Coronary artery bypass surgery cardiopulmonary bypass: Difference between revisions
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==[[Overview]]== | ==[[Overview]]== | ||
There are [[surgery|alternative operative strategies]] such as [[Off-pump coronary artery bypass surgery|off-pump]] or beating [[heart]], which have their own risks and benefits. These alternatives could be used when the risks of [[aorta|aortic]] manipulation outweigh the safe use of a [[Aortic cross-clamp|cross-clamp]] or [[cannulation]] of the [[ascending aorta]]. Furthermore, [[surgery|surgeon]] experience with the strategies mentioned above should be considered. | |||
==Cardiopulmonary Bypass in CABG Patients== | ==Cardiopulmonary Bypass in CABG Patients== | ||
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*Furthermore, [[surgery|surgeon]] experience with the aforementioned strategies should be taken into consideration. | *Furthermore, [[surgery|surgeon]] experience with the aforementioned strategies should be taken into consideration. | ||
*One major concern that exists for the [[Off-pump coronary artery bypass surgery|off-pump approach]] is the technical difficulty of bypassing [[coronary arteries]] in the circumflex distribution, in addition to small and intramyocardial segments. This concern created a tendency toward fewer grafts per [[patient]], a higher rate of incomplete [[revascularization]], and more concern regarding the [[graft]] patency in long term.<ref name="pmid29495998">{{cite journal| author=Smart NA, Dieberg G, King N| title=Long-Term Outcomes of On- Versus Off-Pump Coronary Artery Bypass Grafting. | journal=J Am Coll Cardiol | year= 2018 | volume= 71 | issue= 9 | pages= 983-991 | pmid=29495998 | doi=10.1016/j.jacc.2017.12.049 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29495998 }} </ref><ref name="pmid26276839">{{cite journal| author=Deppe AC, Arbash W, Kuhn EW, Slottosch I, Scherner M, Liakopoulos OJ | display-authors=etal| title=Current evidence of coronary artery bypass grafting off-pump versus on-pump: a systematic review with meta-analysis of over 16,900 patients investigated in randomized controlled trials†. | journal=Eur J Cardiothorac Surg | year= 2016 | volume= 49 | issue= 4 | pages= 1031-41; discussion 1041 | pmid=26276839 | doi=10.1093/ejcts/ezv268 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26276839 }} </ref><ref name="pmid21511187">{{cite journal| author=Edelman JJ, Yan TD, Bannon PG, Wilson MK, Vallely MP| title=Coronary artery bypass grafting with and without manipulation of the ascending aorta--a meta-analysis. | journal=Heart Lung Circ | year= 2011 | volume= 20 | issue= 5 | pages= 318-24 | pmid=21511187 | doi=10.1016/j.hlc.2011.02.003 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21511187 }} </ref><ref name="pmid27771985">{{cite journal| author=Lamy A, Devereaux PJ, Prabhakaran D, Taggart DP, Hu S, Straka Z | display-authors=etal| title=Five-Year Outcomes after Off-Pump or On-Pump Coronary-Artery Bypass Grafting. | journal=N Engl J Med | year= 2016 | volume= 375 | issue= 24 | pages= 2359-2368 | pmid=27771985 | doi=10.1056/NEJMoa1601564 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27771985 }} </ref><ref name="pmid28813218">{{cite journal| author=Shroyer AL, Hattler B, Wagner TH, Collins JF, Baltz JH, Quin JA | display-authors=etal| title=Five-Year Outcomes after On-Pump and Off-Pump Coronary-Artery Bypass. | journal=N Engl J Med | year= 2017 | volume= 377 | issue= 7 | pages= 623-632 | pmid=28813218 | doi=10.1056/NEJMoa1614341 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28813218 }} </ref><ref name="pmid20494043">{{cite journal| author=Takagi H, Matsui M, Umemoto T| title=Off-pump coronary artery bypass may increase late mortality: a meta-analysis of randomized trials. | journal=Ann Thorac Surg | year= 2010 | volume= 89 | issue= 6 | pages= 1881-8 | pmid=20494043 | doi=10.1016/j.athoracsur.2010.03.010 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20494043 }} </ref><ref name="pmid22419321">{{cite journal| author=Møller CH, Penninga L, Wetterslev J, Steinbrüchel DA, Gluud C| title=Off-pump versus on-pump coronary artery bypass grafting for ischaemic heart disease. | journal=Cochrane Database Syst Rev | year= 2012 | volume= | issue= 3 | pages= CD007224 | pmid=22419321 | doi=10.1002/14651858.CD007224.pub2 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22419321 }} </ref> | *One major concern that exists for the [[Off-pump coronary artery bypass surgery|off-pump approach]] is the technical difficulty of bypassing [[coronary arteries]] in the circumflex distribution, in addition to small and intramyocardial segments. This concern created a tendency toward fewer grafts per [[patient]], a higher rate of incomplete [[revascularization]], and more concern regarding the [[graft]] patency in long term.<ref name="pmid29495998">{{cite journal| author=Smart NA, Dieberg G, King N| title=Long-Term Outcomes of On- Versus Off-Pump Coronary Artery Bypass Grafting. | journal=J Am Coll Cardiol | year= 2018 | volume= 71 | issue= 9 | pages= 983-991 | pmid=29495998 | doi=10.1016/j.jacc.2017.12.049 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29495998 }} </ref><ref name="pmid26276839">{{cite journal| author=Deppe AC, Arbash W, Kuhn EW, Slottosch I, Scherner M, Liakopoulos OJ | display-authors=etal| title=Current evidence of coronary artery bypass grafting off-pump versus on-pump: a systematic review with meta-analysis of over 16,900 patients investigated in randomized controlled trials†. | journal=Eur J Cardiothorac Surg | year= 2016 | volume= 49 | issue= 4 | pages= 1031-41; discussion 1041 | pmid=26276839 | doi=10.1093/ejcts/ezv268 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26276839 }} </ref><ref name="pmid21511187">{{cite journal| author=Edelman JJ, Yan TD, Bannon PG, Wilson MK, Vallely MP| title=Coronary artery bypass grafting with and without manipulation of the ascending aorta--a meta-analysis. | journal=Heart Lung Circ | year= 2011 | volume= 20 | issue= 5 | pages= 318-24 | pmid=21511187 | doi=10.1016/j.hlc.2011.02.003 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21511187 }} </ref><ref name="pmid27771985">{{cite journal| author=Lamy A, Devereaux PJ, Prabhakaran D, Taggart DP, Hu S, Straka Z | display-authors=etal| title=Five-Year Outcomes after Off-Pump or On-Pump Coronary-Artery Bypass Grafting. | journal=N Engl J Med | year= 2016 | volume= 375 | issue= 24 | pages= 2359-2368 | pmid=27771985 | doi=10.1056/NEJMoa1601564 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27771985 }} </ref><ref name="pmid28813218">{{cite journal| author=Shroyer AL, Hattler B, Wagner TH, Collins JF, Baltz JH, Quin JA | display-authors=etal| title=Five-Year Outcomes after On-Pump and Off-Pump Coronary-Artery Bypass. | journal=N Engl J Med | year= 2017 | volume= 377 | issue= 7 | pages= 623-632 | pmid=28813218 | doi=10.1056/NEJMoa1614341 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28813218 }} </ref><ref name="pmid20494043">{{cite journal| author=Takagi H, Matsui M, Umemoto T| title=Off-pump coronary artery bypass may increase late mortality: a meta-analysis of randomized trials. | journal=Ann Thorac Surg | year= 2010 | volume= 89 | issue= 6 | pages= 1881-8 | pmid=20494043 | doi=10.1016/j.athoracsur.2010.03.010 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20494043 }} </ref><ref name="pmid22419321">{{cite journal| author=Møller CH, Penninga L, Wetterslev J, Steinbrüchel DA, Gluud C| title=Off-pump versus on-pump coronary artery bypass grafting for ischaemic heart disease. | journal=Cochrane Database Syst Rev | year= 2012 | volume= | issue= 3 | pages= CD007224 | pmid=22419321 | doi=10.1002/14651858.CD007224.pub2 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22419321 }} </ref> | ||
