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Core Concepts in Cardiac Surgery
Core Concepts
in Cardiac Surgery

Edited by

David Taggart
Professor of Cardiovascular Surgery, University of Oxford, Oxford, UK

and

Yasir Abu-​Omar
Consultant Cardiothoracic and Transplant Surgeon, Royal Papworth
Hospital, Cambridge, UK

1
1
Great Clarendon Street, Oxford, OX2 6DP,
United Kingdom
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First Edition published in 2018
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Published in the United States of America by Oxford University Press
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Oxford University Press makes no representation, express or implied, that the
drug dosages in this book are correct. Readers must therefore always check
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 Contents

List of abbreviations vii

List of contributors ix

1 CABG conduits and graft configuration 1

David Glineur
2 Off-​pump versus on-​pump coronary artery bypass grafting 33
Michael E. Halkos, Emmanuel Moss, and John D. Puskas
3 Current status of minimally invasive, robotic and hybrid coronary artery
bypass surgery 53
Stephanie Mick, Suresh Keshavamurthy, and Johannes Bonatti
4 Aortic valve repair 73
Munir Boodhwani and Gebrine El Khoury
5 Aortic valve: Conventional valve replacement and transcatheter valve
implantation 97
Jörg Kempfert and Thomas Walther
6 Open and endovascular treatment options in thoracic aortic surgery 111
Ourania Preventza and Joseph S. Coselli
7 Mitral valve repair: Conventional open techniques 135
A. Marc Gillinov and Tomislav Mihaljevic
8 Minimally invasive mitral valve repair 145
Evelio Rodriguez and W. Randolph Chitwood, Jr
9 Surgical therapy for heart failure 157
Stephen Westaby
10 Surgery for atrial fibrillation 175
Jason O. Robertson, Lindsey L. Saint, and Ralph J. Damiano, Jr
11 Mechanical circulatory support 197
William E. Stansfield, Antigone Koliopoulou, Stephen H. McKellar,
and Craig H. Selzman
12 Current status of heart transplantation 223
Ayyaz Ali and Robert L. Kormos
13 Current status of lung transplantation 241
Varun Puri and G. Alexander Patterson

Index 263
 List of Abbreviations

ACAB atraumatic coronary artery bypass EDHF endothelium-​derived

ACE angiotensin-​converting-​enzyme hyperpolarizing factor
ACT activated clotting time ERP effective refractory period
AF atrial fibrillation FAA functional aortic annulus
AHA American Heart Association FDA Food and Drug Administration
AI aortic insufficiency FFR fractional flow reserve
AR aortic regurgitation GEA gastro-​epiploic artery
AS aortic valve stenosis HF heart failure
AV aortic valve HIFU high-​intensity focused ultrasound
AVJ aorto-​ventricular junction IABP intra-​aortic balloon pump
AVN atrioventricular node ICU intensive care unit
AVR aortic valve replacement IEA inferior epigastric artery
BAV bicuspid aortic valve IEOA indexed effective orifice area
BH-​TECAB beating heart total endoscopic IMA internal mammary artery
coronary bypass grafting IRAD International Registry of Acute
BIMA bilateral internal mammary artery Aortic Dissection
BITA bilateral internal thoracic artery ISDN isosorbide dinitrate
BMI body mass index ITA internal thoracic artery
BOS bronchiolitis obliterans syndrome IVC inferior vena cava
CABG coronary artery bypass graft LA left atrium
CAD coronary artery disease LAA left atrial appendage
CF continuous flow LAD left anterior descending artery
CP chordal procedure LCC left coronary cusp
CPB cardiopulmonary bypass LHB left-​sided heart bypass
CPR cardiopulmonary resuscitation LIMA left internal mammary artery
CT computed tomography LITA left internal thoracic artery
DAPT dual antiplatelet therapy LRA leaflet resection with an
annuloplasty
DCD donation after cardiac death
LV left ventricular
DDAVP desmopressin acetate
LVAD left ventricular assist devices
DES drug-​eluting stent
LVEDP left ventricular end diastolic
DHCA deep hypothermic circulatory arrest
pressure
DLCO diffusing capacity of the lungs for
LVEF left ventricular ejection fraction
carbon monoxide
MACCE major adverse cardiac and
DT destination therapy
cerebrovascular events
EACTS European Association for Cardio-​
MCS mechanical circulatory support
Thoracic Surgery
MI myocardial infarction
ECGI electrocardiographic imaging
MIDCAB minimally invasive direct
ECMO extracorporeal membrane
coronary bypass
oxygenation
viii List of abbreviations

