Published online before print September 28, 2006, doi: 10.1161/01.STR.0000245081.52877.f2
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
(Stroke. 2006;37:2759.)
© 2006 American Heart Association, Inc.
Original Contributions |
Off-Pump Surgery Is Associated With Reduced Occurrence of Stroke and Other Morbidity as Compared With Traditional Coronary Artery Bypass Grafting
A Meta-Analysis of Systematically Reviewed Trials
From the Center for Outcomes and Evidence (A.S.), Agency for Healthcare Research and Quality, Rockville, Md, USA; the Department of Public Health and Policy (A.S., A.P.), London School of Hygiene and Tropical Medicine, London, UK; the Department of Surgery (A.S.), Yale School of Medicine, New Haven, Conn, USA; the Health Services Research and Development Center (A.W.W.), Johns Hopkins University, Baltimore, Md, USA; the Department of Health Policy and Management (A.W.W.), Johns Hopkins Bloomberg School of Public Health, Baltimore, Md; the Evidence-Based Practice Center (E.B.B.), Johns Hopkins University, Baltimore, Md, USA; the Cardiothoracic Unit (T.T.), Guy’s Hospital, London, UK.
Correspondence to Artyom Sedrakyan, Center for Outcomes and Evidence, Agency for Healthcare Research and Quality, 540 Gaither Road, Rockville, MD 20850. E-mail asedraky{at}ahrq.gov
 |
Abstract |
|---|
 Top Abstract IntroductionMethodsResultsDiscussionReferencesRCT-Based Publications |
|---|
Background and Purpose— There is growing enthusiasm for coronary artery bypass grafting (CABG) without cardiopulmonary bypass (CPB). Although deleterious effects of CPB are known, it remains to be proven that avoiding CPB will result in reduction in morbidity. We sought to determine whether off-pump surgery is associated with reduced occurrence of adverse outcomes as compared with CABG with CPB.
Methods— Studies were identified by searching the MEDLINE, EMBASE and the Cochrane Register 1980 to 2006 (February). We also searched the reference lists of randomized clinical trials (RCT) and reviews to look for additional studies. Study selection: RCTs comparing off-pump surgery to CABG with CPB. No restriction applied on the size of the trial or end point reports. Data extraction: 2 reviewers independently searched for studies, read abstracts and abstracted all data. Data synthesis: combined estimates were obtained using fixed or random effect meta-analyses. Relative risks and risk differences were calculated. Heterogeneity was assessed using 
2 and I2 values.
Results— There were 3996 patients enrolled in 41 RCTs (mean age 62, 22% female). No study reported information on race. Off-pump CABG was associated with a 50% reduction in the relative risk of stroke (95% CI, 7% to 73%), 30% reduction in atrial fibrillation (AF; 95% CI, 16% to 43%) and 48% reduction in wound infection (95% CI, 26% to 63%) with no heterogeneity among RCTs. This translated into avoidance of 10 strokes, 80 cases of AF and 40 infections per 1000 CABG. Fewer distal grafts were performed and there was evidence for >10 reinterventions per 1000 with off-pump CABG. Long-term follow-up is not yet reported in the trials.
Conclusions— Off-pump CABG is associated with reduced risk of stroke, AF and infections as compared with CABG with CPB. Evidence should be generalized taking into account RCT enrollment limitations, drawbacks related to training requirements, propensity to perform fewer grafts and likely reinterventions after off-pump surgery.
Key Words: atrial fibrillation • CABG • cardiac surgery • off-pump surgery • outcomes • stroke • systematic review
|
Introduction |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferencesRCT-Based Publications |
|---|
The practice of coronary artery bypass graft surgery (CABG), as developed by Favaloro at the Cleveland Clinic,1 depended heavily on technological improvements in cardiopulmonary bypass (CPB) from its inception in 1967 and during its rapid dissemination in the next few years.2,3 However, there were surgeons who saw that CPB was not essential for myocardial revascularization,4 and the first substantial series (n=593) of CABG without CPB (off-pump) was reported by Buffolo in 1989.5
In the past 10 years we have witnessed growing interest in off-pump CABG.6 Although deleterious effects of CPB have been extensively investigated over the past 30 years, there is limited evidence that off-pump bypass surgery can offer any advantages compared with traditional CABG. When former President Bill Clinton had 4-vessel CABG on September 6, 2004, his surgeon, a known proponent of off-pump surgery, used CPB.7
Most of the recent randomized clinical trials (RCT) were single center studies and were not consistently supportive of off-pump coronary surgery.8 Surgeons favoring CPB (on-pump) express concerns for intraoperative myocardial ischemia, potential for recurrent angina/reinterventions, and for long "learning curve" requirements (ie, performing substantial number of procedures before competency is achieved).9 On the other hand, off-pump surgery has been proposed to have a potential for reducing in-hospital complications.10 Reducing the occurrence of morbidity such as postoperative stroke, myocardial infarction, atrial fibrillation and other complications is a high priority for cardiac care.
Strong evidence of benefits for off-pump bypass would have tremendous policy implications for over 280 000 CABG operations11 conducted in the United States alone. We sought to review systematically the RCT evidence for off-pump surgery to determine whether off-pump CABG is associated with improved mortality and morbidity as compared with on-pump CABG. We also aimed to quantify the benefits and disadvantages of each approach.
|
Methods |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferencesRCT-Based Publications |
|---|
RCTs were identified by searching MEDLINE, EMBASE and the Cochrane Controlled Trials Register from 1980 to February 2006. Only human studies were considered with no language restriction. In addition, we searched the reference lists of RCTs and reviews for additional studies.
The following inclusion criteria were applied: (1) random allocation of techniques, (2) enrollment of only adults, and (3) no use of another experimental medication or device. There was no restriction on the size of the trial or end points evaluated.
MESH terms corresponding to CABG and off-pump surgery as well as any text words that were applicable were used to locate the studies. A standard RCT filter designed by the Cochrane Collaboration for identifying RCTs was used for MEDLINE and EMBASE. These search algorithms are available at the Scottish Intercollegiate Guideline Network website (http://www.sign.ac.uk/methodology/filters. html). Search of the above databases identified 255 potentially relevant abstracts. These were independently reviewed by 2 authors (A.S., A.P.) for inclusion in the review. Then, 62 full reports were ordered. Independent review identified 41 unique trials (supplemental Figure I, and supplemental Appendix I, 1 to 40, available online at http://stroke.ahajournals.org) after including 1 publication that combined 2 trials12 and excluding multiple publications from the same trials (supplemental Appendix I, 41 to 60).
|
Two authors (A.S., A.P.) independently abstracted the data. Reports/descriptions such as "no major complications were observed in the study" were not considered as zero events. Only explicit descriptions of outcome events were tabulated. If the article did not contain information on the adverse event of interest, then the end point was scored as missing.