*The following are some of the advantages of [[off-pump coronary artery bypass surgery]] compared with on-pump [[CABG]]:<ref name="pmid29495998">{{cite journal| author=Smart NA, Dieberg G, King N| title=Long-Term Outcomes of On- Versus Off-Pump Coronary Artery Bypass Grafting. | journal=J Am Coll Cardiol | year= 2018 | volume= 71 | issue= 9 | pages= 983-991 | pmid=29495998 | doi=10.1016/j.jacc.2017.12.049 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29495998 }} </ref><ref name="pmid16740529">{{cite journal| author=Al-Ruzzeh S, George S, Bustami M, Wray J, Ilsley C, Athanasiou T | display-authors=etal| title=Effect of off-pump coronary artery bypass surgery on clinical, angiographic, neurocognitive, and quality of life outcomes: randomised controlled trial. | journal=BMJ | year= 2006 | volume= 332 | issue= 7554 | pages= 1365 | pmid=16740529 | doi=10.1136/bmj.38852.479907.7C | pmc=1476725 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16740529 }} </ref><ref name="pmid11955537">{{cite journal| author=Angelini GD, Taylor FC, Reeves BC, Ascione R| title=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. | journal=Lancet | year= 2002 | volume= 359 | issue= 9313 | pages= 1194-9 | pmid=11955537 | doi=10.1016/S0140-6736(02)08216-8 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11955537 }} </ref><ref name="pmid22523305">{{cite journal| author=Houlind K, Kjeldsen BJ, Madsen SN, Rasmussen BS, Holme SJ, Nielsen PH | display-authors=etal| title=On-pump versus off-pump coronary artery bypass surgery in elderly patients: results from the Danish on-pump versus off-pump randomization study. | journal=Circulation | year= 2012 | volume= 125 | issue= 20 | pages= 2431-9 | pmid=22523305 | doi=10.1161/CIRCULATIONAHA.111.052571 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22523305 }} </ref><ref name="pmid23477676">{{cite journal| author=Lamy A, Devereaux PJ, Prabhakaran D, Taggart DP, Hu S, Paolasso E | display-authors=etal| title=Effects of off-pump and on-pump coronary-artery bypass grafting at 1 year. | journal=N Engl J Med | year= 2013 | volume= 368 | issue= 13 | pages= 1179-88 | pmid=23477676 | doi=10.1056/NEJMoa1301228 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23477676 }} </ref> | |||
**Earlier [[Mechanical ventilation|extubation]] | |||
**Lower rate of [[blood transfusion]] | |||
**Better outcome for [[patients]] with increased [[pulmonary disease]] risks | |||
*[[Cardiopulmonary bypass]] is associated with a less [[Inflammation|systemic inflammatory response]], and therefore has a less negative impact on [[Lung|pulmonary]] function.<ref name="pmid29495998">{{cite journal| author=Smart NA, Dieberg G, King N| title=Long-Term Outcomes of On- Versus Off-Pump Coronary Artery Bypass Grafting. | journal=J Am Coll Cardiol | year= 2018 | volume= 71 | issue= 9 | pages= 983-991 | pmid=29495998 | doi=10.1016/j.jacc.2017.12.049 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29495998 }} </ref><ref name="pmid16740529">{{cite journal| author=Al-Ruzzeh S, George S, Bustami M, Wray J, Ilsley C, Athanasiou T | display-authors=etal| title=Effect of off-pump coronary artery bypass surgery on clinical, angiographic, neurocognitive, and quality of life outcomes: randomised controlled trial. | journal=BMJ | year= 2006 | volume= 332 | issue= 7554 | pages= 1365 | pmid=16740529 | doi=10.1136/bmj.38852.479907.7C | pmc=1476725 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16740529 }} </ref><ref name="pmid11955537">{{cite journal| author=Angelini GD, Taylor FC, Reeves BC, Ascione R| title=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. | journal=Lancet | year= 2002 | volume= 359 | issue= 9313 | pages= 1194-9 | pmid=11955537 | doi=10.1016/S0140-6736(02)08216-8 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11955537 }} </ref><ref