Deleterious effects of cardiopulmonary bypass in coronary artery surgery and scientific interpretation of off-pump's logic

Acute Cardiac Care

Volumn 8, Issue 4, 2006, Pages 196-209

  Elahi, Maqsood M ^a   Khan, Jawad S ^b   Matata, Bashir M ^c  

^a SOUTHAMPTON GENERAL HOSPITAL   (United Kingdom)

^b PUNJAB INSTITUTE OF CARDIOLOGY   (Pakistan)

^c LIVERPOOL HEART AND CHEST HOSPITAL   (United Kingdom)

Author keywords

Beating heart surgery; Cardiopulmonary bypass; Complete myocardial revascularization; Intra myocardial coronaries; Myocardial protection; Off pump; Predictors

Indexed keywords

CELL ADHESION MOLECULE; CYTOKINE; TUMOR NECROSIS FACTOR ALPHA;

ANASTOMOSIS; BRAIN INJURY; CARDIOPULMONARY BYPASS; CLINICAL ASSESSMENT; CLINICAL TRIAL; COMPLEMENT ACTIVATION; CORONARY ARTERY BYPASS GRAFT; CORONARY HEMODYNAMICS; HEART ATRIUM FIBRILLATION; HEART MUSCLE ISCHEMIA; HEART MUSCLE REVASCULARIZATION; HUMAN; INFLAMMATION; OFF PUMP CORONARY SURGERY; OUTCOMES RESEARCH; OXIDATIVE STRESS; PERIOPERATIVE PERIOD; POSTOPERATIVE COMPLICATION; PRIORITY JOURNAL; REOPERATION; REPERFUSION INJURY; RETROSPECTIVE STUDY; REVIEW; SAFETY; SURGICAL TECHNIQUE; SURVIVAL TIME;

CARDIOPULMONARY BYPASS; CLINICAL TRIALS; CORONARY ARTERY BYPASS, OFF-PUMP; HUMANS; INFLAMMATION MEDIATORS; OXIDATIVE STRESS; REPERFUSION INJURY; SYSTEMIC INFLAMMATORY RESPONSE SYNDROME;

EID: 33845617466     PISSN: 17482941     EISSN: 1748295X     Source Type: Journal    
DOI: 10.1080/17482940600981730     Document Type: Review

References (109)

