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Ushioda R, Hirofuji A, Yoongtong D, Sakboon B, Cheewinmethasiri J, Lokeskrawee T, Patumanond J, Lawanaskol S, Kamiya H, Arayawudhikul N. Multi-vessel coronary artery grafting: analyzing the minimally invasive approach and its safety. Front Cardiovasc Med 2024; 11:1391881. [PMID: 38774658 PMCID: PMC11106462 DOI: 10.3389/fcvm.2024.1391881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 04/18/2024] [Indexed: 05/24/2024] Open
Abstract
Introduction At our institution, we perform off-pump coronary artery bypass (OPCAB) as a standard procedure. Moreover, patients with favorable coronary anatomy and condition are selected for minimally invasive cardiac surgery (MICS)-OPCAB. We retrospectively compared early outcomes, focusing on safety, between MICS-OPCAB and conventional off-pump techniques for multivessel coronary artery bypass grafting (CABG). Methods From August 2017 to September 2022, 1,220 patients underwent multivessel coronary artery grafting at our institution. They were divided into the MICS-OPCAB group (MICS group = 163 patients) and the conventional OPCAB group (MS group = 1057 patients). Propensity score matching (1 : 1 ratio) was applied to the MICS-OPCAB and MS groups (149 patients per group) based on 23 preoperative clinical characteristics. Results After matching, there were no significant differences in preoperative characteristics between the groups. The MICS group had a lower total graft number (2.3 ± 0.6 vs. 2.9 ± 0.8, p < 0.001) and fewer distal anastomoses (2.7 ± 0.8 vs. 3.2 ± 0.9, p < 0.001). There were no significant differences in hospital stay, intensive care unit stay, postoperative complications, and 30-day mortality. The MICS group had less drain output (MICS 350 ml [250-500], MS 450 ml [300-550]; p = 0.013). Kaplan-Meier analysis revealed no significant differences in postoperative MACCE (major adverse cardiac or cerebrovascular events)-free and survival rates between the groups (MACCE-free rate p = 0.945, survival rate p = 0.374). Conclusion With proper patient selection, MICS-OPCAB can provide good short to mid-term results, similar to those of conventional OPCAB.
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Affiliation(s)
- Ryohei Ushioda
- Cardiovascular and Thoracic Surgery Unit, Department of Surgery, Lampang Hospital, Lampang, Thailand
- Department of Cardiac Surgery, Asahikawa Medical University, Asahikawa, Japan
| | - Aina Hirofuji
- Department of Cardiac Surgery, Asahikawa Medical University, Asahikawa, Japan
| | - Dit Yoongtong
- Cardiovascular and Thoracic Surgery Unit, Department of Surgery, Lampang Hospital, Lampang, Thailand
| | - Boonsap Sakboon
- Cardiovascular and Thoracic Surgery Unit, Department of Surgery, Lampang Hospital, Lampang, Thailand
| | - Jaroen Cheewinmethasiri
- Cardiovascular and Thoracic Surgery Unit, Department of Surgery, Lampang Hospital, Lampang, Thailand
| | | | - Jayanton Patumanond
- Center for Clinical Epidemiology and Clinical Statistics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | | | - Hiroyuki Kamiya
- Department of Cardiac Surgery, Asahikawa Medical University, Asahikawa, Japan
| | - Nuttapon Arayawudhikul
- Cardiovascular and Thoracic Surgery Unit, Department of Surgery, Lampang Hospital, Lampang, Thailand
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Sakai H, Kikuchi K, Masuda K, Sai Y, Yoshino K, Ito J, Fukita K. Adjunctive Technique for Proximal Anastomosis via Right Anterior Small Thoracotomy in Minimally Invasive Coronary Artery Bypass Grafting. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2024:15569845241237541. [PMID: 38504143 DOI: 10.1177/15569845241237541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2024]
Affiliation(s)
- Hiroki Sakai
- Department of Cardiovascular Surgery, Tokyo Bay Urayasu Ichikawa Medical Center, Japan
| | - Keita Kikuchi
- Department of Cardiovascular Surgery, Tokyo Bay Urayasu Ichikawa Medical Center, Japan
| | - Kaito Masuda
- Department of Cardiovascular Surgery, Tokyo Bay Urayasu Ichikawa Medical Center, Japan
| | - Yoshun Sai
- Department of Cardiovascular Surgery, Tokyo Bay Urayasu Ichikawa Medical Center, Japan
| | - Kunihiko Yoshino
- Department of Cardiovascular Surgery, Tokyo Bay Urayasu Ichikawa Medical Center, Japan
| | - Joji Ito
- Department of Cardiovascular Surgery, Tokyo Bay Urayasu Ichikawa Medical Center, Japan
| | - Kouji Fukita
- Department of Cardiovascular Surgery, Tokyo Bay Urayasu Ichikawa Medical Center, Japan
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Guo MH, Toubar O, Issa H, Glineur D, Ponnambalam M, Vo TX, Rahmouni K, Chong AY, Ruel M. Long-term survival, cardiovascular, and functional outcomes after minimally invasive coronary artery bypass grafting in 566 patients. J Thorac Cardiovasc Surg 2023:S0022-5223(23)00652-9. [PMID: 37544476 DOI: 10.1016/j.jtcvs.2023.07.047] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 07/24/2023] [Accepted: 07/29/2023] [Indexed: 08/08/2023]
Abstract