name="pmid22523305">{{cite journal| author=Houlind K, Kjeldsen BJ, Madsen SN, Rasmussen BS, Holme SJ, Nielsen PH | display-authors=etal| title=On-pump versus off-pump coronary artery bypass surgery in elderly patients: results from the Danish on-pump versus off-pump randomization study. | journal=Circulation | year= 2012 | volume= 125 | issue= 20 | pages= 2431-9 | pmid=22523305 | doi=10.1161/CIRCULATIONAHA.111.052571 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22523305 }} </ref><ref name="pmid23477676">{{cite journal| author=Lamy A, Devereaux PJ, Prabhakaran D, Taggart DP, Hu S, Paolasso E | display-authors=etal| title=Effects of off-pump and on-pump coronary-artery bypass grafting at 1 year. | journal=N Engl J Med | year= 2013 | volume= 368 | issue= 13 | pages= 1179-88 | pmid=23477676 | doi=10.1056/NEJMoa1301228 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23477676 }} </ref> | |||
===2021 ACA Revascularization Guideline=== | ===2021 ACA Revascularization Guideline=== | ||
{|class="wikitable" | {|class="wikitable" | ||
Latest revision as of 19:19, 30 September 2022
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Anahita Deylamsalehi, M.D.[2]
Synonyms and keywords:
Overview
There are alternative operative strategies such as off-pump or beating heart, which have their own risks and benefits. These alternatives could be used when the risks of aortic manipulation outweigh the safe use of a cross-clamp or cannulation of the ascending aorta. Furthermore, surgeon experience with the strategies mentioned above should be considered.
Cardiopulmonary Bypass in CABG Patients
- The risks and benefits of alternative operative strategies such as off-pump or beating heart, can be considered when the risks of aortic manipulation outweigh the safe use of a cross-clamp or cannulation of the ascending aorta.[1]
- Furthermore, surgeon experience with the aforementioned strategies should be taken into consideration.
- One major concern that exists for the off-pump approach is the technical difficulty of bypassing coronary arteries in the circumflex distribution, in addition to small and intramyocardial segments. This concern created a tendency toward fewer grafts per patient, a higher rate of incomplete revascularization, and more concern regarding the graft patency in long term.[2][3][4][5][6][7][8]
- The following are some of the advantages of off-pump coronary artery bypass surgery compared with on-pump CABG:[2][9][10][11][12]
- Earlier extubation
- Lower rate of blood transfusion
- Better outcome for patients with increased pulmonary disease risks
- Cardiopulmonary bypass is associated with a less systemic inflammatory response, and therefore has a less negative impact on pulmonary function.[2][9][10][11][12]
2021 ACA Revascularization Guideline
| Class 2a Recommendation, Level of Evidence: B-R [1][13][2] |
| When significant calcification of the aorta is present, usage of techniques such as off-pump techniques or beating heart (to avoid aortic manipulation) is rational to reduce the perioperative stroke incidence when performed by experienced surgeons. |
| Class 2b Recommendation, Level of Evidence: B-R [1][2][9][10][11][12] |
| Utilizing off-pump surgery could be rational for patients with significant pulmonary disease in order to decrease perioperative risk when performed by experienced surgeons. |
References
- ↑ 1.0 1.1 1.2 Writing Committee Members. Lawton JS, Tamis-Holland JE, Bangalore S, Bates ER, Beckie TM; et al. (2022). "2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines". J Am Coll Cardiol. 79 (2): e21–e129. doi:10.1016/j.jacc.2021.09.006. PMID 34895950 Check
|pmid=value (help). - ↑ 2.0 2.1 2.2 2.3 2.4 Smart NA, Dieberg G, King N (2018). "Long-Term Outcomes of On- Versus Off-Pump Coronary Artery Bypass Grafting". J Am Coll Cardiol. 71 (9): 983–991. doi:10.1016/j.jacc.2017.12.049. PMID 29495998.