1. Elahi MM, Khan JS. Living with off-pump coronary artery surgery: evolution, development, and clinical potential for coronary heart disease patients. Heart Surg Forum. 2006;9:630-7.
2. Sabik JF, Gillinov AM, Blackstone EH, et al. Does off-pump coronary surgery reduce morbidity and mortality? J Thorac Cardiovasc Surg. 2002;124:698-707.
3. Cleveland JC, Shroyer AL, Chen AY, Peterson E, Grover FL. Off-pump coronary artery bypass grafting decrease risk-adjusted mortality and morbidity. Ann Thorac Surg. 2001;72:1282-9.
4. Ascione R, Angelini GD. Off-pump coronary artery bypass surgery: the implications of the evidence. J Thorac Cardiovasc Surg. 2003;125:779-81.
5. Abu-Omar Y, Taggart DP. Off-pump coronary artery bypass grafting. Lancet. 2002;360:327-30.
6. Pepper J. Controversies in off-pump coronary artery surgery. Clin Med Res. 2005;3:27-33.
7. 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;65:420-4.
8. Struber M, Cremer JT, Gohrbandt B, et al. Human cytokine responses to coronary artery bypass grafting with and without cardiopulmonary bypass. Ann Thorac Surg. 1999;68:1330-5.
9. 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;69:1198-204.
10. Matata BM, Sosnowski AW, Galinanes M. Off-pump bypass graft operation significantly reduces oxidative stress and inflammation. Ann Thorac Surg. 2000;69:785-91.
11. Diegeler A, Doll N, Rauch T, Haberer D. Humoral immune response during coronary artery bypass grafting: a comparison of limited approach, 'off-pump' technique, and conventional cardiopulmonary bypass. Circulation. 2000;102:95-100.
12. Schulze C, Conrad N, Schutz A, et al. Reduced expression of systemic proinflammatory cytokines after off-pump versus conventional coronary artery bypass grafting. Thorac Cardiovasc Surg. 2000;48:364-9.
13. Chello M, Mastroroberto P, Quirino A, et al. Inhibition of neutrophil apoptosis after coronary bypass operation with cardiopulmonary bypass. Ann Thorac Surg. 2002;73:123-30.
14. Massoudy P, Zahler S, Tassani P, et al. Reduction of proinflammatory cytokine levels and cellular adhesion in CABG procedures with separated pulmonary and systemic extracorporeal circulation without an oxygenator. Eur J Cardiothorac Surg. 2000;17:729-36.
15. Czerny M, Baumer H, Kilo J, et al. Inflammatory response and myocardial injury following coronary artery bypass grafting with or without cardiopulmonary bypass. Eur J Cardiothorac Surg. 2000;17:737-42.
16. Wan S, Izzat MB, Lee TW, Wan IY, Tang NL, Yim AP. Avoiding cardiopulmonary bypass in multivessel CABG reduces cytokine response and myocardial injury. Ann Thorac Surg. 1999;68:52-6.
17. Wei M, Kuukasjarvi P, Laurikka J, et al. Cytokine responses and myocardial injury in coronary bypass grafting. Scand J Clin Lab Invest. 2001;61:161-6.
18. Oz MC, Liao H, Naka Y, et al. Ischemia-induced interleukin-8 release after human heart transplantation. A potential role for endothelial cells. Circulation. 1995;92:428-32.
19. Isomaki P, Punnonen J. Pro- and anti-inflammatory cytokines in rheumatoid arthritis. Ann Med. 1997;29:499-507.
20. Casati V, Gerli C, Franco A, et al. Activation of coagulation and fibrinolysis during coronary surgery: on-pump versus off-pump techniques. Anesthesiology. 2001;95:1103-9.
21. Gerritsen WBM, van Boven WJP, Driessen AHG, Haas FJLM, Aarts LPHJ. Off-pump versus on-pump coronary artery bypass grafting: oxidative stress and renal function. Eur J Cardiothorac Surg. 2001;20:923-92.
22. van Dijk D, Nierich AP, Jansen E, et al. Early outcome after off-pump versus on-pump coronary bypass surgery- results from a randomized study. Circulation. 2001;104:1761-6.
23. Elahi MM, Elahi M, Matata BM. Covalent modification of C3 and C4 protein chains by ROS augment Mannan Binding-Lectin Pathway activation in an extracorporeal blood recirculation model. Mol Immunol. 2006;43:153.