OBJECTIVE Sternotomy has been the gold standard incision for surgical revascularization but may be associated with chronic pain and sternal malunion. Minimally invasive coronary artery bypass grafting allows for complete surgical revascularization through a small thoracotomy in selected patients. There is a paucity of long-term data, particularly functional outcomes, for patients who underwent minimally invasive coronary artery bypass grafting. METHODS Patients (N = 566) who underwent minimally invasive coronary artery bypass grafting at a single institution over a 17-year period were prospectively followed. The primary outcome was survival. At late follow-up, patients were contacted for a questionnaire on functional outcomes. Multivariable Cox proportional hazard model identified correlates of the primary outcome. RESULTS Clinical follow-up was complete for 100% of patients (mean 7.0 ± 4.4 years); a follow-up questionnaire was also completed for 83.9% (N = 427) of live patients. Fifty percent of patients (N = 283) had undergone multivessel grafting. At 12 years, survival for the entire cohort was 82.2% ± 2.6%. On late follow-up questionnaire, 12 patients (2.8%) had greater than Canadian Cardiovascular Score Class II angina and 19 patients (4.5%) had greater than New York Heart Association Class II symptoms. More than 98% of patients did not have pain related to the incision site. Cox proportional hazards analysis identified older age, peripheral vascular disease, prior myocardial infarction, left ventricular dysfunction, cancer in the past 5 years, intraoperative transfusion, and hybrid revascularization as correlates of mortality during follow-up. CONCLUSIONS Minimally invasive coronary artery bypass grafting is a safe and durable alternative to sternotomy coronary artery bypass grafting in selected patients, with excellent short- and long-term outcomes, including for multivessel coronary disease. At long-term follow-up, the proportion of patients with significant symptoms and incisional pain was low.
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Affiliation(s)
- Ming Hao Guo
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Omar Toubar
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada; Faculty of Medicine, McGill University, Gatineau, Quebec, Canada
| | - Hugo Issa
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - David Glineur
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Menaka Ponnambalam
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Thin X Vo
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Kenza Rahmouni
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Aun-Yeong Chong
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Marc Ruel
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada.
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Hasan SU, Pervez A, Naseeb MW, Rajput BS, Faheem A, Hameed I, Sá MP, Zubair MM. Clinical outcomes of different revascularization approaches for patients with multi-vessel coronary artery disease: A network meta-analysis. Perfusion 2023:2676591231182585. [PMID: 37294619 DOI: 10.1177/02676591231182585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
BACKGROUND As surgical techniques continue to evolve, the optimal approach for revascularizing multi-vessel coronary artery disease (CAD) remains a matter of ongoing debate. Accordingly, our objective was to compare and contrast various surgical techniques utilized in the management of multi-vessel CAD. METHODS A systematic literature review was performed using PubMed, Embase, and Cochrane central register of controlled trials from inception to May 2022. Random-effects network meta-analysis was performed for the primary outcome; target vessel revascularization (TVR), and secondary outcomes; mortality, major adverse cardiac and cerebrovascular events, postoperative myocardial infarction, new-onset atrial fibrillation, stroke, new-onset dialysis, in patients undergoing percutaneous coronary intervention (PCI) with a stent, off-pump coronary bypass graft, on-pump coronary artery bypass graft (ONCABG), hybrid coronary revascularization, minimally-invasive coronary artery bypass, or robot-assisted coronary artery bypass (RCAB) surgeries. RESULTS A total of 8841 patients were included from 23 studies. The analysis showed that ONCABG had the highest freedom from TVR, with a mean (SD) absolute risk of 0.027 (0.029); although ONCABG was found to be superior to all other methods, it was only significantly better than first-generation stent PCI. While RCAB did not demonstrate significant superiority over other treatments, it showed a greater probability of preventing postoperative complications. Notably, no significant heterogeneity was calculated for any of the reported outcomes. CONCLUSIONS ONCABG shows a better rank probability compared to all other techniques for preventing TVR, while RCAB offers greater freedom from most postoperative complications. However, given the absence of randomized controlled trials, these results should be interpreted with caution.