- ↑ Deppe AC, Arbash W, Kuhn EW, Slottosch I, Scherner M, Liakopoulos OJ; et al. (2016). "Current evidence of coronary artery bypass grafting off-pump versus on-pump: a systematic review with meta-analysis of over 16,900 patients investigated in randomized controlled trials†". Eur J Cardiothorac Surg. 49 (4): 1031–41, discussion 1041. doi:10.1093/ejcts/ezv268. PMID 26276839.
- ↑ Edelman JJ, Yan TD, Bannon PG, Wilson MK, Vallely MP (2011). "Coronary artery bypass grafting with and without manipulation of the ascending aorta--a meta-analysis". Heart Lung Circ. 20 (5): 318–24. doi:10.1016/j.hlc.2011.02.003. PMID 21511187.
- ↑ Lamy A, Devereaux PJ, Prabhakaran D, Taggart DP, Hu S, Straka Z; et al. (2016). "Five-Year Outcomes after Off-Pump or On-Pump Coronary-Artery Bypass Grafting". N Engl J Med. 375 (24): 2359–2368. doi:10.1056/NEJMoa1601564. PMID 27771985.
- ↑ Shroyer AL, Hattler B, Wagner TH, Collins JF, Baltz JH, Quin JA; et al. (2017). "Five-Year Outcomes after On-Pump and Off-Pump Coronary-Artery Bypass". N Engl J Med. 377 (7): 623–632. doi:10.1056/NEJMoa1614341. PMID 28813218.
- ↑ Takagi H, Matsui M, Umemoto T (2010). "Off-pump coronary artery bypass may increase late mortality: a meta-analysis of randomized trials". Ann Thorac Surg. 89 (6): 1881–8. doi:10.1016/j.athoracsur.2010.03.010. PMID 20494043.
- ↑ Møller CH, Penninga L, Wetterslev J, Steinbrüchel DA, Gluud C (2012). "Off-pump versus on-pump coronary artery bypass grafting for ischaemic heart disease". Cochrane Database Syst Rev (3): CD007224. doi:10.1002/14651858.CD007224.pub2. PMID 22419321.
- ↑ 9.0 9.1 9.2 Al-Ruzzeh S, George S, Bustami M, Wray J, Ilsley C, Athanasiou T; et al. (2006). "Effect of off-pump coronary artery bypass surgery on clinical, angiographic, neurocognitive, and quality of life outcomes: randomised controlled trial". BMJ. 332 (7554): 1365. doi:10.1136/bmj.38852.479907.7C. PMC 1476725. PMID 16740529.
- ↑ 10.0 10.1 10.2 Angelini GD, Taylor FC, Reeves BC, Ascione R (2002). "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. 359 (9313): 1194–9. doi:10.1016/S0140-6736(02)08216-8. PMID 11955537.
- ↑ 11.0 11.1 11.2 Houlind K, Kjeldsen BJ, Madsen SN, Rasmussen BS, Holme SJ, Nielsen PH; et al. (2012). "On-pump versus off-pump coronary artery bypass surgery in elderly patients: results from the Danish on-pump versus off-pump randomization study". Circulation. 125 (20): 2431–9. doi:10.1161/CIRCULATIONAHA.111.052571. PMID 22523305.
- ↑ 12.0 12.1 12.2 Lamy A, Devereaux PJ, Prabhakaran D, Taggart DP, Hu S, Paolasso E; et al. (2013). "Effects of off-pump and on-pump coronary-artery bypass grafting at 1 year". N Engl J Med. 368 (13): 1179–88. doi:10.1056/NEJMoa1301228. PMID 23477676.
- ↑ Lamy A, Devereaux PJ, Prabhakaran D, Taggart DP, Hu S, Paolasso E; et al. (2012). "Off-pump or on-pump coronary-artery bypass grafting at 30 days". N Engl J Med. 366 (16): 1489–97. doi:10.1056/NEJMoa1200388. PMID 22449296.