24. Matata BM, Sosnowski AW, Galinanes M. Off-pump coronary bypass graft surgery: Evidence of a significant reduction in protein nitration and oxidative stress. Circulation. 1999;100:3510.
25. Matata BM, Elahi MM. Peroxynitrite: an intriguing double-agent in biology and cardiovascular disease. In: Pandalai SG, editor. Recent Research Developments in Biophysics Vol 3 Part I Transworld Research Communications, Gayathri Publishers; 2004. pp 93-112.
26. Elahi MM, Matata BM. Blood-dependent redox activity during extracorporeal circulation in health and disease. The Cardiology. 2005;1:156-7.
27. Elahi MM, Matata BM, Galinanes M. Nitric Oxide modulates the inflammatory response to extracorporeal circulation of blood through activation of NF Kappa-B. Circulation. 2004;110:358.
28. Matata BM, Galinanes M. Cardiopulmonary bypass exacerbates oxidative stress but does not increase proinflammatory cytokine release in patients with diabetes compared with patients without diabetes: Regulatory effects of exogenous nitric oxide. J Thorac Cardiovasc Surg. 2000;120:1-11.
29. Favaloro RG, Effler DB, Groves LK, Sheldon WC, Sones FM. Direct myocardial revascularization by saphenous vein graft. Present operative technique and indications. Ann Thorac Surg. 1970;10:97-111.
30. Trapp WG, Bisarya R. Placement of coronary artery bypass graft without pump oxygenator. Ann Thorac Surg. 1975;19:1-9.
31. Benetti FJ, Naselli C, Wood M, Geffner L. Direct myocardial revascularization without extracorporeal circulation. Experience in 700 patients. Chest. 1991;100:312-6.
32. Buffolo E, de Andrade JCS, Rodrigues Branco JNR, Teles CA, Aguiar LF, Gomes WJ. Coronary artery bypass grafting without cardiopulmonary bypass. Ann Thorac Surg. 1996;61:63-6.
33. Buckberg GD, Allen BS. Myocardilal protection management during adult cardiac operations. In: Baue AE, Geha AS, Hammond GL, Laks H, Naunheim KS, editors. Glenn's thoracic and cardiovascular surgery, Apple & Lange, Stamford; 1996. pp 1653-87.
34. Mehlhorn U, Allen SJ, Adams DL, et al. Normothermic continuous antegrade blood cardioplegia does not prevent myocardial edema and cardiac dysfunction. Circulation. 1995;92:1940-6.
35. Bennetts JS, Baker R, Ross IK, Knight JL. Assessment of myocardial injury by troponin T in off-pump coronary artery grafting and conventional coronary artery graft surgery. ANZ J Surg. 2002;72:105-9.
36. Masuda M, Morita S, Tomita H, et al. Off-pump attenuates myocardial enzyme leakage but not postoperative brain natriuretic peptide secretion. Ann Thorac Cardiovasc Surg. 2002;8:139-44.
37. Muraki S, Morris CD, Budde JM, et al. Experimental off-pump coronary artery revascularization with adenosine-enhanced reperfusion. J Thorac Cardiovasc Surg. 2001;121:570-9.
38. Vassiliades TA, Nielsen JL, Lonquist JL. Coronary perfusion methods during off-pump coronary bypass: results of a randomized clinical trial. Ann Thorac Surg. 2002;74:1383-9.
39. Laude K, Thuillez C, Richard V. Coronary endothelial dysfunction after ischemia and reperfusion: a new therapeutic target? Braz Med Biol Res. 2001;34:1-7.
40. Nakamura K, Schmidt I, Gray CC, et al. The effect of chronic L-arginine administration on vascular recovery following cold cardioplegic arrest in rats. Eur J Cardiothorac Surg. 2002;21:753-9.
41. Gray CC, Amrani M, Yacoub MH. Heat stress proteins and myocardial protection: experimental model or potential clinical tool? Int J Biochem Cell Biol. 1999;31:559-73.
42. Kim KB, Lim C, Ahn H, Yang JK. Intra-aortic balloon pump therapy facilitates posterior vessel off-pump coronary artery bypass grafting in high-risk patients. Ann Thorac Surg. 2001;71:1964-8.
43. Patel NC, Patel NU, Loulmet DF, McCabe JC, Subramanian VA. Emergency conversion to cardiopulmonary bypass during attempted off-pump revascularisation results in increased morbidity and mortality. J Thorac Cardiovasc Surg. 2004;128:655-61.
44. Edgerton JR, Dewey TM, Magee MJ, et al. Conversion in off-pump coronary artery bypass grafting: An analysis of predictors and outcomes. Ann Thorac Surg. 2003;76:1138-43.
