Skip to main content
SpringerLink
Log in

Off-Pump and On-Pump Coronary Artery Surgery and the Brain

  • Chapter
  • First Online:
Brain Protection in Cardiac Surgery

Abstract

Since its introduction into clinical practice in the early 1950s, cardiopulmonary bypass (CPB) has been the keystone that enabled many millions of patients to undergo heart surgery around the world.1 However, brain damage has long been recognized as a complication of heart surgery with CPB.2–4 By the 1970s, major neurological complications were frequently associated with heart surgery with an incidence of 19%.5 In the intervening years, the incidences of major neurological complications have fallen to very low levels and, currently, less than two percent of patients undergoing coronary artery bypass grafting (CABG) surgery will develop strokes.6–8 Nevertheless, with the burgeoning of CABG surgery in the 1980s, it became increasingly recognized that heart surgery was very commonly associated with another form of brain damage, cognitive decline, as almost 80% of patient had decrements in the early postoperative period following surgery.9 Today, about 20–40% of patients undergoing CABG surgery will experience long-term cognitive decline, defined as 1 month or longer after surgery.10–13 This form of brain damage is now so widely attributed to CPB that it is commonly referred to as “pump head,” being a reference to the pump that is used to mechanically drive the blood around the body.14 A news item in 2008 even cited the CPB used for his CABG surgery as the cause of former President Bill Clinton’s uncharacteristic behavior when he was easily angered by hecklers and made factual mistakes and racial slurs while aggressively defending his wife, Hillary Clinton, and her campaign for presidency.15

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
eBook
USD 16.99
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 119.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info
Hardcover Book
USD 169.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  1. Gibbon JH Jr. Application of a mechanical heart and lung apparatus to cardiac surgery. Minn Med. 1954;37:171-185.

    PubMed  Google Scholar 

  2. Javid H, Tufo HM, Najafi H, Dye WS, Hunter JA, Julian OC. Neurological abnormalities following open-heart surgery. J Thorac Cardiovasc Surg. 1969;58:502-509.

    CAS  PubMed  Google Scholar 

  3. Gilman S. Cerebral disorders after open-heart operations. N Engl J Med. 1965;272:489-498.

    Article  CAS  PubMed  Google Scholar 

  4. Aberg T. Effect of open heart surgery on intellectual function. Scand J Thorac Cardiovasc Surg Suppl. 1974;15:1-63.

    PubMed  Google Scholar 

  5. Branthwaite MA. Neurological damage related to open-heart surgery. A clinical survey. Thorax. 1972;27:748-753.

    Article  CAS  PubMed  Google Scholar 

  6. Sedrakyan A, Wu AW, Parashar A, Bass EB, Treasure T. Off-pump surgery is associated with reduced occurrence of stroke and other morbidity as compared with traditional coronary artery bypass grafting: a meta-analysis of systematically reviewed trials. Stroke. 2006;37:2759-2769.

    Article  PubMed  Google Scholar 

  7. Takagi H, Tanabashi T, Kawai N, Umemoto T. Off-pump surgery does not reduce stroke, compared with results of on-pump coronary artery bypass grafting: a meta-analysis of randomized clinical trials. J Thorac Cardiovasc Surg. 2007; 134:1059-1060.

    Article  PubMed  Google Scholar 

  8. Wijeysundera DN, Beattie WS, Djaiani G, et al. Off-pump coronary artery surgery for reducing mortality and morbidity: meta-analysis of randomized and observational studies. J Am Coll Cardiol. 2005;46:872-882.

    Article  PubMed  Google Scholar 

  9. Shaw PJ, Bates D, Cartlidge NE, et al. Neurologic and neuropsychological morbidity following major surgery: comparison of coronary artery bypass and peripheral vascular surgery. Stroke. 1987;18:700-707.

    CAS  PubMed  Google Scholar 

  10. Robson MJ, Alston RP, Deary IJ, Andrews PJ, Souter MJ, Yates S. Cognition after coronary artery surgery is not related to postoperative jugular bulb oxyhemoglobin desaturation. Anesth Analg. 2000;91:1317-1326.

    Article  CAS  PubMed  Google Scholar 

  11. Roach GW, Newman MF, Murkin JM, et al. Ineffectiveness of burst suppression therapy in mitigating perioperative cerebrovascular dysfunction. Multicenter Study of Perioperative Ischemia (McSPI) Research Group. Anesthesiol. 1999;90:1255-1264.