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Affiliation(s)
| | | | | | | | - Ariba Faheem
- Dow University of Health Sciences, Karachi, Pakistan
| | - Irbaz Hameed
- Department of Cardiothoracic Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Michel Pompeu Sá
- Department of Cardiac Surgery, Lankenau Heart Institute, Wynnewood, PA, USA
| | - M Mujeeb Zubair
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Liang L, Liu JJ, Kong QY, You B, Ma XL, Chi LQ, Zhu JM. Comparison of early outcomes associated with coronary artery bypass grafting for multi-vessel disease conducted using minimally invasive or conventional off-pump techniques: a propensity-matched study based on SYNTAX score. J Cardiothorac Surg 2022; 17:144. [PMID: 35672764 PMCID: PMC9175317 DOI: 10.1186/s13019-022-01905-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 05/28/2022] [Indexed: 11/17/2022] Open
Abstract
Background This study was designed to compare early outcomes associated with coronary artery bypass grafting for multi-vessel disease conducted using either minimally invasive or conventional off-pump techniques. Methods From January 2017 through January 2021, 582 patients with multi-vessel lesion coronary artery disease underwent either minimally invasive cardiac surgery coronary artery bypass grafting (MICS CABG) or conventional off-pump coronary artery bypass grafting (OPCABG) treatment by our team at Anzhen Hospital. Patients in the MICS CABG group were propensity score-matched with those in the OPCABG at a 1:1 ratio (MICS CABG = 172; OPCABG = 172), using epidemiological data, preoperative clinical characteristics, and SYNTAX score as covariates. Perioperative outcomes and 6-month computed tomography angiography findings were compared between these groups. Results No significant differences between groups were observed with respect to 30-day postoperative mortality, myocardial infarction, and stroke incidence. Surgical data indicated that the MICS CABG procedure was able to cover all three main arterial territories with a relatively low need for circulatory assistance. The MICS CABG procedure was associated with a longer operative duration, but was also associated with higher postoperative hemoglobin and activities of daily living index values as well as a shorter duration of postoperative hospitalization (P < 0.05). No differences in 6-month graft patency were observed between groups. Conclusions MICS CABG is a safe, less invasive alternative to OPCABG when performing complete revascularization provided patients are properly selected, yielding similar in-hospital outcomes and 6-month graft patency rates together with an earlier return of physical function.
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Surgical Challenges in Multi-Vessel Minimally Invasive Coronary Artery Bypass Grafting. J Interv Cardiol 2022; 2021:1195613. [PMID: 35035305 PMCID: PMC8731297 DOI: 10.1155/2021/1195613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 11/21/2021] [Accepted: 12/01/2021] [Indexed: 11/17/2022] Open
Abstract
Objectives Minimally invasive coronary artery bypass grafting (MICS CABG) has emerged as an alternative treatment for patients with multi-vessel coronary artery disease, but there are certain surgical challenges inherent in the adoption of this approach. The present study was conducted to provide insight regarding the outcomes associated with our first 118 cases, to discuss the surgical difficulties encountered in these patients, and to outline the potential countermeasures. Methods Between January 2017 and January 2020, 118 patients underwent multi-vessel MICS CABG. These patients were stratified into two groups based upon whether they did or did not experience surgical challenges, and early clinical outcomes were compared between these groups to assess the incidence of technical difficulties and associated factors. Results Surgical challenges arose in 38 of the 118 cases in this study, including 13 cases of exposure-related difficulties, 11 cases of proximal anastomosis-related difficulties, 15 cases of distal anastomosis-related difficulties, 4 cases of LITA-related difficulties, and 3 cases of lung-related difficulties. Relative to the other 80 patients, those patients for whom intraoperative technical challenges arose experience significant increases in operative duration (4.94 ± 0.89 vs. 5.59 ± 1.11 h, P=0.001), intraoperative blood loss (667 ± 313 vs. 892 ± 532 mL, P=0.005), length of the ICU admission (17.59 ± 3.51 vs. 22.59 ± 17.31 h, P=0.015), and the duration of postoperative hospitalization (5.96 ± 1.23 vs. 6.71 ± 1.92 days, P=0.012). There were no significant differences between these groups with respect to the mean graft number, major complications such as stroke or organ dysfunction, or one-year graft patency. Conclusions There is a substantial learning curve associated with performing off-pump MICS CABG to treat multi-vessel disease. Surgical challenges encountered during this procedure may increase the operative duration, intraoperative blood loss, ICU admission, and the duration of postoperative hospitalization. However, these issues do not appear to compromise the efficacy of complete revascularization, and early clinical outcomes associated with this procedure remain acceptable.
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Fatehi Hassanabad A, Kang J, Maitland A, Adams C, Kent WDT. Review of Contemporary Techniques for Minimally Invasive Coronary Revascularization. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2021; 16:231-243. [PMID: 34081874 PMCID: PMC8217892 DOI: 10.1177/15569845211010767] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/22/2021] [Indexed: 11/17/2022]
Abstract
Minimally invasive coronary revascularization techniques aim to avoid median sternotomy with its associated complications, while facilitating recovery and maintaining the benefits of surgical revascularization. The 3 most common procedures are minimally invasive coronary artery bypass grafting, totally endoscopic coronary artery bypass, and hybrid coronary revascularization. For a variety of reasons, including cost and technical difficulty, not many centers are routinely performing minimally invasive coronary revascularization. Nevertheless, many studies have assessed the safety and efficacy of each of these procedures in different clinical contexts. Thus far results have been promising, and with the evolution of procedural techniques, these approaches have the potential to redefine coronary revascularization in the future. This review highlights the current state of minimally invasive coronary revascularization techniques by exploring their benefits, identifying barriers to their adoption, and discussing future potential paradigms.
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Affiliation(s)
- Ali Fatehi Hassanabad
- Section of Cardiac Surgery, Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, Calgary, Canada
| | - Jimmy Kang
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Andrew Maitland
- Section of Cardiac Surgery, Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, Calgary, Canada
| | - Corey Adams
- Section of Cardiac Surgery, Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, Calgary, Canada
| | - William D. T. Kent
- Section of Cardiac Surgery, Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, Calgary, Canada
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Rajput NK, Kalangi TKV, Andappan A, Swain AK. MICS CABG: a single-center experience of the first 100 cases. Indian J Thorac Cardiovasc Surg 2021; 37:16-26. [PMID: 33442204 PMCID: PMC7778645 DOI: 10.1007/s12055-020-01048-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 08/27/2020] [Accepted: 09/01/2020] [Indexed: 12/30/2022] Open
Abstract
PURPOSE To study the learning curve and outcomes of the first 100 cases of minimally invasive cardiac surgery (MICS) coronary artery bypass grafting (CABG) performed at our center. METHODS From January 2017 to November 2019, a total of 100 patients underwent CABG via left anterior thoracotomy approach. We have studied the operative times within the MICS CABG patients to analyze our learning curve. We also studied the postoperative outcomes and compared these with those of patients who underwent sternotomy during the same period. RESULTS The mean age was 59.33 ± 9.95 (range 37-82) years. The numbers of males and females were 72 and 28 respectively. The preoperative average ejection fraction (EF) was 51.08 ± 9.75%. All these patients underwent CABG via left thoracotomy approach, after satisfying the exclusion criteria. All patients received left internal mammary artery (LIMA) to left anterior descending (LAD) as a standard graft, with the radial artery and saphenous vein being the next alternative conduits. The average length of the incision was 6.06 ± 0.45 cm. Only 2 cases were done on pump. The average number of grafts per patient was 2.33 ± 0.92. The mean operative time was 132.40 ± 11.56 min. The mean duration of ventilation was 4.79 ± 1.90 h and average intensive care unit (ICU) stay was 2.62 ± 0.84 days. There was one conversion and no mortalities in our study. We had analyzed our operative times and noticed a significant reduction after the first 20 cases, which was our learning curve. CONCLUSION MICS CABG can be performed for multivessel disease with the same comfort as for a single or a double vessel disease, once the learning curve has been achieved. Only significant difference from the sternotomy approach was noted in the longer operative times for MICS CABG during the learning curve, and not thereafter. Significant benefits of MICS over sternotomy were noticed in the immediate postoperative parameters like duration of ventilation, mean drainage, postoperative pain, ICU stay, and hospital stay, with no difference in postoperative adverse events.
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Affiliation(s)
- Nitin Kumar Rajput
- Department of Cardiothoracic Surgery, NHMMI Narayana Superspeciality Hospital, Raipur, Chhattishgarh 492001 India
| | - Tej Kumar Varma Kalangi
- Department of Cardiothoracic Surgery, NHMMI Narayana Superspeciality Hospital, Raipur, Chhattishgarh 492001 India
| | - Arun Andappan
- Department of Anaesthesiology and Critical Care, NHMMI Narayana Superspeciality Hospital, Raipur, Chhattishgarh 492001 India
| | - Alok Kumar Swain
- Department of Anaesthesiology and Critical Care, NHMMI Narayana Superspeciality Hospital, Raipur, Chhattishgarh 492001 India
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Teman NR, Hawkins RB, Charles EJ, Mehaffey JH, Speir AM, Quader MA, Ailawadi G. Minimally Invasive vs Open Coronary Surgery: A Multi-Institutional Analysis of Cost and Outcomes. Ann Thorac Surg 2020; 111:1478-1484. [PMID: 32961136 DOI: 10.1016/j.athoracsur.2020.06.136] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 05/17/2020] [Accepted: 06/23/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Limited multi-institutional data evaluating minimally invasive cardiac surgery (MICS) coronary artery bypass surgery (CABG) outcomes have raised concern for increased resource utilization compared with standard sternotomy. The purpose of this study was to assess short-term outcomes and resource utilization with MICS CABG in a propensity-matched regional cohort. METHODS Isolated CABG patients (2012-2019) were extracted from a regional Society of Thoracic Surgeons database. Patients were stratified by MICS CABG vs open CABG via sternotomy, propensity-score matched 1:2 to balance baseline differences, and compared by univariate analysis. RESULTS Of 26,255 isolated coronary artery bypass graft patients, 139 MICS CABG and 278 open CABG patients were well balanced after matching. There was no difference in the operative mortality rate (2.2% open vs 0.7% MICS CABG, P = .383) or major morbidity (7.9% open vs 7.2% MICS CABG, P = .795). However, open CABG patients received more blood products (22.2% vs 12.2%, P = .013), and had longer intensive care unit (45 vs 30 hours, P = .049) as well as hospital lengths of stay (7 vs 6 days, P = .005). Finally, median hospital cost was significantly higher in the open CABG group ($35,011 vs $27,906, P < .001) compared with MICS CABG. CONCLUSIONS Open CABG via sternotomy and MICS CABG approaches are associated with similar, excellent perioperative outcomes. However, MICS CABG was associated with fewer transfusions, shorter length of stay, and ∼$7000 lower hospital cost, a superior resource utilization profile that improves patient care and lowers cost.