The criteria for stroke included clinical diagnosis of "stroke" and "severe neurological deficit" as well as descriptions such as "cerebrovascular accident," "cerebral embolism" and "cerebral infarct."
Atrial fibrillation was based on the reports of "atrial fibrillation," "atrial flutter" and "atrial tachyarrhythmia." Wound infection included any reported "deep sternal infection," "superficial sternal infection," "wound infection." Renal failure was based on descriptions of "renal insufficiency," "renal failure," "dialysis" or "new renal failure." Definitions such as requirement for dialysis, creatinine >2 mg/dL or 50% increase over baseline creatinine were considered. The criteria for myocardial infarction (MI) measurement were based on "definite MI" report according to the Minnesota coding classification. In the absence of such reports, "myocardial infarction" or "new Q wave MI" descriptions were considered. Crossover of patients was defined as initial assignment to one treatment but receipt of the alternative therapy.
Statistical Analyses
The risk estimates from the trials were combined using the fixed effect model. A more conservative random effect method was used to combine the relative risk estimates in case of heterogeneity. In this method, the variance for each individual study is the sum of within and between-study components of the variance. The combined relative risk (RR) estimate is based on weighted average of the individual log RR estimates. The 95% CIs were based on the asymptotic normality of the combined estimates. The assumption of homogeneity was tested using a 2 statistic formed by summing the weighted difference between each individual estimate and the pooled estimate. In addition, I2 values were evaluated to assess heterogeneity. The I2 describes the percentage of the variability in effect estimates that is attributable to heterogeneity rather than sampling error. To be conservative, an I2 value >20% was considered as indicative of heterogeneity.
Number-needed-to-treat and CIs were also calculated using risk difference (RD). Based on number-needed-to-treat statistics, the numbers of events averted/induced were calculated per 1000 procedures. RevMan 4.2 developed by the Cochrane Collaboration was used in all analyses.
Because blinding in these trials was not applicable, methodological quality of included studies was evaluated based on the following criteria:
1. "Randomized" study description
2. Description of a correct randomization procedure
3. Intention to treat analysis
4. Allocation concealment (the method [sealed envelope, central telephone] and the time of the announcement of the allocation [in the operating room versus before])
Studies were classified as "high" (no flaws) and "low" (multiple flaws) quality. This was not a rigid classification and sensitivity analyses were performed for intermediate quality studies by including them in "high and "low" groups to determine their impact. However, we did not find any results that were influenced by methodological quality.
|
Results |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferencesRCT-Based Publications |
|---|
There were 3996 patients enrolled in 41 trials. The average age of the patients was 62 years (reported in 40 trials) and 22% of patients were female (reported in 38 trials). None of the studies reported information on the race of the participants. Left ventricular ejection fraction was reported in 28 trials and few enrolled patients had reduced ejection fraction (Table 1
). Follow-up periods of studies mostly ranged from 30 days to 1 year (Tables 2 and 3).
|
|
|
|
|
|
Mortality
Mortality was assessed in 32 randomized trials including 3298 patients (Figure 1 and Table 2
). There was no significant increased or decreased risk of mortality associated with off-pump surgery (RR, 0.96; 95% CI, 0.58 to 1.60). The study by Raja et al13 reported substantially heterogeneous results and was not included in the meta-analytic estimate. Sensitivity analyses with inclusion of this study did not substantially change the results (RR, 0.74; 95% CI, 0.46 to 1.19).
|
Stroke
Stroke was reported in 27 trials and evaluated in 3062 patients (Figures 1 and 2 and Table 2). Off-pump use was associated with consistently fewer strokes in most of the individual trials. Off-pump use was associated with 50% relative risk reduction of stroke (RR, 0.50; 95% CI, 0.27 to 0.93) as compared with on-pump CABG. RD statistics showed 10 fewer strokes per 1000 CABG patients operated off-pump as compared with on-pump.
|
Atrial Fibrillation
Only 19 studies (Figure 1 and Table 2) involving 2613 patients reported information on atrial fibrillation. There was a substantial risk reduction associated with off-pump surgery (RR, 0.70; 95% CI, 0.57 to 0.84). RD statistics showed over 80 event reductions per 1000 CABG associated with the use of off-pump. The study by Raja et al13 that reported substantially heterogeneous results favoring off-pump surgery was not included in the meta-analytic estimate. Sensitivity analyses with inclusion of this study showed an even larger reduction in the risk of atrial fibrillation (RR, 0.62) but also increased heterogeneity statistics (P value for 2 changed from 0.15 to 0.003 and I2 changed from 26% to 54%).
Wound Infection
Wound infection was assessed in 15 trials enrolling 2111 patients reported this information (Figure 1 and Table 2). Off-pump surgery was associated with 48% reduction in the risk of wound infection as compared with on-pump surgery (RR, 0.52; 95% CI, 0.37 to 0.74). Risk difference analyses showed 40 wound infections prevented per 1000 CABG surgeries with an off-pump approach.
Renal Failure and Myocardial Infarction
There were 10 studies (with 1336 patients) that reported information on renal failure (Figure 1 and Table 2). There was an insignificant trend toward risk reduction associated with off-pump surgery (RR, 0.61; 95% CI, 0.26 to 1.45).
Information on myocardial infarction was reported in 27 trials that included 2988 patients. There was an insignificant trend toward reduction in the occurrence of myocardial infarction in the off-pump group (RR, 0.80; 95% CI, 0.54 to 1.19; Figure 1 and Table 3).
Angina Recurrence and Reintervention
Angina recurrence was reported in 6 trials that included 890 patients (Figure 1 and Table 3), with no difference between the off-pump and on-pump surgeries (RR, 0.90; 95% CI, 0.56 to 1.46).
Reintervention (CABG or angioplasty) was assessed in 9 trials that enrolled 1659 patients (Figure 1 and Table 3). Seven of these trials had a follow-up of >1 year. Off-pump surgery tended to be associated with increased risk of reintervention (RR, 1.90; 95% CI, 0.92 to 3.90; 10 additional reinterventions per 1000 CABG).
Crossover
Crossover after randomization was reported in 23 trials that included 2804 patients (Figure 1 and Table 3). Meta-analysis has shown increased crossover from off-pump to on-pump (RR, 3.82; 95% CI, 2.12 to 6.88). This meant that of 1000 operations, 50 additional patients crossed over from off-pump to on-pump surgery.
Number of Distal Grafts
The mean number of distal grafts and standard deviations were reported in 29 trials (2457 patients; Figure 3).
|
There were significantly fewer distal grafts performed in the off-pump group as compared with on-pump group (weighted mean difference [WMD]=–0.27 per patient; 95% CI, 0.37 to 0.17). However, there was a marked heterogeneity among the trials for this outcome (P<0.00001 and I2=69.6%). To explain the heterogeneity, studies were stratified by size: large (>50 patients in each group), medium (25 to 50 patients in each group), small (<25 patients in each group; Figure 3). There was a much smaller difference between off-pump and on-pump surgical patients in the largest studies (WMD=–0.15; 95% CI, –0.24, –0.06). In the intermediate size studies there was a moderate difference (WMD=–0.26; 95% CI, –0.40, –0.12) and in the small trials there was a much larger difference (WMD=–0.39; 95% CI, –0.61, –0.18).