    Article  CAS  Google Scholar 

  12. Croughwell ND, Newman MF, Blumenthal JA, et al. Jugular bulb saturation and cognitive dysfunction after cardiopulmonary bypass. Ann Thorac Surg. 1994;58:1702-1708.

    Article  CAS  PubMed  Google Scholar 

  13. Newman MF, Kirchner JL, Phillips-Bute B, et al. Longitudinal assessment of neurocognitive function after coronary-artery bypass surgery. N Engl J Med. 2001;344:395-402.

    Article  CAS  PubMed  Google Scholar 

  14. Alston RP. Pumphead - or not! Does avoiding cardiopulmonary bypass for coronary artery bypass surgery result in less brain damage? Br J Anaesth. 2005;94:699-701.

    Article  PubMed  Google Scholar 

  15. McDougall J. Bill Clinton’s madness: a consequence of heart-bypass surgery brain damage. Available at: http://www.drmcdougall.com/misc/20080ther/080412clinton.htm. Accessed June 29, 2008.

  16. Murkin JM, Boyd WD, Ganapathy S, Adams SJ, Peterson RC. Beating heart surgery: why expect less central nervous system morbidity? Ann Thorac Surg. 1999;68:1498-1501.

    Article  CAS  PubMed  Google Scholar 

  17. Newman SP, Harrison MJG, Stump DA, Smith P, Taylor K. The brain and cardiac surgery: causes of neurological complications and their prevention. Amsterdam: Harwood Academic; 2000.

    Google Scholar 

  18. Al-Ruzzeh S, Nakamura K, Athanasiou T, et al. Does off-pump coronary artery bypass (OPCAB) surgery improve the outcome in high-risk patients? A comparative study of 1398 high-risk patients. Eur J Cardiothorac Surg. 2003;23:50-55.

    Article  PubMed  Google Scholar 

  19. Patel NC, Deodhar AP, Grayson AD, et al. Neurological outcomes in coronary surgery: independent effect of avoiding cardiopulmonary bypass. Ann Thorac Surg. 2002;74:400-405.

    Article  PubMed  Google Scholar 

  20. Bowles BJ, Lee JD, Dang CR, et al. Coronary artery bypass performed without the use of cardiopulmonary bypass is associated with reduced cerebral microemboli and improved clinical results. Chest. 2001;119:25-30.

    Article  CAS  PubMed  Google Scholar 

  21. Puskas JD, Thourani VH, Marshall JJ, et al. Clinical outcomes, angiographic patency, and resource utilization in 200 consecutive off-pump coronary bypass patients. Ann Thorac Surg. 2001;71:1477-1483.

    Article  CAS  PubMed  Google Scholar 

  22. van Dijk D, Jansen EW, Hijman R, et al. Cognitive outcome after off-pump and on-pump coronary artery bypass graft surgery: a randomized trial. JAMA. 2002;287:1405-1412.

    Article  PubMed  Google Scholar 

  23. Lee JD, Lee SJ, Tsushima WT, et al. Benefits of off-pump bypass on neurologic and clinical morbidity: a prospective randomized trial. Ann Thorac Surg. 2003;76:18-25.

    Article  PubMed  Google Scholar 

  24. Zamvar V, Williams D, Hall J, et al. Assessment of neurocognitive impairment after off-pump and on-pump techniques for coronary artery bypass graft surgery: prospective randomized controlled trial. BMJ. 2002;325:1268.

    Article  PubMed  Google Scholar 

  25. Lund C, Sundet K, Tennoe B, et al. Cerebral ischemic injury and cognitive impairment after off-pump and on-pump coronary artery bypass grafting surgery. Ann Thorac Surg. 2005; 80:2126-2131.

    Article  PubMed  Google Scholar 

  26. Ernest CS, Worcester MU, Tatoulis J, et al. Neurocognitive outcomes in off-pump versus on-pump bypass surgery: a randomized controlled trial. Ann Thorac Surg. 2006;81:2105-2114.

    Article  PubMed  Google Scholar 

  27. Vedin J, Nyman H, Ericsson A, Hylander S, Vaage J. Cognitive function after on or off pump coronary artery bypass grafting. Eur J Cardiothorac Surg. 2006;30:305-310.