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Affiliation(s)
- Nicholas R Teman
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Virginia.
| | - Robert B Hawkins
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Virginia
| | - Eric J Charles
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Virginia
| | - J Hunter Mehaffey
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Virginia
| | - Alan M Speir
- INOVA Heart and Vascular Institute, Falls Church, Virginia
| | - Mohammed A Quader
- Division of Cardiothoracic Surgery, Virginia Commonwealth University, Richmond, Virginia
| | - Gorav Ailawadi
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Virginia
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Multivessel coronary artery revascularization through left mini-anterior thoracotomy. TURK GOGUS KALP DAMAR CERRAHISI DERGISI-TURKISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2020; 28:557-559. [PMID: 32953225 DOI: 10.5606/tgkdc.dergisi.2020.19279] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 05/04/2020] [Indexed: 11/21/2022]
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Computed tomography improves the differentiation of infectious mediastinitis from normal postoperative changes after sternotomy in cardiac surgery. Eur Radiol 2019; 29:2949-2957. [PMID: 30631921 DOI: 10.1007/s00330-018-5946-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 11/02/2018] [Accepted: 12/03/2018] [Indexed: 01/21/2023]
Abstract
OBJECTIVES To identify CT parameters independently associated with infectious mediastinitis after cardiac surgery and to improve the discrimination of patients with acute infection from those with normal postoperative changes. METHODS In this single-center, retrospective, observational cohort study, we evaluated thoracic CT scans of poststernotomy cardiac surgery patients. Inclusion criteria were clinically suspected mediastinitis, unclear CT signs (e.g., retrosternal mass), and subsequent deep revision surgery. Revision surgery and microbiological samples determined the mediastinitis status. Overall, 22 qualitative and quantitative CT imaging parameters were assessed and associated with infectious mediastinitis in univariate and multivariate regression models. Discriminative capacity and incremental value of the CT features to available clinical parameters were determined by AUC and likelihood-ratio tests, respectively. RESULTS Overall 105 patients (82% men; 67.0 ± 10.3 years) underwent CT and deep revision surgery. Mediastinitis was confirmed in 83/105 (79%) patients. Among available clinical parameters, only C-reactive protein (CRP) was independently associated with infectious mediastinitis (multivariate odds ratio (OR) (per standard deviation) = 2.3; p < 0.001). In the CT, the presence of free gas, pleural effusions, and brachiocephalic lymph node size were independently associated with mediastinitis (multivariate ORs = 1.3-6.3; p < 0.001-0.039). Addition of these CT parameters to CRP increased the model fit significantly (X2 = 17.9; p < 0.001; AUC, 0.83 vs. 0.73). CONCLUSION The presence of free gas, pleural effusions, and brachiocephalic lymph node size in CT is independently associated with infectious mediastinitis in poststernotomy patients with retrosternal mass. These imaging features may help to differentiate mediastinitis from normal postoperative changes beyond traditional clinical parameters such as CRP. KEY POINTS • Presence of free gas, pleural effusions, and brachiocephalic lymph node size on CT are associated independently with infectious mediastinitis. • Combination of these CT parameters increases the discriminatory capacity of clinical parameters such as CRP.
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Une D, Sakaguchi T. Initiation and modification of minimally invasive coronary artery bypass grafting. Gen Thorac Cardiovasc Surg 2018; 67:349-354. [PMID: 30569257 DOI: 10.1007/s11748-018-1050-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 12/10/2018] [Indexed: 11/24/2022]
Abstract
Minimally invasive coronary artery bypass grafting (MICS CABG) via a small left thoracotomy has been proposed as an alternative to standard coronary artery bypass grafting. However, this technique is still limited to skillful surgeons. Off-pump multi-vessel bypass grafting and the use of bilateral internal thoracic arteries are particularly challenging via a small thoracotomy, while they are widely performed via a full median sternotomy. The purpose of this review is to serve as a guide for the proper introduction of MICS CABG in the current era. We examine the advances, current techniques, outcomes and learning curves of MICS CABG and discuss the safe introduction.