MIMVS minimally invasive mitral valve RAA right atrial appendage

surgery RCA right coronary artery
MLD minimal lumen diameter RCC right coronary cusp
MR mitral regurgitation RCT randomized controlled trial
MRA magnetic resonance angiography RFA radiofrequency ablation
MV mitral valve RGEA right gastroepiploic artery
MVST multivessel small thoracotomy RIMA right internal mammary artery
NC non-​coronary RITA right internal thoracic artery
NCC non-​compaction cardiomyopathy RV right ventricular
NIRS near-​infrared spectroscopy RVAD right ventricular assist device
NYHA New York Heart Association SAM systolic anterior motion
ONCAB on-​pump coronary artery bypass SAN sinoatrial node
OPCAB off-​pump coronary artery bypass SAVR surgical aortic valve replacement
OR operative room SCA sudden cardiac arrest
PA pulmonary artery STJ sinotubular junction
PAU penetrating atherosclerotic ulcer STS Society of Thoracic Surgeons
PCI percutaneous coronary intervention SV stroke volume
PDA patent ductus arteriosus SVC superior vena cava
PGD primary graft dysfunction SVG saphenous vein graft
PLA posterolateral artery SVST single-​vessel small thoracotomy
PPM patient–​prosthesis mismatch direct-​vision bypass grafting
PTCA percutaneous transluminal TAAA thoracoabdominal aortic aneurysm
coronary angioplasty TAVI transcatheter aortic valve
PTFE polytetrafluoroethylene implantation
PTLD post-​transplantation TECAB totally endoscopic coronary
lymphoproliferative disease artery bypass
PV pulmonary vein TEE transesophageal echocardiography
PVI pulmonary vein isolation VAD ventricular assist device
PVR pulmonary vascular resistance VAJ ventriculo-​aortic junction
QoL quality of life VAS ventricular assist system
RA radial artery
 List of Contributors

Ayyaz Ali A. Marc Gillinov

Assistant Professor, Chairman,
Director of Heart Transplantation, Department of Thoracic and
Department of Cardiac Surgery, Cardiovascular Surgery,
Yale School of Medicine, Cleveland Clinic,
Connecticut, USA Ohio, USA
Johannes Bonatti David Glineur
Chair of Cardiac Surgery, Cardiac Surgeon,
Cleveland Clinic, University of Ottawa Heart Institute,
Abu Dhabi, United Arab Emirates Ottawa, Canada
Munir Boodhwani Michael E. Halkos
Associate Professor in the Division of Associate Professor of Surgery,
Cardiac Surgery at the University of Chief, Division of Cardiothoracic Surgery,
Ottawa Heart Institute, Emory University School of Medicine,
Ottowa, Canada Georgia, USA
W. Randolph Chitwood, Jr Jörg Kempfert
Emeritus Professor and Founding Consultant Cardiac Surgeon,
Director, German Heart Center,
East Carolina Heart Institute, Berlin, Germany
North Carolina, USA Suresh Keshavamurthy
Joseph S. Coselli Assistant Professor of Surgery,
Vice-Chair, Michael E. DeBakey Temple University Hospital,
Department of Surgery, Philadelphia, USA
Professor and Chief, Division of Gebrine El Khoury
Cardiothoracic Surgery, Professor,
Baylor College of Medicine, Department of Cardiac Surgery,
Texas, USA; Clinique Saint-​Luc,
Chief, Section of Adult Cardiac Surgery, Brussels, Belgium
Texas Heart Institute,
Texas, USA Antigone Koliopoulou
Assistant Professor of Surgery,
Ralph J. Damiano, Jr Division of Cardiothoracic Surgery,
Evarts A. Graham Professor and Surgery University of Utah,
Chief, Salt Lake City, USA
Division of Cardiothoracic Surgery,
Barnes-​Jewish Hospital,
Missouri, USA
x List of contributors