    Article  PubMed  Google Scholar 

  28. Al-Ruzzeh S, George S, Bustami M, et al. Effect of off-pump coronary artery bypass surgery on clinical, angiographic, neurocognitive, and quality of life outcomes: randomized controlled trial. BMJ. 2006;332:1365.

    Article  PubMed  Google Scholar 

  29. Motallebzadeh R, Bland JM, Markus HS, Kaski JC, Jahangiri M. Neurocognitive function and cerebral emboli: randomized study of on-pump versus off-pump coronary artery bypass surgery. Ann Thorac Surg. 2007;83:475-482.

    Article  PubMed  Google Scholar 

  30. Reston JT, Tregear SJ, Turkelson CM. Meta-analysis of short-term and mid-term outcomes following off-pump coronary artery bypass grafting. Ann Thorac Surg. 2003;76:1510-1515.

    Article  PubMed  Google Scholar 

  31. Parolari A, Alamanni F, Cannata A, et al. Off-pump versus on-pump coronary artery bypass: meta-analysis of currently available randomized trials. Ann Thorac Surg. 2003;76:37-40.

    Article  PubMed  Google Scholar 

  32. Athanasiou T, Al-Ruzzeh S, Kumar P, et al. Off-pump myocardial revascularization is associated with less incidence of stroke in elderly patients. Ann Thorac Surg. 2004;77:745-753.

    Article  PubMed  Google Scholar 

  33. van der Heijden GJ, Nathoe HM, Jansen EW, Grobbee DE. Meta-analysis on the effect of off-pump coronary bypass surgery. Eur J Cardiothorac Surg. 2004;26:81-84.

    Article  PubMed  Google Scholar 

  34. Cheng DC, Bainbridge D, Martin JE, Novick RJ. Does off-pump coronary artery bypass reduce mortality, morbidity, and resource utilization when compared with conventional coronary artery bypass? A meta-analysis of randomized trials. Anesthesiol. 2005;102:188-203.

    Article  Google Scholar 

  35. Parolari A, Alamanni F, Polvani G, et al. Meta-analysis of randomized trials comparing off-pump with on-pump coronary artery bypass graft patency. Ann Thorac Surg. 2005;80:2121-2125.

    Article  PubMed  Google Scholar 

  36. Puskas J, Cheng D, Knight J, et al. Off-pump versus conventional coronary artery bypass grafting: a meta-analysis and consensus statement from the 2004 ISMICS Consensus Conference. Innovations. 2005;1:3-27.

    Google Scholar 

  37. Takagi H, Tanabashi T, Kawai N, Umemoto T. Cognitive decline after off-pump versus on-pump coronary artery bypass graft surgery: meta-analysis of randomized controlled trials. J Thorac Cardiovasc Surg. 2007;134:512-513.

    Article  PubMed  Google Scholar 

  38. Marasco SF, Sharwood LN, Abramson MJ. No improvement in neurocognitive outcomes after off-pump versus on-pump coronary revascularisation: a meta-analysis. Eur J Cardio­thorac Surg. 2008;33:961-970.

    Article  PubMed  Google Scholar 

  39. Hernandez F Jr, Brown JR, Likosky DS, et al. Neurocognitive outcomes of off-pump versus on-pump coronary artery bypass: a prospective randomized controlled trial. Ann Thorac Surg. 2007;84:1897-1903.

    Article  PubMed  Google Scholar 

  40. Tully PJ, Baker RA, Kneebone AC, Knight JL. Neuro­psychologic and quality-of-life outcomes after coronary artery bypass surgery with and without cardiopulmonary bypass: a prospective randomized trial. J Cardiothorac Vasc Anesth. 2008;22:515-521.

    Article  PubMed  Google Scholar 

  41. SIGN. Search filters. Available at: http://www.sign.ac.uk/methodology/filters.html. Accessed June 15, 2008.

  42. Hogue CW Jr, Palin CA, Arrowsmith JE. Cardiopulmonary bypass management and neurologic outcomes: an evidence-based appraisal of current practices. Anesth Analg. 2006;103:21-37.

    Article  PubMed  Google Scholar 

  43. Diephuis JC, Moons KG, Nierich AN, Bruens M, van Dijk D, Kalkman CJ. Jugular bulb desaturation during coronary artery surgery: a comparison of off-pump and on-pump procedures. Br J Anaesth. 2005;94:715-720.