These observations were confirmed when reviewing 2 large trials that reported the data in terms of medians,12,13 although the third study still reported a larger difference between off-pump and on-pump in terms of number of grafts received.14
Events by Subgroups of Different On-Pump CABG Technique
CPB Techniques for CABG
Subgroup analyses stratified by different CPB use were evaluated in fewer trials (data on subgroups reported in Table 1). In addition, sufficient numbers of events were available regarding only 4 outcomes (mortality, stroke, atrial fibrillation and MI).
The effect of off-pump surgery was consistent across 2 constructed subgroups: (1) normothermic bypass and (2) hypothermic (included moderately hypothermic and hypothermic). Relative risks for mortality range from 1.02 to 1.08, for stroke from 0.38 to 0.55, for atrial fibrillation from 0.62 to 0.76 and for MI from 0.84 to 0.86 with substantial overlap of 95% CIs.
Cardioplegia Techniques
As in the case of CPB techniques, only 4 outcomes (mortality, MI, atrial fibrillation and stroke) were evaluated in the subgroup analyses stratified by 3 cardioplegia techniques: (1) cold crystalloid, (2) cold blood, (3) warm or tepid blood. The effect of off-pump CABG was again consistent across all subgroups. Relative risk for mortality range from 1.59 to 0.57, for stroke from 0.42 to 0.78, for atrial fibrillation from 0.86 to 0.41 and for MI from 0.72 to 0.92. All estimates had very wide CIs and substantial overlap.
|
Discussion |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferencesRCT-Based Publications |
|---|
We found that off-pump CABG was associated with a reduced risk of stroke, atrial fibrillation and surgical wound infection as compared with on-pump groups. When expressed as events prevented, reductions translated into 10 fewer patients with strokes, 80 with atrial fibrillation and 40 wound infections per 1000 CABG using off-pump. There were also 10 additional reinterventions associated with off-pump surgery (median 1-year follow-up), statistically significant at 10% level (P=0.08).
To our knowledge, this is the first systematic analysis based on randomized clinical trials to report substantial stroke reduction associated with off-pump use. A number of theories describing the effect of off-pump surgery on risk of stroke are discussed. Angelini and colleagues have shown reduced coagulation impairment associated with off-pump CABG.12,15 Similarly, Ascione and colleagues16 reported reduced inflammatory response after off-pump surgery, a finding that was also supported by other investigators.17–22
One of the most important predictors of stroke after cardiac surgery is manipulation of the ascending thoracic aorta which may be atherosclerotic.23,24 Off-pump surgery has a potential to reduce the need for aortic manipulation and there is evidence that off-pump CABG is associated with substantially reduced levels of S-100 protein (indicative of minor or major brain injury)25–27 and reduced microembolic release27–29 as compared with on-pump CABG.
Our investigation provides additional data describing the cerebrovascular effect of off-pump surgery. We found substantial reduction in atrial fibrillation occurrence associated with off-pump. Atrial fibrillation is associated with a higher risk of cerebrovascular accidents, and preventing atrial fibrillation has been shown to reduce postoperative stroke occurrence.30 One recent study also reported the importance of the postoperative atrial fibrillation, microemboli and hypoperfusion during CPB as strong predictors of postoperative stroke.31 Thus, prevention of 
80 atrial fibrillations per 1000 patients undergoing CABG could potentially contribute to the observation of fewer strokes associated with off-pump.
As disadvantages of off-pump surgery, we found that 50 patients are likely to be converted to on-pump surgery per 1000 procedures, and there is some recent evidence that conversions are potentially associated with higher mortality.32 This suggests that conversion sometimes fails to rescue the adverse situation. In addition, 0.15 to 0.4 fewer grafts will be performed in patient having off-pump surgery. Thus, this review demonstrates the possibility of less complete revascularization associated with off-pump as well as more reinterventions. The number of conversions and the difference in number of grafts performed was much smaller in larger trials. This might reflect surgical experience and the size of the center. Fewer grafts performed goes along with evidence for the higher reintervention rate observed in the off-pump group (RR, 1.90; P=0.08). Whereas the evidence for more reinterventions is not statistically significant at the 5% level, more stringent regulatory requirements for adverse events (ie, P<0.1) than for therapeutic benefit should alert us to the need for careful evaluation and reflection in the future.
Surgical experience is an important factor when generalizing the evidence favoring off-pump surgery.6 There might be a significant learning curve associated with off-pump surgery8 and, although learning curve–related problems should not serve as justification for not adopting the evidence,33 they still should be studied thoroughly because they are related to the application and dissemination of the evidence. Most of the large and high quality trials of off-pump surgery were conducted by enthusiasts of the procedure, as suggested by the large number of publications (supplemental Appendix I) generated by 3 groups of investigators. Inclusion of the off-pump training in cardiothoracic residency programs, and establishing off-pump training centers, preferably at institutions performing high volume of these procedures are some of the measures that can be implemented on a policy level to reduce the impact of the learning curve.
RCT enrollment limitations can also affect generalizibility of the evidence. Race is not reported and RCTs enrolled younger, male and healthier patients. Thus, evidence found in our study cannot be easily extrapolated to other groups. This is important to consider when generalizing the evidence to individual patients and institutions.
Limited data suggests that CABG is estimated to have a mean charge of $61 000, a sum which may increase dramatically when factoring nonsurgical and societal costs.11,34 Off-pump might be a less expensive alternative.8,34,35 However, there are no cost-effectiveness analyses conducted, and single-use device costs for off-pump surgery can be substantial. As for averting adverse events, an occurrence of atrial fibrillation is associated with 2 to 5 additional days in the hospital and up to $10 000 in hospital-related costs.36,37 Furthermore, a single stroke can amount to over $10 000 in hospital costs and could rise to anywhere from $50 000 to $100 000 after rehabilitative and other costs are taken into account.38 The long-term consequences of stroke and reintervention should be considered in further cost-effectiveness analyses.
Simplifying CABG surgical technology and reducing the need for skilled staffing required for off-pump procedure as compared with the on-pump might be additional benefits of off-pump surgery in developing countries or locations unable to perform a large number of operations because of the need for CPB technology. Therefore, it is possible that this off-pump CABG will improve the equity and access to surgical care if training needs are met.