Robert L. Kormos Varun Puri

Brack G. Hattler Professor of Associate Professor of Surgery,
Cardiothoracic Transplantation, Washington University School of Medicine,
UPMC Presbyterian, Pittsburgh, Missouri, USA
Pennsylvania, USA John D. Puskas
Stephen H. McKellar Professor of Surgery (Cardiothoracic),
Associate Professor of Surgery, Chair of Cardiovascular Surgery,
Division of Cardiothoracic Surgery, Mount Sinai Saint Luke’s Hospital,
University of Utah, New York, USA
Salt Lake City, USA Jason O. Robertson
Stephanie Mick Resident, Cardiothoracic Surgery,
Thoracic and Cardiovascular Surgeon, Washington University,
Cleveland Clinic, St. Louis, Missouri, USA
Ohio, USA Evelio Rodriguez
Tomislav Mihaljevic Chief of Cardiac Surgery,
Department of Cardiothoracic Surgery, Saint Thomas Health, Nashville,
Cleveland Clinic Abu Dhabi, Tennessee, USA
Abu Dhabi, United Arab Emirates Lindsey L. Saint
Emmanuel Moss Resident, Cardiothoracic Surgery,
Assistant Professor of Surgery, Washington University, St. Louis,
Jewish General Hospital/McGill Missouri, USA
University, Craig H. Selzman
Division of Cardiac Surgery, Professor and Chief Division of
Montreal, Canada Cardiothoracic Surgery,
G. Alexander Patterson University of Utah,
Joseph Bancroft Professor of Surgery, Utah, USA
Washington University School of William E. Stansfield
Medicine, Affiliate Scientist,
Missouri, USA Toronto General Hospital Research
Ourania Preventza Institute,
Associate Professor, Toronto, Canada
Michael E. DeBakey Department of Thomas Walther
Surgery, Director of the Department of Cardiac,
Division of Cardiothoracic Surgery, Thoracic and Thoracic Vascular Surgery,
Baylor College of Medicine, Hospital of the Goethe University,
Texas, USA; Frankfurt, Germany
Cardiac Surgeon,
Department of Cardiovascular Surgery, Stephen Westaby
Texas Heart Institute, Surgeon,
Texas, USA Department of Cardiothoracic Surgery,
John Radcliffe Hospital,
Oxford, UK
 Chapter 1

CABG conduits and graft configuration

David Glineur

Coronary artery bypass graft (CABG) conduits

Left internal thoracic artery (LITA)
Anatomy
The internal thoracic artery (ITA) supplies the anterior chest wall; it arises from the sub­
clavian artery near its origin and travels downward inside the chest wall, approximately
one centimeter from the edges of the sternum. It runs pos erior Ito the internal intercostal
muscles, but anterior to the transverse muscles. The ITA divides into the musculophrenic
artery and the superior epigastric artery around the sixfn ·ntercostal space.