    Article  CAS  PubMed  Google Scholar 

  44. Chassot PG, van der Linden P, Zaugg M, Mueller XM, Spahn DR. Off-pump coronary artery bypass surgery: ­physiology and anaesthetic management. Br J Anaesth. 2004;92:400-413.

    Article  PubMed  Google Scholar 

  45. Rees K, Beranek-Stanley M, Burke M, Ebrahim S. Hypothermia to reduce neurological damage following coronary artery bypass surgery Cochrane Database of Systematic Reviews 2005; Issue 1. Art. No.: DOI: 10.1002/14651858.CD002138.

    Google Scholar 

  46. Grigore AM, Grocott HP, Mathew JP, et al. The rewarming rate and increased peak temperature alter neurocognitive outcome after cardiac surgery. Anesth Analg. 2002;94:4-10.

    Article  PubMed  Google Scholar 

  47. Shann KG, Likosky DS, Murkin JM, et al. An evidence-based review of the practice of cardiopulmonary bypass in adults: a focus on neurologic injury, glycemic control, hemodilution, and the inflammatory response. J Thorac Cardiovasc Surg. 2006;132:283-290.

    Article  PubMed  Google Scholar 

  48. Mathew JP, Mackensen GB, Phillips-Bute B, et al. Effects of extreme hemodilution during cardiac surgery on cognitive function in the elderly. Anesthesiology. 2007;107:577-584.

    Article  PubMed  Google Scholar 

  49. DeFoe GR, Ross CS, Olmstead EM, et al. Lowest hematocrit on bypass and adverse outcomes associated with coronary artery bypass grafting. Northern New England Cardiovascular Disease Study Group. Ann Thorac Surg. 2001;71:769-776.

    Article  CAS  PubMed  Google Scholar 

  50. Gourlay T, Taylor KM. Pulsatile flow and membrane oxygenators. Perfusion. 1994;9:189-196.

    Article  CAS  PubMed  Google Scholar 

  51. Watanabe T, Orita H, Kobayashi M, Washio M. Brain tissue pH, oxygen tension, and carbon dioxide tension in profoundly hypothermic cardiopulmonary bypass. Comparative study of circulatory arrest, nonpulsatile low-flow perfusion, and pulsatile low-flow perfusion. J Thorac Cardiovasc Surg. 1989;97:396-401.

    CAS  PubMed  Google Scholar 

  52. Undar A, Masai T, Beyer EA, Goddard-Finegold J, McGarry MC, Fraser CD Jr. Pediatric physiologic pulsatile pump enhances cerebral and renal blood flow during and after cardiopulmonary bypass. Artif Organs. 2002;26:919-923.

    Article  PubMed  Google Scholar 

  53. Mutch WA, Warrian RK, Eschun GM, et al. Biologically variable pulsation improves jugular venous oxygen saturation during rewarming. Ann Thorac Surg. 2000;69:491-497.

    Article  CAS  PubMed  Google Scholar 

  54. Murkin JM, Martzke JS, Buchan AM, Bentley C, Wong CJ. A randomized study of the influence of perfusion technique and pH management strategy in 316 patients undergoing coronary artery bypass surgery: II. neurologic and cognitive outcomes. J Thorac Cardiovasc Surg. 1995;110:349-362.

    Article  CAS  PubMed  Google Scholar 

  55. Murkin JM, Farrar JK, Tweed WA, McKenzie FN, Guiraudon G. Cerebral autoregulation and flow/metabolism coupling during cardiopulmonary bypass: the influence of PaCO2. Anesth Analg. 1987;66:825-832.

    CAS  PubMed  Google Scholar 

  56. Goto T, Baba T, Matsuyama K, Honma K, Ura M, Koshiji T. Aortic atherosclerosis and postoperative neurological dysfunction in elderly coronary surgical patients. Ann Thorac Surg. 2003;75:1912-1918.

    Article  PubMed  Google Scholar 

  57. Mariani MA, D’Alfonso A, Grandjean JG. Total arterial off-pump coronary surgery: time to change our habits? Ann Thorac Surg. 2004;78:1591-1597.

    Article  PubMed  Google Scholar 

  58. Legare JF, Hassan A, Buth KJ, Sullivan JA. The effect of total arterial grafting on medium-term outcomes following coronary artery bypass grafting. J Cardiothorac Surg. 2007; 2:44.