Our study has limitations. The outcomes considered in our review were not necessarily the outcomes of interest to the trial authors. We did not evaluate cognitive dysfunction after surgery in this review because of scarcity of data and heterogeneity of the methodology. Publication bias may occur when trials that show favorable results are more likely to be published. However, RCTs of off-pump surgery are hotly debated, and it is unlikely that they will not be published. Our analysis of funnel plots did not reveal any indication for publication bias. Selective reporting and relatively short to intermediate follow-up reported so far is another possible limitation of the evidence particularly for long-term outcomes such as angina recurrence and reintervention. Reintervention occurrence can serve as an illustrative example. If the incidence and relative risk of reintervention were the same over time, then the difference between off-pump and on-pump will become highly statistically significant and potentially double or triple additional numbers of reinterventions related to off-pump (from current +10 to +20 or +30 additional events per 1000 CABG at the median of 2 or 3 years of follow-up). These outcomes are reported in fewer trials and should be studied further in future.
Conclusions
Off-pump surgery is associated with reduced occurrences of stroke, atrial fibrillation, and wound infection. There are likely drawbacks in terms of reinterventions and unknown long-term effects of off-pump surgery possibly attributable to lack of training and the tendency to perform fewer grafts. The future of off-pump procedures looks promising from a technology assessment perspective, when taking into account likelihood of future better technical performance of surgeons and equity issues.
|
Acknowledgments |
|---|
We would like to acknowledge David Atkins, MD, MPH, Chief Medical Officer, Center for Outcomes and Evidence, Agency for Healthcare Research and Quality; Julius Petterson, Office of Communications and Knowledge Transfer, Agency for Healthcare Research and Quality; and David Matchar, MD, Duke University Center for Clinical Health Policy Research for important editorial comments.
Disclosures
Dr Artyom Sedrakyan is employed by the Agency for Healthcare Research and Quality. The authors of this article are responsible for its contents. No statement in this article should be construed as an official position of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.
Received March 13, 2006; revision received July 18, 2006; accepted August 9, 2006.
|
References |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferencesRCT-Based Publications |
|---|
1. Favaloro RG. The aortocoronary bypass. The challenging dream of heart surgery. Boston, Mass: Little, Brown Company; 1994: 94–125.
2. Favaloro RG, Effler DB, Groves LK, Shelton WC, Sones FMJ. Direct myocardial revascularisation by saphenous vein graft. Present operative techniques and indications. Ann Thorac Surg. 1970; 10: 97–111.[Medline] [Order article via Infotrieve]
3. Effler DB, Favaloro RG, Groves LK. Coronary artery surgery utilizing saphenous vein graft techniques. Clinical experience with 224 operations. J Thorac Cardiovasc Surg. 970; 59: 147–154.
4. Kolessov VI. Mammary artery-coronary artery anastomosis as method of treatment for angina pectoris. J Thorac Cardiovasc Surg. 1967; 54: 535–544.[Medline] [Order article via Infotrieve]
5. Buffolo E, Andrade JC, Branco JN, Aguiar LF, Ribeiro EE, Jatene AD. Myocardial revascularization without extracorporeal circulation. Seven-year experience in 593 cases. Eur J Cardiothorac Surg. 1990; 4: 504–507.[Abstract]
6. Mitka M. Beat goes on in "off-pump" bypass surgery: surgeon experience may be key to best outcome. JAMA. 2004; 291: 1821–1822.
7. Clinton’s Heart Bypass Surgery Called a Success, Tuesday, September 7, 2004. Available at: http://www.washingtonpost.com/wp-dyn/articles/A2001–2004Sep7.html?nav=rss_politics. Accessed July 18, 2006.
8. Peterson ED, Mark DB. Off-pump bypass surgery–ready for the big dance? JAMA. 2004; 291: 1897–1899.
9. Ascione R, Angelini GD. Off-pump coronary artery bypass surgery: the implications of the evidence. J Thorac Cardiovasc Surg. 2003; 125: 779–781.
10. Stamou SC. Stroke and encephalopathy after cardiac surgery: the search for the holy grail. Stroke. 2006; 37: 284–285.
11. Heart and stroke statistical update. Dallas, TX: American Heart Association, 2006.
12. Angelini GD, Taylor FC, Reeves BC, Ascione R. Early and midterm outcome after off-pump and on-pump surgery in Beating Heart Against Cardioplegic Arrest Studies (BHACAS 1 and 2): a pooled analysis of two randomised controlled trials. Lancet. 2002; 359: 1194–1199.[CrossRef][Medline] [Order article via Infotrieve]
13. Raja SG, Ahmad HM. Predictors of gastrointestinal complications after conventional and beating heart coronary surgery. Surg J R Coll Surg Edinb Irel. 2003; 1: 221–228.
14. Straka Z, Widimsky P, Jirasek K, Stros P, Votava J, Vanek T, Brucek P, Kolesar M, Spacek R. Off-pump versus on-pump coronary surgery: final results from a prospective randomized study PRAGUE-4. Ann Thorac Surg. 2004; 77: 789–793.
15. 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.
16. Ascione R, Lloyd CT, Underwood MJ, Lotto AA, Pitsis AA, Angelini GD. Inflammatory response after coronary revascularization with or without cardiopulmonary bypass. Ann Thorac Surg. 2000; 69: 1198–1204.
17. Al-Ruzzeh S, Hoare G, Marczin N, Asimakopoulos G, George S, Taylor K, Amrani M. Off-pump coronary artery bypass surgery is associated with reduced neutrophil activation as measured by the expression of CD11b: a prospective randomized study. Heart Surg Forum. 2003; 6: 89–93.[Medline] [Order article via Infotrieve]
18. Czerny M, Baumer H, Kilo J, Lassnigg A, Hamwi A, Vukovich T, Wolner E, Grimm M. Inflammatory response and myocardial injury following coronary artery bypass grafting with or without cardiopulmonary bypass. Eur J Cardiothorac Surg. 2000; 17: 737–742.
19. Gu YJ, Mariani MA, van Oeveren W, Grandjean JG, Boonstra PW. Reduction of the inflammatory response in patients undergoing minimally invasive coronary artery bypass grafting. Ann Thorac Surg. 1998; 65: 420–424.
20. Matata BM, Sosnowski AW, Galinanes M. Off-pump bypass graft operation significantly reduces oxidative stress and inflammation. Ann Thorac Surg. 2000; 69: 785–791.
21. Wan IY, Arifi AA, Wan S, Yip JH, Sihoe AD, Thung KH, Wong EM, Yim AP. Beating heart revascularization with or without cardiopulmonary bypass: evaluation of inflammatory response in a prospective randomized study. J Thorac Cardiovasc Surg. 2004; 127: 1624–1631.
22. Wehlin L, Vedin J, Vaage J, Lundahl J. Activation of complement and leukocyte receptors during on- and off pump coronary artery bypass surgery. Eur J Cardiothorac Surg. 2004; 25: 35–42.
23. Kapetanakis EI, Stamou SC, Dullum MK, Hill PC, Haile E, Boyce SW, Bafi AS, Petro KR, Corso PJ. The impact of aortic manipulation on neurologic outcomes after coronary artery bypass surgery: a risk-adjusted study. Ann Thorac Surg. 2004; 78: 1564–1571.