45. Vassiliades TA, Nielsen JL, Lonquist JL. Hemodynamic collapse during off-pump coronary artery bypasses grafting. Ann Thorac Surg. 2002;73:1874-9.
46. Sinclair MC, Wilsker GA, Morris DL, Mohan R, Hollenbeak CS. Coronary artery bypass: the increasing role of off-pump surgery in a large community hospital. Heart Surg Forum. 2002;5:130-44.
47. Iaco AL, Contini M, Teodori G, et al. Off or on bypass: what is the safety threshold. Ann Thorac Surg. 1999;58:1486-9.
48. Anyanwu AC, Al-Ruzzeh SA, George SJ, Patel R, Yacoub MH, Amrani M. Conversion to off-pump coronary bypass without increased morbidity or change in practice. Ann Thorac Surg. 2002;73:798-802.
49. Baumgartner FJ, Cheissari A, Capouya ER, Panagiotides GP, Katouzian A, Yokoyama T. Technical aspects of total revascularisation in off-pump coronary bypass via sternotomy approach. Ann Thorac Surg. 1999;67:1653-8.
50. Soltoski P, Salerno T, Levinsky L, et al. Conversion to cardiopulmonary bypass in off-pump coronary artery bypass grafting: its effect on outcome. J Card Surg. 1998;13:328-34.
51. Jegaden O, Mikaeloff.. Off-pump coronary artery bypass surgery. The beginning of the end? Eur J Cardiothoracic Surg. 2001;19:237-8.
52. Detter C, Deuse T, Christ F, Boehm DH, Reichenspurner H, Reichart B. Comparison of two stabilizer concepts for off-pump coronary artery bypass grafting. Ann Thorac Surg. 2002;74:497-501.
53. Kim KB, Lim C, Lee C, et al. Off-pump coronary artery bypass may decrease the patency of saphenous vein grafts. Ann Thorac Surg. 2001;72:1033-7.
54. Lund O, Christensen J, Holme S, et al. On-pump versus off-pump coronary artery bypass: independent risk factors and off-pump patency. Eur J Cardiothorac Surg. 2001;20:901-7.
55. Ömeroǧlu SN, Kirali K, Güler M, Toker ME, İpek G, Işik Öyakut C. Midterm angiographic assessment of coronary artery bypass grafting without cardiopulmonary bypass. Ann Thorac Surg. 2000;70:844-50.
56. Jatene FB, Pêgo-Fernandes PM, Hueb AC, et al. Angiographic evaluation of graft patency in minimally invasive direct coronary artery bypass grafting. Ann Thorac Surg. 2000;70:1066-9.
57. Puskas JD, Thourani VH, Marshall JJ, et al. Clinical outcomes, angiographic patency, and resource utilization in 200 consecutive off-pump coronary bypass patients. Ann Thorac Surg. 2001;71:1477-84.
58. Kleisli T, Cheng W, Jacobs MJ, et al. In the current era, complete revascularisation improves survival after coronary artery bypass surgery. J Thorac Cardiovasc Surg. 2005;129:1283-91.
59. Puskas JD, Williams WH, Duke PG, et al. 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.
60. Bull DA, Neumayer LA, Stringham JC, Meldrum P, Affleck DG, Karwnande SV. Coronary artery bypass grafting with cardiopulmonary bypass versus off-pump cardiopulmonary bypass grafting: does eliminating the pump reduce morbidity and cost? Ann Thorac Surg. 2001;71:170-5.
61. Sabik JF, Gillinov AM, Blackstone EH, et al. Does off-pump coronary surgery reduce morbidity and mortality? J Thorac Cardiovasc Surg. 2002;124:698-707.
62. Buffolo E. Why is off-pump coronary artery bypass grafting better? Heart Surg Forum. 2002;5:154-6.
63. Arom KV, Flavin TF, Emery RW, Kshettry VR, Janey PA, Petersen RJ. Safety and efficacy of off-pump coronary artery bypass grafting. Ann Thorac Surg. 2000;69:704-10.
64. Cleveland JC, Shroyer ALW, Chen AY, Peterson E, Grover FL. Off-pump coronary artery bypass grafting decreases risk-adjusted mortality and morbidity. Ann Thorac Surg. 2001;72:1282-9.
65. Yokoyama T, Baumgartner FJ, Gheissari A, Capouya ER, Panagiotides GP, Declusin RJ. Off-pump versus on-pump coronary bypass in high-risk subgroups. Ann Thorac Surg. 2000;70:1546-50.
66. Prifti E, Bonacchi M, Giunti G, et al. Does on-pump/beating-heart coronary artery bypass grafting offer better outcome in end-stage coronary artery disease patients? J Card Surg. 2000;15:403-10.