    Article  PubMed  Google Scholar 

  59. Rosenberger P, Shernan SK, Loffler M, et al. The influence of epiaortic ultrasonography on intraoperative surgical management in 6051 cardiac surgical patients. Ann Thorac Surg. 2008;85:548-553.

    Article  PubMed  Google Scholar 

  60. Pugsley W, Klinger L, Paschalis C, Treasure T, Harrison M, Newman S. The impact of microemboli during cardiopulmonary bypass on neuropsychological functioning. Stroke. 1994;25:1393-1399.

    CAS  PubMed  Google Scholar 

  61. Stump DA, Rogers AT, Hammon JW, Newman SP. Cerebral emboli and cognitive outcome after cardiac surgery. J Cardiothorac Vasc Anesth. 1996;10:113-118.

    Article  CAS  PubMed  Google Scholar 

  62. Scharfschwerdt M, Richter A, Boehmer K, Repenning D, Sievers HH. Improved hydrodynamics of a new aortic cannula with a novel tip design. Perfusion. 2004;19:193-197.

    Article  PubMed  Google Scholar 

  63. Muehrcke DD, Cornhill JF, Thomas JD, Cosgrove DM. Flow characteristics of aortic cannulae. J Card Surg. 1995; 10:514-519.

    Article  CAS  PubMed  Google Scholar 

  64. Djaiani G, Ali M, Borger MA, et al. Epiaortic scanning modifies planned intraoperative surgical management but not cerebral embolic load during coronary artery bypass surgery. Anesth Analg. 2008;106:1611-1618.

    Article  PubMed  Google Scholar 

  65. Ott E, Nussmeier NA, Duke PC, et al. Efficacy and safety of the cyclooxygenase 2 inhibitors parecoxib and valdecoxib in patients undergoing coronary artery bypass surgery. J Thorac Cardiovasc Surg. 2003;125:1481-1492.

    Article  CAS  PubMed  Google Scholar 

  66. Nussmeier NA, Whelton AA, Brown MT, et al. Complications of the COX-2 inhibitors parecoxib and valdecoxib after cardiac surgery. N Engl J Med. 2005;352:1081-1091.

    Article  CAS  PubMed  Google Scholar 

  67. Robson MJA, Alston RP, Deary IJ, Andrews PJD, Souter MJ. Jugular bulb oxyhemoglobin desaturation, S100β and neurologic and cognitive outcome after coronary artery surgery. Anesth Analg. 2001;93:839-845.

    Article  CAS  PubMed  Google Scholar 

  68. Shaw PJ, Bates D, Cartlidge NE, Heaviside D, Julian DG, Shaw DA. Early neurological complications of coronary artery bypass surgery. BMJ. 1985;291:1384-1387.

    Article  CAS  PubMed  Google Scholar 

  69. Egger M, Schneider M, Smith GD. Meta-analysis Spurious precision? Meta-analysis of observational studies. BMJ. 1998;316:140-144.

    CAS  PubMed  Google Scholar 

  70. Alston RP. Cardiothoracic anesthesia and critical care. In: Moller A, Pederson T, eds. Evidence-based anesthesia and intensive care. Cambridge: Cambridge University Press; 2006.

    Google Scholar 

  71. Tramer MR, Reynolds DJM, Moore RA, McQuay HJ. Impact of covert duplicate publication on meta-analysis: a case study. BMJ. 1997;315:635-640.

    CAS  PubMed  Google Scholar 

  72. Polunina AG. Selection of neurocognitive tests and outcomes of cardiac surgery trials. Ann Thorac Surg. 2008;85:362.

    Article  PubMed  Google Scholar 

  73. MacCallum RC, Zhang S, Preacher KJ, Rucker DD. On the practice of dichotomization of quantitative variables. Psychol Methods. 2002;7:19-40.

    Article  PubMed  Google Scholar 

  74. Altman DG, Royston P. The cost of dichotomising continuous variables. BMJ. 2006;332:1080.

    Article  PubMed  Google Scholar 

  75. Motallebzadeh R, Jahangiri M. Meta-analysis of randomized controlled trials of cognitive decline after on-pump versus off-pump coronary artery bypass graft surgery. J Thorac Cardiovasc Surg. 2008;135:1400-1401.