24. Hogue CW Jr, Murphy SF, Schechtman KB, Davila-Roman VG. Risk factors for early or delayed stroke after cardiac surgery. Circulation. 1999; 100: 642–647.
25. Wandschneider W, Thalmann M, Trampitsch E, Ziervogel G, Kobinia G. Off-pump coronary bypass operations significantly reduce S100 release: an indicator for less cerebral damage? Ann Thorac Surg. 2000; 70: 1577–1579.
26. Diegeler A, Hirsch R, Schneider F, Schilling LO, Falk V, Rauch T, Mohr FW. Neuromonitoring and neurocognitive outcome in off-pump versus conventional coronary bypass operation. Ann Thorac Surg. 2000; 69: 1162–1166.
27. Motallebzadeh R, Kanagasabay R, Bland M, Kaski JC, Jahangiri M. S100 protein and its relation to cerebral microemboli in on-pump and off-pump coronary artery bypass surgery. Eur J Cardiothorac Surg. 2004; 25: 409–414.
28. Lund C, Hol PK, Lundblad R, Fosse E, Sundet K, Tennoe B, Brucher R, Russell D. Comparison of cerebral embolization during off-pump and on-pump coronary artery bypass surgery. Ann Thorac Surg. 2003; 76: 765–770;discussion 770.
29. Lee JD, Lee SJ, Tsushima WT, Yamauchi H, Lau WT, Popper J, Stein A, Johnson D, Lee D, Petrovitch H, Dang CR. Benefits of off-pump bypass on neurologic and clinical morbidity: a prospective randomized trial. Ann Thorac Surg. 2003; 76: 18–25;discussion 25–26.
30. Giri S, White CM, Dunn AB, Felton K, Freeman-Bosco L, Reddy P, Tsikouris JP, Wilcox HA, Kluger J. Oral amiodarone for prevention of atrial fibrillation after open heart surgery, the Atrial Fibrillation Supression Trial (AFIST): a randomised lacebo-controlled trial. Lancet. 2001; 357: 830–836.[CrossRef][Medline] [Order article via Infotrieve]
31. McKhann GM, Grega MA, Borowicz LM Jr, Baumgartner WA, Selnes OA. Stroke and encephalopathy after cardiac surgery: an update. Stroke. 2006; 37: 562–571.
32. Legare JF, Buth KJ, Hirsch GM. Conversion to on pump from OPCAB is associated with increased mortality: results from a randomized controlled trial. Eur J Cardiothorac Surg. 2005; 27: 296–301.
33. Sedrakyan A, Van Der Meulen J, Lewsey J, Treasure T. Video-assisted thoracic surgery for treatment of pneumothorax and lung resections: a systematic review of the randomised clinical trials. BMJ. 2004; 329: 1008–1011.
34. Ascione R, Lloyd CT, Underwood MJ, Lotto AA, Pitsis AA, Angelini GD. Economic outcome of off-pump coronary artery bypass surgery: a prospective randomized study. Ann Thorac Surg. 1999; 68: 2237–2242.
35. Nathoe HM, van Dijk D, Jansen EW, Suyker WJ, Diephuis JC, van Boven WJ, de la Riviere AB, Borst C, Kalkman CJ, Grobbee DE, Buskens E, de Jaegere PP. A comparison of on-pump and off-pump coronary bypass surgery in low-risk patients. N Engl J Med. 2003; 348: 394–402.
36. Mathew JP, Parks R, Savino JS, Friedman ES, Koch C, Mangano DT. Atrial fibrillation following CABG: predictors, outcomes, and resource utilization. Multi-center Study of Perioperative Ischemia Research Group. JAMA. 1996; 276: 300–306.
37. Aranki SF, Shaw DP, Adams DH, Rizzo RJ, Couper GS, VanderVilet M. Predictors of atrial fibrillation after coronary artery surgery. Current trends and impact on hospital resources. Circulation. 1996; 94: 390–397.
38. Roach GW, Kanchuger M, Mangano CM, Newman M, Nussmeier N, Wolman R, Aggarwal A, Marschall K, Graham SH, Ley C. Adverse cerebral outcomes after coronary bypass surgery. Multicenter Study of Perioperative Ischemia Research Group and the Ischemia Research and Education Foundation Investigators. N Engl J Med. 1996; 335: 1857–1863.
39. Ascione R, Caputo M, Calori G, Lloyd CT, Underwood MJ, Angelini GD. Predictors of atrial fibrillation after conventional and beating heart coronary surgery: a prospective, randomized study. Circulation. 2000; 102: 1530–1535.
40. Keizer AM, Hijman R, van Dijk D, Kalkman CJ, Kahn RS. Cognitive self-assessment one year after on-pump and off-pump coronary artery bypass grafting. Ann Thorac Surg. 2003; 75: 835–838;discussion 838–839.
41. Van Dijk D, Jansen EW, Hijman R, Nierich AP, Diephuis JC, Moons KG, Lahpor JR, Borst C, Keizer AM, Nathoe HM, Grobbee DE, De Jaegere PP, Kalkman CJ. Cognitive outcome after off-pump and on-pump coronary artery bypass graft surgery: a randomized trial. JAMA. 2002; 287: 1405–1412.
42. van Dijk D, Nierich AP, Jansen EW, Nathoe HM, Suyker WJ, Diephuis JC, van Boven WJ, Borst C, Buskens E, Grobbee DE, Robles De Medina EO, de Jaegere PP. Early outcome after off-pump versus on-pump coronary bypass surgery: results from a randomized study. Circulation. 2001; 104: 1761–1766.
43. Puskas JD, Williams WH, Duke PG, Staples JR, Glas KE, Marshall JJ, Leimbach M, Huber P, Garas S, Sammons BH, McCall SA, Petersen RJ, Bailey DE, Chu H, Mahoney EM, Weintraub WS, Guyton RA. Off-pump coronary artery bypass grafting provides complete revascularization with reduced myocardial injury, transfusion requirements, and length of stay: a prospective randomized comparison of two hundred unselected patients undergoing off-pump versus conventional coronary artery bypass grafting. J Thorac Cardiovasc Surg. 2003; 125: 797–808.
Supplemental Appendix I
|
Footnotes |
|---|
This study was presented at International Stroke Conference 2006, Kissimmee, Florida.
|
RCT-Based Publications |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferencesRCT-Based Publications |
|---|
1. Al-Ruzzeh S, Hoare G, Marczin N, Asimakopoulos G, George S, Taylor K, Amrani M. Off-pump coronary artery bypass surgery is associated with reduced neutrophil activation as measured by the expression of CD11b: a prospective randomized study. Heart Surg Forum. 2003; 6: 89–93.[Medline] [Order article via Infotrieve]
2. Alwan K, Falcoz PE, Alwan J, Mouawad W, Oujaimi G, Chocron S, Etievent JP. Beating versus arrested heart coronary revascularization: evaluation by cardiac troponin I release. Ann Thorac Surg. 2004; 77: 2051–2055.