67. Larsson S, Nilsson F. A method for surgical exposure of intramyocardial coronary arteries for bypass grafting. Scand J Thorac Cardiovasc Surg. 1998;22:47-9.
68. Stamou SC, Corso PJ. Coronary revascularisation without cardiopulmonary bypass in high risk patients: A route to the future. Ann Thorac Surg. 2001;71:1056-61.
69. Stamou SC, Pfister AJ, Dangas G, et al. Beating heart versus conventional single vessel reoperative coronary artery bypass surgery. Ann Thorac Surg. 2000;69:1383-7.
70. Mohr R, Moshkovitz Y, Gurevitch J, Benetti FJ. Reoperative coronary artery bypass without cardiopulmonary bypass. Ann Thorac Surg. 1997;63:40-3.
71. Stamou SC, Bafi AS, Boyce SW, et al. Coronary revascularisation of the circumflex: different approaches and outcomes. Ann Thorac Surg. 2000;70:1371-7.
72. Talwalker NG, Cooley DA, Ott DA, Livesay JJ. Limited access coronary artery bypass grafting. The Texas Heart Institute experience. Tex Heart Inst J. 1998;25:175-80.
73. Jain U. Myocardial injury during reoperation for coronary artery bypass surgery. J Cardiothorac Vasc Anesth. 1995;9:389-94.
74. Koutlas TC, Elbeery JR, Williams JM, et al. Myocardial revascularisation in the elderly using beating heart coronary artery bypass surgery. Ann Thorac Surg. 2000;69:1042-7.
75. Ricci M, Karamanoukian HL, Abraham R, et al. Stroke in octogenarians undergoing coronary artery surgery with or without cardiopulmonary bypass. Ann Thorac Surg. 2000;69:1471-5.
76. Stamou SC, Pfister AJ, Dullum MKC, et al. Beating heart versus conventional coronary artery bypass grafting in octogenarians: early clinical outcomes. J Am Coll Cardiol. 2000;35:341.
77. Boyd WD, Desai ND, Del Rizzo DF, Novick RJ, Mckenzie FN, Menkis AH. Off-pump surgery decreases postoperative complications and resource utilization in the elderly. Ann Thorac Surg. 1999;68:1490-3.
78. O'Connor GT, Plume SK, Olmstead EM, et al. Multivariate prediction of in-hospital mortality associated with coronary artery bypass graft surgery. Northern New England Cardiovascular Disease Study Group. Circulation. 1992;85:2110-8.
79. Akins CW, Boucher CA, Pohost GM. Preservation of interventricular septal function in patients having coronary artery bypass grafts without cardiopulmonary bypass. Am Heart J. 1984;107:304-9.
80. Dipla K, Mattiello JA, Jeevanandam V, Houser SR, Margulies KB. Myocyte recovery after mechanical circulatory support in humans with end-stage heart failure. Circulation. 1998;97:2316-22.
81. Tasdemir O, Vural KM, Karagoz H, Bayazit K. Coronary artery bypass grafting on the beating heart without the use of extracorporeal circulation: review of 2052 cases. J Thorac Cardiovasc Surg. 1998;116:68-73.
82. Patel NC, Deodhar AP, Grayson AD, et al. Neurological outcomes in coronary surgery: independent effect of avoiding cardiopulmonary bypass. Ann Thorac Surg. 2002;74:400-5.
83. Diegeler A, Hirsch R, Schneider F, et al. Neuro monitoring and neuroprotective outcome in off-pump versus conventional coronary bypass operation. Ann Thorac Surg. 2002;69:1162-6.
84. Lloyd CT, Ascione R, Underwood MJ, Gardner F, Black A, Angelini GD. Serum S-100 protein release and neuropsychologic outcome during coronary revascularisation on the beating heart: a prospective randomized study. J Thorac Cardiovasc Surg. 2000;119:148-54.
85. Athanasiou T, Al-Ruzzeh S, Kumar P, Crossman MC, Amrani M, Pepper JR, et al. Off-pump myocardial revascularization is associated with less incidence of stroke in elderly patients. Ann Thorac Surg. 2004;77:745-53.
86. Athanasiou T, Aziz O, Mangoush O, Weerasinghe A, Al-Ruzzeh S, Purkayastha S, et al. Do off-pump techniques reduce the incidence of postoperative atrial fibrillation in elderly patients undergoing coronary artery bypass grafting? Ann Thorac Surg. 2004;77:1567-74.
87. Taggart D. Off-pump surgery and cerebral injury. J Thorac Cardiovasc Surg. 2004;127:7-9.