    PubMed  Google Scholar 

  76. Murkin JM, Newman SP, Stump DA, Blumenthal JA. Statement of consensus on assessment of neurobehavioral outcomes after cardiac surgery. Ann Thorac Surg. 1995; 59: 1289-1295.

    Article  CAS  PubMed  Google Scholar 

  77. Phillips-Bute B, Mathew JP, Blumenthal JA, et al. Association of neurocognitive function and quality of life 1 year after coronary artery bypass graft (CABG) surgery. Psychosom Med. 2006;68:369-375.

    Article  PubMed  Google Scholar 

  78. Takagi H, Kawai N, Umemoto T. Reply to the Editor. J Thorac Cardiovasc Surg. 2008;135:1400-1401.

    Google Scholar 

  79. Phillips-Bute B, Mathew JP. Cognitive outcomes analyses: two steps forward, one step back? J Cardiothorac Vasc Anesth. 2008;22:513-514.

    Article  PubMed  Google Scholar 

  80. van Dijk D, Spoor M, Hijman R, et al. Cognitive and cardiac outcomes 5 years after off-pump vs on-pump coronary artery bypass graft surgery. JAMA. 2007;297:701-708.

    Article  PubMed  Google Scholar 

  81. Gallagher EG, Pearson DT. Ultrasonic identification of sources of gaseous microemboli during open heart surgery. Thorax. 1973;28:295-305.

    Article  CAS  PubMed  Google Scholar 

  82. Deverall PB, Padayachee TS, Parsons S, Theobold R, Battistessa SA. Ultrasound detection of micro-emboli in the middle cerebral artery during cardiopulmonary bypass surgery. Eur J Cardiothorac Surg. 1988;2:256-260.

    Article  CAS  PubMed  Google Scholar 

  83. Selnes OA, Grega MA, Bailey MM, et al. Cognition 6 years after surgical or medical therapy for coronary artery disease. Ann Neurol. 2008;63:581-590.

    Article  PubMed  Google Scholar 

  84. Wahrborg P, Booth JE, Clayton T, et al. Neuropsychological outcome after percutaneous coronary intervention or coronary artery bypass grafting: results from the stent or surgery (SoS) trial. Circulation. 2004;110:3411-3417.

    Article  PubMed  Google Scholar 

  85. Aleman A, Muller M, de Haan EH, van der Schouw YT. Vascular risk factors and cognitive function in a sample of independently living men. Neurobiol Aging. 2005;26:485-490.

    Article  PubMed  Google Scholar 

  86. van Dijk D, Moons KG, Nathoe HM, et al. Cognitive outcomes five years after not undergoing coronary artery bypass graft surgery. Ann Thorac Surg. 2008;85:60-64.

    Article  PubMed  Google Scholar 

Download references

Acknowledgments

I wish to thank Linda Alston for her assistance in preparing and proofing this chapter.

Author information

Authors and Affiliations

  1. Department of Anaesthesia, Critical Care and Pain Medicine, Royal Infirmary of Edinburgh, Edinburgh, Scotland, UK

    R. Peter Alston

Authors
  1. R. Peter Alston
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to R. Peter Alston .

Editor information

Editors and Affiliations

  1. Dept. Cardiothoracic Surgeon, Queen Elizabeth Hospital, Birmingham, B15 2TH, United Kingdom

    Robert S. Bonser

  2. Cardiothoracic Surgery, Beaumont Road 208, Birmingham, B30 1NX, United Kingdom

    Domenico Pagano

  3. Klinik für Herz-, Thorax-,, Transplantations- und Gefäßchirurgie, Medizinische Hochschule Hannover (MHH), Carl-Neuberg-Str. 1, Hannover, 30625, Germany

    Axel Haverich

Rights and permissions

Reprints and permissions

Copyright information

© 2011 Springer London

About this chapter

Cite this chapter

Alston, R.P. (2011). Off-Pump and On-Pump Coronary Artery Surgery and the Brain. In: Bonser, R., Pagano, D., Haverich, A. (eds) Brain Protection in Cardiac Surgery. Springer, London. https://doi.org/10.1007/978-1-84996-293-3_16

Download citation

  • DOI: https://doi.org/10.1007/978-1-84996-293-3_16

  • Published:

  • Publisher Name: Springer, London

  • Print ISBN: 978-1-84996-292-6

  • Online ISBN: 978-1-84996-293-3

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation