Thoracic Surgery, April 1, 2007; 6(2): 167 - 171.
[Abstract] [Full Text] [PDF]

Home page
 J. Thorac. Cardiovasc. Surg.Home page
C. M. Dyke, N. G. Smedira, A. Koster, S. Aronson, H. L. McCarthy II, R. Kirshner, A. M. Lincoff, and B. D. Spiess
A comparison of bivalirudin to heparin with protamine reversal in patients undergoing cardiac surgery with cardiopulmonary bypass: The EVOLUTION-ON study
J. Thorac. Cardiovasc. Surg., March 1, 2006; 131(3): 533 - 539.
[Abstract] [Full Text] [PDF]

Home page
 Eur. J. Cardiothorac. Surg.Home page
T. Vanek, M. Jares, R. Fajt, Z. Straka, K. Jirasek, M. Kolesar, P. Brucek, and M. Maly
Fibrinolytic inhibitors in off-pump coronary surgery: a prospective, randomized, double-blind TAP study (tranexamic acid, aprotinin, placebo)
Eur. J. Cardiothorac. Surg., October 1, 2005; 28(4): 563 - 568.
[Abstract] [Full Text] [PDF]

Home page
 Eur. J. Cardiothorac. Surg.Home page
S. G. Raja
OPCAB: time to call off the search for the Holy Grail!
Eur. J. Cardiothorac. Surg., September 1, 2005; 28(3): 515 - 516.
[Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Sotiris C. Stamou
Robert C. Lowery
Emmanouil I. Kapetanakis
Peter C. Hill
Paul J. Corso
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Frankel, T. L.
Right arrow Articles by Corso, P. J.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Frankel, T. L.
Right arrow Articles by Corso, P. J.
Related Collections
Right arrow Coronary disease
Right arrow Minimally invasive surgery

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
ANN THORAC SURG ASIAN CARDIOVASC THORAC ANN EUR J CARDIOTHORAC SURG
J THORAC CARDIOVASC SURG ICVTS ALL CTSNet JOURNALS