3. Angelini GD, Taylor FC, Reeves BC, Ascione R. Early and midterm outcome after off-pump and on-pump surgery in Beating Heart Against Cardioplegic Arrest Studies (BHACAS 1 and 2): a pooled analysis of two randomized controlled trials. Lancet. 2002; 359: 1194–1199.[CrossRef][Medline] [Order article via Infotrieve]
4. Baker RA, Andrew MJ, Ross IK, Knight JL. The Octopus II stabilizing system: biochemical and neuropsychological outcomes in coronary artery bypass surgery. Heart Surg Forum. 2001; 4 (Suppl 1): S19–S23.[Medline] [Order article via Infotrieve]
5. Carrier M, Perrault LP, Jeanmart H, Martineau R, Cartier R, Page P. Randomized trial comparing off-pump to on-pump coronary artery bypass grafting in high-risk patients. Heart Surg Forum. 2003; 6: e89–e92.[Medline] [Order article via Infotrieve]
6. Covino E, Santise G, Di Lello F, De Amicis V, Bonifazi R, Bellino I, Spampinato N. Surgical myocardial revascularization (CABG) in patients with pulmonary disease: beating heart versus cardiopulmonary bypass. J Cardiovasc Surg (Torino). 2001; 42: 23–26.[Medline] [Order article via Infotrieve]
7. Czerny M, Baumer H, Kilo J, Lassnigg A, Hamwi A, Vukovich T, Wolner E, Grimm M. Inflammatory response and myocardial injury following coronary artery bypass grafting with or without cardiopulmonary bypass. Eur J Cardiothorac Surg. 2000; 17: 737–742.
8. Czerny M, Baumer H, Kilo J, Zuckermann A, Grubhofer G, Chevtchik O, Wolner E, Grimm M. Complete revascularization in coronary artery bypass grafting with and without cardiopulmonary bypass. Ann Thorac Surg. 2001; 71: 165–169.
9. Diegeler A, Hirsch R, Schneider F, Schilling LO, Falk V, Rauch T, Mohr FW. Neuromonitoring and neurocognitive outcome in off-pump versus conventional coronary bypass operation. Ann Thorac Surg. 2000; 69: 1162–1166.
10. Dorman BH, Kratz JM, Multani MM, Baron R, Farrar E, Walton S, Payne K, Ikonomiois J, Reeves S, Mukherjee R, Spinale FG. A prospective, randomized study of endothelin and postoperative recovery in off-pump versus conventional coronary artery bypass surgery. J Cardiothorac Vasc Anesth. 2004; 18: 25–29.[CrossRef][Medline] [Order article via Infotrieve]
11. Gasz B, Benko L, Jancso G, Lantos J, Szato Z, Alotti N, Roth E. Comparison of inflammatory response following coronary revascularization with or without cardopulmonary bypass. Experimental and Clinical Cardiology. 2004; 9: 26–30.
12. Gerola LR, Buffolo E, Jasbik W, Botelho B, Bosco J, Brasil LA, Branco JN. Off-pump versus on-pump myocardial revascularization in low-risk patients with one or two vessel disease: perioperative results in a multicenter randomized controlled trial. Ann Thorac Surg. 2004; 77: 569–573.
13. Gu YJ, Mariani MA, van Oeveren W, Grandjean JG, Boonstra PW. Reduction of the inflammatory response in patients undergoing minimally invasive coronary artery bypass grafting. Ann Thorac Surg. 1998; 65: 420–424.
14. Guler M, Kirali K, Toker ME, Bozbuga N, Omeroglu SN, Akinci E, Yakut C. Different CABG methods in patients with chronic obstructive pulmonary disease. Ann Thorac Surg. 2001; 71: 152–157.
15. Gulielmos V, Menschikowski M, Dill H, Eller M, Thiele S, Tugtekin SM, Jaross W, Schueler S. Interleukin-1, interleukin-6 and myocardial enzyme response after coronary artery bypass grafting - a prospective randomized comparison of the conventional and three minimally invasive surgical techniques. Eur J Cardiothorac Surg. 2000; 18: 594–601.
16. Khan NE, De Souza A, Mister R, Flather M, Clague J, Davies S, Collins P, Wang D, Sigwart U, Pepper J. A randomized comparison of off-pump and on-pump multivessel coronary-artery bypass surgery. N Engl J Med. 2004; 350: 21–28.
17. Kobayashi J, Tashiro T, Ochi M, Yaku H, Watanabe G, Satoh T, Tagusari O, Nakajima H, Kitamura S; Japanese Off-Pump Coronary Revascularization Investigation (JOCRI) Study Group. Early outcome of a randomized comparison of off-pump and on-pump multiple arterial coronary revascularization. Circulation. 2005; 112 (9 Suppl): I338–I343.[Medline] [Order article via Infotrieve]
18. Lee JD, Lee SJ, Tsushima WT, Yamauchi H, Lau WT, Popper J, Stein A, Johnson D, Lee D, Petrovitch H, Dang CR. Benefits of off-pump bypass on neurologic and clinical morbidity: a prospective randomized trial. Ann Thorac Surg. 2003; 76: 18–25;discussion 25–26.
19. Legare JF, Buth KJ, King S, Wood J, Sullivan JA, Friesen CH, Lee J, Stewart K, Hirsch GM. Coronary bypass surgery performed off pump does not result in lower in-hospital morbidity than coronary artery bypass grafting performed on pump. Circulation. 2004; 109: 887–892.Epub 2004 Feb 2.
20. Lingaas PS, Hol PK, Lunblad R, Rein KA, Tonnesen TI, Svennevig JL, Hauge SN, Vatne K, Fosse E. Clinical and angiographic outcome of coronary surgery with and without cardiopulmonary bypass: aprospective randomized trial. Heart Surg Forum. 2004; 7: 37–71.[Medline] [Order article via Infotrieve]
21. Lund C, Hol PK, Lundblad R, Fosse E, Sundet K, Tennoe B, Brucher R, Russell D Comparison of cerebral embolization during off-pump and on-pump coronary artery bypass surgery. Ann Thorac Surg. 2003; 76: 765–770;discussion 770.
22. Matata BM, Sosnowski AW, Galinanes M Off-pump bypass graft operation significantly reduces oxidative stress and inflammation. Ann Thorac Surg. 2000; 69: 785–791.
23. Motallebzadeh R, Kanagasabay R, Bland M, Kaski JC, Jahangiri M. S100 protein and its relation to cerebral microemboli in on-pump and off-pump coronary artery bypass surgery. Eur J Cardiothorac Surg. 2004; 25: 409–414.
24. Muneretto C, Bisleri G, Negri A, Manfredi J, Metra M, Nodari S, Dei Cas L. Off-pump coronary artery bypass surgery technique for total arterial myocardial revascularization: a prospective randomized study. Ann Thorac Surg. 2003; 76: 778–782;discussion 783.