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Affiliation(s)
- Dai Une
- Department of Cardiovascular Surgery, National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Taichi Sakaguchi
- Department of Cardiovascular Surgery, Hyogo College of Medicine, 1-1 Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan.
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Minimally invasive cardiac surgery coronary artery bypass grafting (MICS CABG): a review of technique and literature. Indian J Thorac Cardiovasc Surg 2017. [DOI: 10.1007/s12055-017-0614-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Nicolini F, Vezzani A, Romano G, Carino D, Ricci M, Chicco MVD, Gherli T. Coronary Artery Bypass Grafting with Arterial Conduits in the Elderly. Int Heart J 2017; 58:647-653. [PMID: 28966319 DOI: 10.1536/ihj.16-468] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Although improved long-term outcomes obtained with the use of arterial grafts for coronary revascularization in comparison with the traditional association of a single arterial and saphenous vein grafts have been demonstrated in the overall population, the efficacy of this newer technique in the elderly is difficult to prove because their shorter life expectancy due to advanced heart disease, associated with severe comorbidities. Moreover, more widespread use of this technique is limited by the concerns on the potential morbidity, particularly the longer time required to perform the operation and the possibility of deep sternal wound infection in case of bilateral internal thoracic artery harvesting due to the decreased blood supply to the sternum and surrounding tissues.The review of the recent literature indicates that the use of bilateral internal thoracic arteries in very elderly patients should not be considered routinely. It seems reasonable to avoid it in octogenarians in the presence of well-known predictors of sternal complications such as diabetes, morbid obesity, and severe chronic lung disease.There is also still controversy about the superiority of the radial artery over the saphenous vein graft as a second or third conduit for surgical myocardial revascularization, although the majority of recent studies seem to support more liberal use of the radial artery as second arterial conduit in the elderly. Although a clinical benefit of arterial graft revascularization cannot be formally excluded for elderly patients, the increased complexity of this technique suggests that careful clinical judgment is necessary to select grafts for individual patients.
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Affiliation(s)
- Francesco Nicolini
- Cardiac Surgery Unit, Department of Clinical and Experimental Medicine, University of Parma
| | | | - Giorgio Romano
- Cardiac Surgery Unit, Department of Clinical and Experimental Medicine, University of Parma
| | - Davide Carino
- Cardiac Surgery Unit, Department of Clinical and Experimental Medicine, University of Parma
| | - Matteo Ricci
- Cardiac Surgery Unit, Department of Clinical and Experimental Medicine, University of Parma
| | | | - Tiziano Gherli
- Cardiac Surgery Unit, Department of Clinical and Experimental Medicine, University of Parma
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Farcy DA, Lapietra A, Abo BN, Dalley M. Pericardial Herniation of Small Bowel Post Minimally Invasive Hybrid Maze of Atrial Fibrillation. J Emerg Med 2017; 53:e33-e36. [PMID: 28756933 DOI: 10.1016/j.jemermed.2017.03.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Revised: 03/24/2017] [Accepted: 03/24/2017] [Indexed: 11/26/2022]
Abstract
BACKGROUND Herniation of intraabdominal contents into the pericardial cavity is exceptionally rare, and when seen, it is most often the result of trauma, postsurgical complication, or genetic defect. There have been only a few case reports describing spontaneous bowel herniation into the pericardium in minimally invasive cardiac procedures like cardiac ablation, pacemaker placement, and minimally invasive coronary artery bypass graft. CASE REPORT We report the case of a 65-year-old man who presented to an urgent care center complaining of abdominal and chest pain. This patient had recently undergone a laparoscopic hybrid maze procedure and ultimately had an incarcerated loop of small bowel herniate into the pericardial sac. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: We present this case to increase awareness among emergency physicians of the diagnosis of a pericardial hernia in patients presenting with gastrointestinal or cardiorespiratory symptoms after surgical procedures involving the diaphragm.
