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Sef D, Thet MS, Hashim SA, Kikuchi K. Minimally Invasive Coronary Artery Bypass Grafting for Multivessel Coronary Artery Disease: A Systematic Review. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2024:15569845241265867. [PMID: 39267397 DOI: 10.1177/15569845241265867] [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: 09/17/2024]
Abstract
OBJECTIVE We conducted a systematic review of all available evidence on the feasibility and safety of minimally invasive coronary artery bypass grafting (MICS CABG) in patients with multivessel coronary artery disease (CAD). METHODS A systematic literature search in PubMed, MEDLINE via Ovid, Embase, Scopus, and Web of Science was performed to identify all relevant studies evaluating outcomes of MICS CABG among patients with multivessel CAD and including at least 15 patients with no restriction on the publication date. RESULTS A total of 881 studies were identified, of which 26 studies met the eligibility criteria. The studies included a total of 7,556 patients. The average patient age was 63.3 years (range 49.5 to 69.0 years), male patients were an average of 77.8% (54.0% to 89.8%), and body mass index was 29.8 kg/m2 (24.5 to 30.1 kg/m2). Early mortality and stroke were on average 0.6% (range 0% to 2.0%) and 0.4% (range 0% to 1.3%), respectively. The average number of grafts was 2.8 (range 2.1 to 3.7). The average length of hospital stay was 5.6 days (range 3.1 to 9.3 days). CONCLUSIONS MICS CABG appears to be a safe method in well-selected patients with multivessel CAD. This approach is concentrated at dedicated centers, and there is no widespread application, although it has potential to be widely applicable as an alternative for surgical revascularization. However, large randomized controlled studies with longer follow-up are still required to compare the outcomes with conventional CABG and other revascularization strategies.
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Affiliation(s)
- Davorin Sef
- Department of Cardiac Surgery, University Hospitals of Leicester, UK
| | - Myat Soe Thet
- Department of Surgery and Cancer, Faculty of Medicine, Imperial College London & Imperial College Healthcare NHS Trust, UK
| | - Shahrul Amry Hashim
- Department of Cardiothoracic Surgery, University of Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Keita Kikuchi
- Department of Cardiovascular Surgery, Tokyo Bay Urayasu Ichikawa Medical Center, Japan
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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 2024; 39:1041-1056. [PMID: 37294619 DOI: 10.1177/02676591231182585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [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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Rufa MI, Ursulescu A, Dippon J, Aktuerk D, Nagib R, Albert M, Franke UFW. Is minimally invasive multi-vessel off-pump coronary surgery as safe and effective as MIDCAB? Front Cardiovasc Med 2024; 11:1385108. [PMID: 39280035 PMCID: PMC11393739 DOI: 10.3389/fcvm.2024.1385108] [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: 02/11/2024] [Accepted: 08/16/2024] [Indexed: 09/18/2024] Open
Abstract
Introduction The safety and efficacy of minimally invasive direct coronary artery bypass (MIDCAB) surgery has been confirmed in numerous reports. However, minimally invasive multi-vessel off-pump coronary artery bypass grafting (MICS CABG) has lower uptake and has not yet gained widespread adoption. The study aimed to investigate the non-inferiority of MICS CABG to MIDCAB in long-term follow-up for several clinical outcomes, including angina pectoris, major adverse cardiac and cerebrovascular events (MACCE) and overall survival. Methods This is an observational, retrospective, single center study of 1,149 patients who underwent either MIDCAB (n = 626) or MICS CABG (n = 523) at our institution between 2007 and 2018. The left internal thoracic artery and portions of the radial artery and saphenous vein were used for the patients' single-, double-, or triple-vessel revascularization procedures. We used gradient boosted propensity-score estimation to account for possible interactions between variables. After propensity-score adjustment, the two groups were similar in terms of preoperative demographics and risk profile. Long-term follow-up (mean 5.87, median 5.6 years) was available for 1,089 patients (94.8%). Results A total of 626, 454 and 69 patients underwent single, double and triple coronary revascularization, respectively. The long-term outcomes of freedom from angina pectoris, acute myocardial infarction, and revascularization rate were similar between the two groups. During follow-up, there were 123 deaths in the MIDCAB group and 96 in the MICS CABG group. The 1-, 3-, 5-, and 10-year survival rates were 97%, 92%, 85%, and 69% for the MIDCAB group and 97%, 93%, 89%, and 74% for the MICS CABG group, respectively. The hazard ratio of overall survival for patients with two or more bypass grafts compared to those with one bypass graft was 1.190 (p-value = 0.234, 95% CI: 0.893-1.586). This indicates that there was no significant difference in survival between the two groups. Furthermore, if we consider a hazard ratio of 1.2 to be clinically non-relevant, surgery with two or more grafts was significantly non-inferior to surgery with just one graft (p-value = 0.0057). Conclusion In experienced hands, MICS CABG is a safe and effective procedure. Survival and durability are comparable with MIDCAB.