25. Nathoe HM, van Dijk D, Jansen EW, Suyker WJ, Diephuis JC, van Boven WJ, de la Riviere AB, Borst C, Kalkman CJ, Grobbee DE, Buskens E, de Jaegere PP. A comparison of on-pump and off-pump coronary bypass surgery in low-risk patients. N Engl J Med. 2003; 348: 394–402.
26. Parolari A, Alamani F, Juliano G, Polvani G, Roberto M, Veglia F, Fumero A, Carlucci C, Rona P, Brambillasca C, Sisillo E, Biglioli P. Oxygen metabolism during and after cardiac surgery: Role of CPB. Ann Thorac Surg. 2003; 76: 737–743.
27. Penttila HJ, Lepojarvi MV, Kiviluoma KT, Kaukoranta PK, Hassinen IE, Peuhkurinen KJ. Myocardial preservation during coronary surgery with and without cardiopulmonary bypass. Ann Thorac Surg. 2001; 71: 565–571.
28. Puskas JD, Williams WH, Mahoney EM, Huber PR, Block PC, Duke PG, Staples JR, Glas KE, Marshall JJ, Leimbach ME, McCall SA, Petersen RJ, Bailey DE, Weintraub WS, Guyton RA. Off-pump versus conventional coronary artery bypass grafting: early and 1-year graft patency, cost, and quality-of-life outcomes: a randomized trial. JAMA. 2004; 291: 1841–1849.
29. Raja SG, Ahmad HM. Predictors of gastrointestinal complications after conventional and beating heart coronary surgery. Surg J R Coll Surg Edinb Irel. 2003; 1: 221–228.
30. Sahlman A, Ahonen J, Nemlander A, Salmenpera M, Eriksson H, Ramo J, Vento A. Myocardial metabolism on off-pump surgery; a randomized study of 50 cases. Scand Cardiovasc J. 2003; 37: 211–215.[CrossRef][Medline] [Order article via Infotrieve]
31. Selvanayagam JB, Petersen SE, Francis JM, Robson MD, Kardos A, Neubauer S, Taggart DP. Effects of off-pump versus on-pump coronary surgery on reversible and irreversible myocardial injury: a randomized trial using cardiovascular MRI and biochemical markers. Circulation. 2004; 109: 345–350.Epub 2004 Jan 19.
32. Straka Z, Widimsky P, Jirasek K, Stros P, Votava J, Vanek T, Brucek P, Kolesar M, Spacek R. Off-pump versus on-pump coronary surgery: final results from a prospective randomized study PRAGUE-4. Ann Thorac Surg. 2004; 77: 789–793.
33. Syed A, Fawzy H, Farag A, Nemlander A. Comparison of pulmonary gas exchange in OPCAB versus conventional CABG. Heart lung and Circulation. 2004; 13: 168–172.[CrossRef]
34. Tang AT, Knott J, Nanson J, Hsu J, Haw MP, Ohri SK. A prospective randomized study to evaluate the renoprotective action of beating heart coronary surgery in low risk patients. Eur J Cardiothorac Surg. 2002; 22: 118–123.
35. Vedin J, Jensen U, Eriksson A, Bitkover C, Samuelssen S, Bredin F, Vaage J. Cardiovascular function during the first 24 hours after off pump coronary artery bypass grafting- A prospective, randomized study. Interactive Cardiovascular and Thoracic Surgery. 2003; 2: 489–494.
36. Velissaris T, Tang A, Murray M, El-Minshawy A, Hett D, Ohri S. A prospective randomized study to evaluate splanchnic hypoxia during beating-heart and conventional coronary revascularization. Eur J Cardiothorac Surg. 2003; 23: 917–924;discussion 924.
37. Vural KM, Tasdemir O, Karagoz H, Emir M, Tarcan O, Bayazit K. Comparison of early results of coronary artery bypass grafting with and without extracorporal circulation. Thorac Cardiovasc Surg. 1995; 43: 320–325.[Medline] [Order article via Infotrieve]
38. Wan IY, Arifi AA, Wan S, Yip JH, Sihoe AD, Thung KH, Wong EM, Yim AP. Beating heart revascularization with or without cardiopulmonary bypass: evaluation of inflammatory response in a prospective randomized study. J Thorac Cardiovasc Surg. 2004; 127: 1624–1631.
39. Wandschneider W, Thalmann M, Trampitsch E, Ziervogel G, Kobinia G. Off-pump coronary bypass operations significantly reduce S100 release: an indicator for less cerebral damage? Ann Thorac Surg. 2000; 70: 1577–1579.
40. Zamvar V, Williams D, Hall J, Payne N, Cann C, Young K, Karthikeyan S, Dunne J. Assessment of neurocognitive impairment after off-pump and on-pump techniques for coronary artery bypass graft surgery: prospective randomized controlled trial. Bmj. 2002; 325: 1268.
41. Ascione R, Caputo M, Calori G, Lloyd CT, Underwood MJ, Angelini GD. Predictors of atrial fibrillation after conventional and beating heart coronary surgery: a prospective, randomized study. Circulation. 2000; 102: 1530–1535.
42. Ascione R, Lloyd CT, Gomes WJ, Caputo M, Bryan AJ, Angelini GD. Beating versus arrested heart revascularization: evaluation of myocardial function in a prospective randomized study. Eur J Cardiothorac Surg. 1999; 15: 685–690.
43. Ascione R, Lloyd CT, Underwood MJ, Gomes WJ, Angelini GD. On-pump versus off-pump coronary revascularization: evaluation of renal function. Ann Thorac Surg. 1999; 68: 493–498.
44. Ascione R, Lloyd CT, Underwood MJ, Lotto AA, Pitsis AA, Angelini GD. Economic outcome of off-pump coronary artery bypass surgery: a prospective randomized study. Ann Thorac Surg. 1999; 68: 2237–2242.
45. Ascione R, Lloyd CT, Underwood MJ, Lotto AA, Pitsis AA, Angelini GD. Inflammatory response after coronary revascularization with or without cardiopulmonary bypass. Ann Thorac Surg. 2000; 69: 1198–1204.
46. Ascione R, Reeves BC, Taylor FC, Seehra HK, Angelini GD. Beating heart against cardioplegic arrest studies (BHACAS 1 and 2): quality of life at mid-term follow up in two randomized controlled trials. Eur Heart J. 2004; 25: 765–770.
47. 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.
48. Cox CM, Ascione R, Cohen AM, Davies IM, Ryder IG, Angelini GD. Effect of cardiopulmonary bypass on pulmonary gas exchange: a prospective randomized study. Ann Thorac Surg. 2000; 69: 140–145.
49. Lloyd CT, Ascione R, Underwood MJ, Gardner F, Black A, Angelini GD. Serum S-100 protein release and neuropsychologic outcome during coronary revascularization on the beating heart: a prospective randomized study. J Thorac Cardiovasc Surg. 2000; 119: 148–154.