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Affiliation(s)
- David A Farcy
- Department of Emergency Medicine, Mount Sinai Medical Center of Miami, Miami Beach, Florida
| | - Angelo Lapietra
- Division of Cardiothoracic Surgery, Mount Sinai Medical Center of Miami, Miami Beach, Florida
| | - Benjamin N Abo
- Department of Emergency Medicine, Mount Sinai Medical Center of Miami, Miami Beach, Florida
| | - Michael Dalley
- Department of Emergency Medicine, Mount Sinai Medical Center of Miami, Miami Beach, Florida
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Kikuchi K, Endo Y. Assistive Techniques for Proximal Anastomosis in Minimally Invasive Coronary Artery Bypass Grafting. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2017. [DOI: 10.1177/155698451701200312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Keita Kikuchi
- Department of Cardiac Surgery, Wuhan Asia Heart Hospital, Wuhan, China
| | - Yoshiki Endo
- Division of Cardiovascular Surgery, Yamato Seiwa Hospital, Yamato City, Japan
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Assistive Techniques for Proximal Anastomosis in Minimally Invasive Coronary Artery Bypass Grafting. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2017; 12:224-226. [PMID: 28562467 DOI: 10.1097/imi.0000000000000366] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
We introduce assistive techniques for proximal anastomosis in off-pump minimally invasive coronary artery bypass grafting (MICS CABG) to overcome difficult access to the ascending aorta in MICS CABG. An 8-cm left thoracotomy is made in the fifth intercostal space. ThoraTrak retractor (Medtronic Inc, Minneapolis, MN USA) is used to open the thoracotomy and is pulled to the cephalad and rightward direction toward to the ascending aorta. The pericardium is opened from the ascending aorta to the left ventricular apex and to the inferior vena cava. Two retraction sutures on the pericardial edge are used to laterally displace the heart. After dissecting between the ascending aorta and main pulmonary artery, the Octopus tissue stabilizer (Medtronic Inc, Minneapolis, MN USA), of which the suction tip is bent 60 degrees, is used to retract the pulmonary artery caudally. A flexible side-biting clamp (Vitalitec Inc.) is placed on the ascending aorta, and proximal anastomoses are handsewn on the ascending aorta. A total of 31 proximal anastomoses were completed with this technique between November 2013 and June 2015. All proximal anastomosis was completed without any difficulty. In MICS CABG, the technical challenges in proximal anastomosis due to difficult access to the aorta can be overcome safely by using this technique.
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Chang M, Lee CW, Ahn JM, Cavalcante R, Sotomi Y, Onuma Y, Park DW, Kang SJ, Lee SW, Kim YH, Park SW, Serruys PW, Park SJ. Outcomes of Coronary Artery Bypass Graft Surgery Versus Drug-Eluting Stents in Older Adults. J Am Geriatr Soc 2017; 65:625-630. [PMID: 28165613 DOI: 10.1111/jgs.14780] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVES Little data are available to compare coronary artery bypass graft surgery (CABG) vs percutaneous coronary intervention (PCI) with drug-eluting stents (DES) in older adults. We evaluate the long-term outcomes of CABG vs PCI with DES in older adults with left main or multivessel coronary artery disease (CAD). DESIGN Individual patient-level meta-analysis. SETTINGS Databases from the BEST, PRECOMBAT, and SYNTAX trials were combined. PARTICIPANTS A total 1,079 adults aged 70 to 89 years were pooled. MEASUREMENTS The primary outcome was a composite of death from any causes, myocardial infarction, stroke, or repeat revascularization. RESULTS During a total of 6.3 (median, 4.9) years of follow-up, the primary composite outcome of all-cause mortality, myocardial infarction, stroke, or repeat revascularization occurred in 26% (141/550) and 34% (179/529) of patients in the CABG and PCI groups, respectively (hazard ratio (HR), 0.75; 95% confidence interval (CI), 0.60-0.94; P = .012). CABG was associated with fewer myocardial infarction (4% vs 8% for PCI; HR, 0.48; 95% CI, 0.29-0.80; P = .037); and repeat revascularizations (8% vs 17% for PCI; HR, 044; 95% CI, 0.31-0.64; P < .001), but had little association with all-cause mortality or stroke. CONCLUSION Older adults age 70 to 89 years with left main or multivessel CAD who participated in the BEST, PRECOMBAT, and SYNTAX trials; compared to PCI, CABG was associated with lower risk of primary outcome which was mostly driven by lower risk of myocardial infarction.