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Affiliation(s)
- Magdalena I Rufa
- Department of Cardiovascular Surgery, Robert Bosch Hospital, Stuttgart, Germany
| | - Adrian Ursulescu
- Department of Cardiovascular Surgery, Robert Bosch Hospital, Stuttgart, Germany
| | - Juergen Dippon
- Institute for Stochastic and Applications, Stuttgart University, Stuttgart, Germany
| | - Dincer Aktuerk
- Department of Cardiothoracic Surgery, Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
| | - Ragi Nagib
- Department of Cardiovascular Surgery, Robert Bosch Hospital, Stuttgart, Germany
| | - Marc Albert
- Department of Cardiovascular Surgery, Robert Bosch Hospital, Stuttgart, Germany
| | - Ulrich F W Franke
- Department of Cardiovascular Surgery, Robert Bosch Hospital, Stuttgart, Germany
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Purmessur R, Wijesena T, Ali J. Minimal-Access Coronary Revascularization: Past, Present, and Future. J Cardiovasc Dev Dis 2023; 10:326. [PMID: 37623339 PMCID: PMC10455416 DOI: 10.3390/jcdd10080326] [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: 05/20/2023] [Revised: 07/16/2023] [Accepted: 07/22/2023] [Indexed: 08/26/2023] Open
Abstract
Minimal-access cardiac surgery appears to be the future. It is increasingly desired by cardiologists and demanded by patients who perceive superiority. Minimal-access coronary artery revascularisation has been increasingly adopted throughout the world. Here, we review the history of minimal-access coronary revascularization and see that it is almost as old as the history of cardiac surgery. Modern minimal-access coronary revascularization takes a variety of forms-namely minimal-access direct coronary artery bypass grafting (MIDCAB), hybrid coronary revascularisation (HCR), and totally endoscopic coronary artery bypass grafting (TECAB). It is noteworthy that there is significant variation in the nomenclature and approaches for minimal-access coronary surgery, and this truly presents a challenge for comparing the different methods. However, these approaches are increasing in frequency, and proponents demonstrate clear advantages for their patients. The challenge that remains, as for all areas of surgery, is demonstrating the superiority of these techniques over tried and tested open techniques, which is very difficult. There is a paucity of randomised controlled trials to help answer this question, and the future of minimal-access coronary revascularisation, to some extent, is dependent on such trials. Thankfully, some are underway, and the results are eagerly anticipated.
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Affiliation(s)
- Rushmi Purmessur
- Department of Cardiothoracic Surgery, Royal Papworth Hospital NHS Foundation Trust, Cambridge CB2 0AY, UK
| | - Tharushi Wijesena
- Department of Cardiothoracic Surgery, Royal Papworth Hospital NHS Foundation Trust, Cambridge CB2 0AY, UK
| | - Jason Ali
- Department of Cardiothoracic Surgery, Royal Papworth Hospital NHS Foundation Trust, Cambridge CB2 0AY, UK
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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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Zhang L, Fu Y, Gong Y, Zhao H, Wu S, Yang H, Zhang Z, Ling Y. Graft patency and completeness of revascularization in minimally invasive multivessel coronary artery bypass surgery. J Card Surg 2021; 36:992-997. [PMID: 33533054 DOI: 10.1111/jocs.15345] [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: 07/05/2020] [Revised: 11/25/2020] [Accepted: 12/08/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Graft patency and completeness of revascularization were analyzed in patients who underwent off-pump minimally invasive coronary artery bypass grafting via a left small thoracotomy. METHODS We retrospectively reviewed the invasive angiography findings and clinical data of 186 consecutive patients who underwent off-pump minimally invasive coronary artery bypass grafting via a left small thoracotomy. The left internal thoracic artery and saphenous vein were used to bypass two or more of three coronary artery systems: the left anterior descending artery, left circumflex artery, or right coronary artery. Before hospital discharge, invasive angiography was performed to assess graft patency. Clinical variables during hospitalization and follow-up were collected and analyzed. RESULTS All 186 patients successfully underwent off-pump minimally invasive coronary artery bypass grafting without conversion to sternotomy or assistance of cardiopulmonary bypass. The mean graft number was 2.81 per patient (range, 2-5), and the total number of grafts was 522. The in-hospital mortality rate was 1.6% (3 of 186). A total of 181 of 186 (97.3%) patients underwent postoperative invasive angiography. Among the 510 grafts assessed by angiography, the total graft patency rate was 96.3% (491 of 510) (98.3% [171 of 174] for left internal thoracic artery grafts and 95.2% [318 of 334] for saphenous vein grafts). The rate of complete revascularization was 99.5% (185 of 186). CONCLUSIONS Minimally invasive coronary artery bypass grafting using left internal thoracic artery and saphenous vein grafts provides acceptable graft patency and completeness of revascularization for selected patients with multivessel disease.