50. Caputo M, Yeatman M, Narayan P, Marchetto G, Ascione R, Reeves BC, Angelini GD Effect of off-pump coronary surgery with right ventricular assist device on organ function and inflammatory response: a randomized controlled trial. Ann Thorac Surg. 2002; 74: 2088–2095;discussion 2095–2096.
51. 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. The Octopus Study: rationale and design of two randomized trials on medical effectiveness, safety, and cost-effectiveness of bypass surgery on the beating heart. Control Clin Trials. 2000; 21: 595–609.[CrossRef][Medline] [Order article via Infotrieve]
52. van Dijk D, Keizer AM, Diephuis JC, Durand C, Vos LJ, Hijman R. Neurocognitive dysfunction after coronary artery bypass surgery: a systematic review. J Thorac Cardiovasc Surg. 2000; 120: 632–639.
53. van Dijk D, Jansen EW, Hijman R, Nierich AP, Diephuis JC, Moons KG, Lahpor JR, Borst C, Keizer AM, Nathoe HM, Grobbee DE, De Jaegere PP, Kalkman CJ Cognitive outcome after off-pump and on-pump coronary artery bypass graft surgery: a randomized trial. JAMA. 2002; 287: 1405–1412.
54. van Dijk D, Nierich AP, Jansen EW, Nathoe HM, Suyker WJ, Diephuis JC, van Boven WJ, Borst C, Buskens E, Grobbee DE, Robles De Medina EO, de Jaegere PP. Early outcome after off-pump versus on-pump coronary bypass surgery: results from a randomized study. Circulation. 2001; 104: 1761–1766.
55. Keizer AM, Hijman R, van Dijk D, Kalkman CJ, Kahn RS. Cognitive self-assessment one year after on-pump and off-pump coronary artery bypass grafting. Ann Thorac Surg. 2003; 75: 835–838;discussion 838–839.
56. Velissaris T, Tang AT, Murray M, Mehta RL, Wood PJ, Hett DA, Ohri SK. A prospective randomized study to evaluate stress response during beating-heart and conventional coronary revascularization. Ann Thorac Surg. 2004; 78: 506–512.
57. Wehlin L, Vedin J, Vaage J, Lundahl J. Activation of complement and leukocyte receptors during on- and off pump coronary artery bypass surgery. Eur J Cardiothorac Surg. 2004; 25: 35–42.
58. Puskas JD, Williams WH, Duke PG, Staples JR, Glas KE, Marshall JJ, Leimbach M, Huber P, Garas S, Sammons BH, McCall SA, Petersen RJ, Bailey DE, Chu H, Mahoney EM, Weintraub WS, Guyton RA. Off-pump coronary artery bypass grafting provides complete revascularization with reduced myocardial injury, transfusion requirements, and length of stay: a prospective randomized comparison of two hundred unselected patients undergoing off-pump versus conventional coronary artery bypass grafting. J Thorac Cardiovasc Surg. 2003; 125: 797–808.
59. Gulielmos V, Eller M, Thiele S, Dill HM, Jost T, Tugtekin SM, Schueler S. Influence of median sternotomy on the psychosomatic outcome in coronary artery single-vessel bypass grafting. Eur J Cardiothorac Surg. 1999; 16 (Suppl 2): S34–S38.
60. Diegeler A, Matin M, Kayser S, Binner C, Autschbach R, Battellini R, Krankenberg H, Mohr FW. Angiographic results after minimally invasive coronary bypass grafting using the minimally invasive direct coronary bypass grafting (MIDCAB) approach. Eur J Cardiothorac Surg. 1999; 15: 680–684.
This article has been cited by other articles:
 |
|
 |
|
  Y. Abu-Omar and D. P. Taggart The present status of off-pump coronary artery bypass grafting Eur. J. Cardiothorac. Surg., August 1, 2009; 36(2): 312 - 321. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 D. Chu, F. G. Bakaeen, T. K. Dao, S. A. LeMaire, J. S. Coselli, and J. Huh On-Pump Versus Off-Pump Coronary Artery Bypass Grafting in a Cohort of 63,000 Patients. Ann. Thorac. Surg., June 1, 2009; 87(6): 1820 - 1827. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
K. Nishiyama, M. Horiguchi, S. Shizuta, T. Doi, N. Ehara, R. Tanuguchi, Y. Haruna, Y. Nakagawa, Y. Furukawa, M. Fukushima, et al. Temporal Pattern of Strokes After On-Pump and Off-Pump Coronary Artery Bypass Graft Surgery. Ann. Thorac. Surg., June 1, 2009; 87(6): 1839 - 1844. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 C. H. Moller, L. Penninga, J. Wetterslev, D. A. Steinbruchel, and C. Gluud Clinical outcomes in randomized trials of off- vs. on-pump coronary artery bypass surgery: systematic review with meta-analyses and trial sequential analyses Eur. Heart J., November 1, 2008; 29(21): 2601 - 2616. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 O. Kuss, J. F. Gummert, and J. Borgermann Meta-analyses with rare events should use adequate methods J. Thorac. Cardiovasc. Surg., July 1, 2008; 136(1): 241 - 241. [Full Text] [PDF]
|
|
|
|
|
|
S. F. Marasco, L. N. Sharwood, and M. J. Abramson No improvement in neurocognitive outcomes after off-pump versus on-pump coronary revascularisation: a meta-analysis Eur. J. Cardiothorac. Surg., June 1, 2008; 33(6): 961 - 970. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 D. M. Bravata, A. L. Gienger, K. M. McDonald, V. Sundaram, M. V. Perez, R. Varghese, J. R. Kapoor, R. Ardehali, D. K. Owens, and M. A. Hlatky Systematic Review: The Comparative Effectiveness of Percutaneous Coronary Interventions and Coronary Artery Bypass Graft Surgery Ann Intern Med, November 20, 2007; 147(10): 703 - 716. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
H. Takagi, T. Tanabashi, N. Kawai, and T. Umemoto Off-pump surgery does not reduce stroke, compared with results of on-pump coronary artery bypass grafting: A meta-analysis of randomized clinical trials. J. Thorac. Cardiovasc. Surg., October 1, 2007; 134(4): 1059 - 1060. [Full Text] [PDF]
|
|
|
|
 |
|
 E. L. Hannan, C. Wu, C. R. Smith, R. S.D. Higgins, R. E. Carlson, A. T. Culliford, J. P. Gold, and R. H. Jones Off-Pump Versus On-Pump Coronary Artery Bypass Graft Surgery: Differences in Short-Term Outcomes and in Long-Term Mortality and Need for Subsequent Revascularization Circulation, September 4, 2007; 116(10): 1145 - 1152. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 C. E. Tourmousoglou, S. Lalos, and C. Rokkas Evaluating Off-Pump Coronary Artery Bypass Grafting Stroke, September 1, 2007; 38(9): e83 - e83. [Full Text] [PDF]
|
|
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||