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Affiliation(s)
- Mineok Chang
- Seoul St. Mary's Hospital, Catholic University of Korea, Seoul, Korea
| | - Cheol Whan Lee
- Heart Institute, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Jung-Min Ahn
- Heart Institute, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | | | - Yohei Sotomi
- Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Yoshinobu Onuma
- Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Duk-Woo Park
- Heart Institute, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Soo-Jin Kang
- Heart Institute, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Seung-Whan Lee
- Heart Institute, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Young-Hak Kim
- Heart Institute, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Seong-Wook Park
- Heart Institute, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Patrick W Serruys
- Erasmus University Medical Center, Rotterdam, The Netherlands.,International Center for Circulatory Health, Imperial College of London, London, UK
| | - Seung-Jung Park
- Heart Institute, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
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O'Neill DE, Knudtson ML, Kieser TM, Graham MM. Considerations in Cardiac Revascularization for the Elderly Patient: Age Isn't Everything. Can J Cardiol 2016; 32:1132-9. [DOI: 10.1016/j.cjca.2016.05.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Revised: 05/04/2016] [Accepted: 05/04/2016] [Indexed: 02/04/2023] Open
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Abstract
A proportion of elderly with coronary artery disease is rapidly growing. They have more severe coronary artery disease, therefore, derive more benefit from revascularization and have a greater need for it. The elderly is a heterogeneous group, but compared to the younger cohort, the choice of the optimal revascularization method is much more complicated among them. In recent decades, results has improved dramatically both in surgery and percutaneous coronary intervention (PCI), even in very old persons. Despite the lack of evidence in elderly, it is obvious, that coronary artery bypass surgery (CABG) has a more pronounced effect on long-term survival in price of more strokes, while PCI is certainly less invasive. Age itself is not a criterion for the selection of treatment strategy, but the elderly are often more interested in quality of life and personal independence instead of longevity. This article discusses the factors that influence the choice of the revascularization method in the elderly with stable angina and presents a complex algorithm for making an individual risk-benefit profile. As a consequence the features of CABG and PCI in elderly patients are exposed. Emphasis is centered on the frailty and non-medical factors, including psychosocial, as essential components in making the decision of what strategy to choose. Good communication with the patients and giving them unbiased information is encouraged.
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Coronary artery bypass grafting in octogenarians: only when percutaneous coronary intervention is not feasible? Curr Opin Cardiol 2015; 30:636-42. [PMID: 26352246 DOI: 10.1097/hco.0000000000000222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The aim of this study was to review recent literature reporting the results of coronary revascularization by percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) in patients older than 80 years. RECENT FINDINGS The review of recent studies on octogenarians demonstrates a surgical CABG advantage in the case of patients with increasing baseline coronary risk, such as severe multivessel disease, chronic total occlusions, and left ventricular dysfunction. PCI seems to be more appropriate for less severe degree and distribution of coronary lesions, and for subgroups of patients with higher surgical risk, such as acute coronary syndromes, reoperations, malignancy, dementia, poor mobility, frailty, and serious comorbidities contraindicating extracorporeal circulation. SUMMARY It is not the case that CABG is indicated only when there are contraindications to PCI. CABG confers more benefit than PCI in patients with increasing baseline cardiac risk, in the absence of serious systemic diseases that can reasonably reduce their life expectancy.CABG and PCI, with proper selection, should be considered complementary rather than competitive procedures in the therapy of octogenarians affected by coronary artery disease.
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Early and Midterm Results of No-Touch Aorta Multivessel Small Thoracotomy Coronary Artery Bypass Grafting: A Propensity Score-Matched Study. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2015; 10:258-67; discussion 267. [DOI: 10.1097/imi.0000000000000185] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Objective To carry out the comparative analysis of early and midterm results of no-touch aorta multivessel small thoracotomy coronary artery bypass grafting (MVST CABG), conventional off-pump (OPCABG) and on-pump CABG (ONCABG). Methods From 2007 to 2014, 537 consecutive patients underwent CABG by the same surgeon. Propensity score computer matching was performed, and a total of 453 patients were successfully matched in 3 groups of 151 patients. Results Significant differences were found in the intraoperative blood loss: 220 (180; 300) mL in MVST CABG versus 400 (300; 550) mL in OPCABG vs 350 (250; 435) mL in ONCABG group; first 24-hour postoperative blood loss: 170 (100; 280), 320 (200; 470), and 380 (200; 500)mL, respectively; operation time: 352.4 ± 74.4,289.3 ± 55.0, and 280.4 ± 56.4 minutes, respectively; median time to return to full physical activity: 14, 56, and 56 days, respectively (P < 0.05); rate of deep wound infection: 0.0%, 2.0%, and 2.0%, respectively; and postoperative length of stay (surgical department): 4.5, 7.0, and 7.5 days, respectively (P < 0.1). No significant differences were observed in rates of severe in-hospital events (P > 0.05), cumulative midterm survival, and freedom from major adverse cardiac and cerebrovascular events (P > 0.05). Conclusions The MVST CABG seems as safe as OPCABG and ONCABG and is associated with less wound infections, perioperative blood loss, shorter hospital length of stay and time to return to full physical activity. Multivessel small thoracotomy CABG can be applied to most patients with coronary heart disease saving the effectiveness during midterm follow-up. The MVST CABG can be introduced avoiding a prolonged learning curve.
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Ziankou A, Ostrovsky Y. Early and Midterm Results of No-Touch Aorta Multivessel Small Thoracotomy Coronary Artery Bypass Grafting: A Propensity Score-Matched Study. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2015. [DOI: 10.1177/155698451501000407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Aliaksandr Ziankou
- Department of Cardiac Surgery, Vitebsk Regional Clinical Hospital, Vitebsk State Medical University, Vitebsk, Belarus
| | - Yuri Ostrovsky
- Cardiac Surgery Laboratory, Republic Scientific and Practical Center of Cardiology, Minsk, Belarus
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