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Affiliation(s)
- Lufeng Zhang
- Department of Cardiovascular Surgery, Peking University Third Hospital, Beijing, China
| | - Yuanhao Fu
- Department of Cardiovascular Surgery, Peking University Third Hospital, Beijing, China
| | - Yichen Gong
- Department of Cardiovascular Surgery, Peking University Third Hospital, Beijing, China
| | - Hong Zhao
- Department of Cardiovascular Surgery, Peking University Third Hospital, Beijing, China
| | - Song Wu
- Department of Cardiovascular Surgery, Peking University Third Hospital, Beijing, China
| | - Hang Yang
- Department of Cardiovascular Surgery, Peking University Third Hospital, Beijing, China
| | - Zhe Zhang
- Department of Cardiovascular Surgery, Peking University Third Hospital, Beijing, China
| | - Yunpeng Ling
- Department of Cardiovascular Surgery, Peking University Third Hospital, Beijing, China
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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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Guo MH, Wells GA, Glineur D, Fortier J, Davierwala PM, Kikuchi K, Lemma MG, Mishra YK, McGinn J, Ramchandani M, Rabindra P, Nambala S, Chiu KM, Kiaii B, Gibson S, Ruel M. Minimally Invasive coronary surgery compared to STernotomy coronary artery bypass grafting: The MIST trial. Contemp Clin Trials 2019; 78:140-145. [PMID: 30634037 DOI: 10.1016/j.cct.2019.01.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 12/18/2018] [Accepted: 01/08/2019] [Indexed: 10/27/2022]
Abstract
RATIONALE Minimally invasive cardiac surgery has emerged as a safe alternative to standard cardiac surgery. Minimally invasive coronary surgery (MICS CABG) was developed to allow adequate exposure and complete revascularization in CABG from a small thoracotomy incision without cardiopulmonary bypass. Multiple studies have reported significant shorter length of hospital stay and earlier postoperative physical recovery for MICS CABG patients when compared to sternotomy CABG patients. However, there have been no convincing clinical trials that demonstrate improvement in post-operative quality of life for patients who undergo MICS CABG. STUDY DESIGN The Minimally Invasive Coronary Surgery compared to Sternotomy Coronary Artery Bypass Grafting (MIST) trial is a multi-centered, prospective randomized controlled trial that compares the quality of life and recovery in the early post-operative period between patients undergoing MICS CABG versus patients undergoing sternotomy CABG. Patients will be randomized either to the MICS CABG group or the sternotomy CABG group, and the target enrollment is 88 patients per group. The primary outcome is quality of life assessment performed by SF-36 questionnaire at 1 month. CONCLUSION The MIST trial is the first prospective study that compares the quality of life between MICS CABG and sternotomy CABG patients. The results of this trial may enhance the procedural desirability of MICS CABG by patients and provide an incentive for surgeons and institutions to increase the availability of MICS CABG in suitable patients.
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Affiliation(s)
- Ming Hao Guo
- Division of cardiac surgery, University of Ottawa Heart Institute, Ottawa, Canada
| | - George A Wells
- Department of Epidemiology, University of Ottawa, Ottawa, Canada
| | - David Glineur
- Division of cardiac surgery, University of Ottawa Heart Institute, Ottawa, Canada
| | - Jacqueline Fortier
- Division of cardiac surgery, University of Ottawa Heart Institute, Ottawa, Canada
| | | | - Keita Kikuchi
- Division of cardiac surgery, Wuhan Asian Heart Hospital, Wuhan, China
| | - Massimo G Lemma
- Division of cardiac surgery, Jilin Heart Hospital, Jilin, China
| | - Yugal K Mishra
- Division of cardiac surgery, Fortis Escorts Heart Institute, New Delhi, India
| | - Joseph McGinn
- Division of cardiothoracic surgery, Carolinas Medical Center, Charlotte, United States
| | - Mahesh Ramchandani
- Division of cardiothoracic surgery, Houston Methodist, Houston, United States
| | - Prem Rabindra
- Division of cardiothoracic surgery, Gundersen Lutheran Medical Center, La Crosse, United States
| | | | - Kuan Ming Chiu
- Division of cardiac surgery, Far Eastern Memorial Hospital, Taipei, Taiwan
| | - Bob Kiaii
- Division of cardiac surgery, London Health Sciences Center, London, Canada
| | - Sarah Gibson
- Division of cardiac surgery, University of Ottawa Heart Institute, Ottawa, Canada
| | - Marc Ruel
- Division of cardiac surgery, University of Ottawa Heart Institute, Ottawa, Canada.
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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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