Histology
The major characteristic of the LITA is the presenee of more elastic laminae com­
pared to gastro-epiploic artery (GEA), inferio epigastric artery (IEA), or radial ar­
tery (RA), which contain more smooth muscle cells in their walls and are therefore
less elastic. 1
Intima Both connective tiss- e ana smootn muscle are present in the intima, the border of
which is delineated by the internal elastic membrane. The internal elastic membrane may
not be conspicuous due to the abundance of elastic material in the tunica media.
Media This is the thickest of the three layers. Smooth muscle cells are arranged in a spiral
around the long axis of the vessel, and secrete elastin in the form of lamellae, which are
fenestrated to facilitate diffusion. These lamellae, and the large size of the media, are the
most striking histological features of elastic arteries. In addition to elastin, the smooth
muscle cells of the media secrete reticular and fine collagen fibers and proteoglycans. No
fibroblasts are present.
Adventitia This is a relatively thin connective tissue layer. Fibroblasts are the predom­
inant cell type, and many macrophages are also present. Collagen fibers predominate
and elastic fibers (not lamellae) are also present. The collagen in the adventitia prevents
elastic arteries from stretching beyond their physiological limits during systole. Blood
vessels supplying the adventitia and outer media, known as the vasa vasorum, are also
present.
2 CABG conduits and graft configuration

Endothelium function
Endothelium acts as an antithrombotic barrier as well as a modulator of vascular tone and
growth. For these reasons, it is believed to be the milestone of the graft long-​term patency. In
response to a variety of agonists, endothelial cells generate three major autacoids that regu-
late vascular relaxation and other endothelium-​dependent vascular functions2: nitric oxide
(NO), prostacyclin (PGI2), and endothelium-​derived hyperpolarizing factor (EDHF).
Lüscher and colleagues3 studied endothelium-​dependent relaxation in internal mam-
mary arteries, internal mammary veins, and saphenous veins. Vascular rings with and
without endothelium were suspended in organ chambers, and isometric tension was re-
corded. Acetylcholine, thrombin, and adenosine diphosphate evoked potent endothelium-​
dependent relaxation in the mammary artery but weak responses in the saphenous vein.
In the mammary artery, relaxation was greatest in response to acetylcholine, followed
by thrombin and adenosine diphosphate. In the saphenous and mammary veins, relax-
ation was less than 25%. Relaxation was unaffected by indomethacin but was inhibited by
methylene blue and hemoglobin, suggesting that endothelium-​derived relaxing factor was
the mediator. Endothelium-​independent relaxation in response to sodium nitroprusside
was similar in arteries and veins. Lüscher concluded that endothelium-​dependent relax-
ation was greater in the mammary artery than in the saphenous vein.
The specificity of the ITA explains why it is less damaged by arteriosclerosis compared
to other arteries, a phenomenon that has been studied with an ultrasonic system.4 This
study revealed that the intima-​media complex of the ITA is protected from the influence
of arteriosclerosis, in comparison with the morphological changes found in the intima-​
media thickness of the common carotid artery. This demonstrated protective mechanism
underlines the widespread use of the ITA as a CABG conduit.
In addition, β-​adrenoceptor agonists do not induce a significant relaxation of the ITA,
and the use of β-​adrenoceptor antagonists do not lead to IMA vasospasm.5

Patency
Long-​term LITA to the left anterior descending artery (LAD) patency is usually greater
than 90% (range 83–​98% in historical studies)6–​27 (Table 1.1). Factors known to poten-
tially influence patency include the degree of preoperative proximal coronary stenosis,
the time from CABG in non-​LAD arteries, sex, date of surgery, target other than LAD,
and smoking status.
Degree of coronary stenosis ITA graft patency decreased as proximal coronary stenosis
decreased.28 These findings are consistent with the physiology of arterial grafts. ITAs are able
to autoregulate size and blood flow in response to demand. As proximal coronary stenosis
decreases, competitive flow increases, and demand for ITA graft flow falls. This cascade of
events results in ITA constriction and, over time, increased risk of atrophy and occlusion.29–​32
Kawasuji and colleagues33 performed angiography one month after CABG in 100 pa-
tients with ITA to LAD grafts; all grafts were patent, but 15% (2/​13) of those performed
to coronary arteries with 50% or less stenosis were severely constricted. Seki and col-
leagues30 observed either severe constriction or occlusion in 9.5% (14/​147) of ITA grafts
 Coronary artery bypass graft (CABG) conduits 3