88. Bucerius J, Gummert JF, Borger MA, Walther T, Doll N, Falk V, et al. Predictors of delirium after cardiac surgery delirium: effect of beating-heart (off-pump) surgery. J Thorac Cardiovasc Surg. 2004;127:57-64.
89. Plasse HM, Spencer FC, Mittleman M, Frost JO. Unilateral sudden loss of hearing: an unusual complication of cardiac operation. J Thorac Cardiovasc Surg. 1980;79:822-6.
90. Cox III AJ, Sergeant EW. Sudden sensorineural hearing loss following nonotologic, noncardiopulmonary bypass surgery. Arch Otolaryngol Head Neck Surg. 1997;123:994-8.
91. Shapiro MJ, Purn JM, Raskin C. A study of the effects of cardiopulmonary bypass surgery on auditory function. Laryngoscope. 1981;91:2046-52.
92. Aytacoglu BN, Ozcan C, Sucu N, et al. Hearing loss in patients undergoing coronary artery bypass grafting with or without extracorporeal circulation. Med Sci Monit. 2006;12:253-9.
93. Elahi M, Hadjinikalau L, Galiñanes M. Incidence and clinical consequences of atrial fibrillation within 1 year of first-time isolated coronary bypass surgery. Circulation. 2003;108:207-12.
94. Athanasiou T, Aziz O, Mangoush O, et al. Do off-pump techniques reduce the incidence of postoperative atrial fibrillation in elderly patients undergoing coronary artery bypass grafting? Ann Thorac Surg. 2004;77:1567-74.
95. Angelini GD, Taylor FC, Reeves BC, et al. 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;359:1194-9.
96. Nathoe HM, van Dijk D, Jansen EW, et al. A comparison of on-pump and off-pump coronary bypass surgery in low-risk patients. N Engl J Med. 2003;348:394-402.
97. Khan NE, De Souza A, Mister R, et al. A randomized comparison of off-pump and on-pump multivessel coronary-artery bypass surgery. N Engl J Med. 2004;350:21-8.
98. Legare JF, Buth KJ, King S, et al. Coronary bypass surgery performed off pump does not result in lower in-hospital morbidity than coronary artery bypass grafting performed on pump. Circulation. 2004;109:887-92.
99. Cleveland JC, Shroyer AL, Chen AY, et al. Off-pump coronary artery bypass grafting decreases risk-adjusted mortality and morbidity. Ann Thorac Surg. 2001;72:1282-8.
100. Calafiore AM, Di Mauro M, Contini M, et al. Myocardial revascularisation with and without cardiopulmonary bypass in multivessel disease: impact of the strategy on early outcome. Ann Thorac Surg. 2001;72:456-62.
101. Al-Ruzzeh S, Nakamura K, Athanasiou T, et al. Does off-pump coronary artery bypass (OPCAB) surgery improve the outcome in high-risk patients? A comparative study of 1398 high-risk patients. Eur J Cardiothorac Surg. 2003;23:50-5.
102. Plomondon ME, Cleveland JC, Jr, Ludwig ST, et al. Off-pump coronary artery bypass is associated with improved risk-adjusted outcomes. Ann Thorac Surg. 2001;72:114-9.
103. Magee MJ, Jablonski KA, Stamou SC, et al. Elimination of cardiopulmonary bypass improves early survival for multivessel coronary artery bypass patients. Ann Thorac Surg. 2002;73:1196-203.
104. Subramanian VA. Less invasive arterial CABG on a beating heart. Ann Thorac Surg. 1997;111:554-5.
105. Gundry SR, Romano MA, Shattuck OH, Razzouk AJ, Bailey LL. Seven year follow up of coronary artery bypasses performed with or without cardiopulmonary bypass. J Thorac Cardiovasc Surg. 1998;115:1273-8.
106. Mehran R, Dangas GD, Stamou C, et al. One-year clinical outcome after minimally invasive direct coronary artery bypass. Circulation. 2000;102:2799-802.
107. Quigley RL, Weiss SJ, Highbloom RY, Pym J. Creative arterial bypass can be performed on the beating heart. Ann Thorac Surg. 2001;72:793-7.
108. Kobayashi J, Sasako Y, Bando K, et al. Multiple off-pump coronary revascularization with 'aorta no-touch' technique using composite and sequential methods. Heart Surg Forum. 2002;5:114-8.
109. Cooper WA, Corvera JS, Thourani VH, et al. Perfusion-assisted direct coronary artery bypass provides early reperfusion of ischemic myocardium, and facilitates complete revascularization. Ann Thorac Surg. 2003;75:1132-9.