Table 1.1 Summary of different studies on LITA patency

First author Year Studied/​ Percent Interval Graft

Operated studied patency (%)
Green6 1972 70/​165 42 2 wk–​3 y 97
Kay 7
1974 91/​628 14 19.5 mo 98
Barner 8
1976 139/​307 45 20 days 95
139/​307 45 13 mo 90
Tector 9
1976 43/​275 15 9–​24 mo 95
Geha10 1979 175/​208 82 2 wk 99
?/​208 49 6 mo–​5 y 97
Tyras 11
1980 527/​765 69 1 mo 95
?/​765 65 1y 93
?/​765 63 5y 90
Lytle12 1980 46/​100 46 20 mo 91
Tector 13
1981 88/​298 29 60–​108 mo 94.40
Singh 14
1983 34/​ NA 3–​12 y 94
Grondin 15
1984 37/​40 92 1 mo 97
32/​40 80 1y 88
20/​40 50 10 y 84
Okies 16
1984 259/​4183 6 5 y, 10 y 83, 70
Lytle 17
1985 140/​? NA 5y 97
Loop 18
1986 855/​2306 37 8.7 y 96
Zeff 19
1988 37/​39 92 8.9 y 95
Ivert20 1988 91/​99 92 2 wk 94
84/​99 85 1y 90
66/​99 67 5y 89
Goldman 21
1990 237/​670 23 1y 93
Fiore 22
1990 182/​200 91 13 y 82
Galbut23 1990 53/​947 6 2 mo–​15 y 92
Boylan 24
1994 57/​100 57 <10 y, >10 y 93, 90
Goldman 25
1994 167/​1,031 25 3y 90
FitzGibbon 26
1996 456/​476 96 6 mo 95
123/​476 26 5y 80
Gills27 1997 25/​25 100 4–​6 h 96
4 CABG conduits and graft configuration

studied 16 days to 62 months after CABG. Two (14%) of these failed ITA grafts bypassed
LADs with more than 50% stenosis, whereas 12 (86%) bypassed LADs with 50% or less
proximal stenosis.
Target ITA patency is the most durable of grafts performed to the LAD, possibly be-
cause of the ease of anterior coronary arteries grafting, but also because the amount of
myocardium supplied by the LAD is greater than that supplied by other coronary arteries,
resulting in a larger blood flow demand. ITA grafts with greater blood flow demand are
less likely to fail.34 In contrast, Glineur et al.35 could not find any significantly difference at
6 months between the right internal thoracic artery (RITA) directed to the lateral wall of
the heart versus the LITA to the LAD territory (Table 1.2).
Gender Because of their smaller size, women have smaller coronary arteries than men.
Technical difficulties associated with grafting small arteries are one possible cause of the higher
operative risk observed in women, and may also be responsible for lower graft patency.28
Risk factors Smoking is strongly associated with progression of coronary artery disease
(CAD), and patients who continue to smoke after CABG have a higher risk of return of
angina, myocardial infarction, and coronary reintervention.28 In addition, multivariable
analysis revealed that a history of smoking decreased ITA graft diameter.6 These effects
on both coronary arteries and ITA grafts probably account for the lower graft patency we
observed in smokers.36

Right internal thoracic artery (RITA)

Anatomy, histology, endothelium function
There are no significant differences between the left ITA and right ITA in terms of anatomy,
histology, and endothelial function.37 There were also no statistical differences between
LITA and RITA concerning mean intimal diameter (1.52 ± 0.24 vs. 1.58 ± 0.28 mm,
P <0.06), medial diameter (2.21 ± 0.27 vs. 2.52 ± 0.28 mm, P <0.15), or wall thickness
(0.39 ± 0.12 vs. 0.41 ± 0.16 mm, P <0.47). The intimal diameters diminished signifi-
cantly from the origins (1.69 ± 0.34 and 1.86 ± 0.41 mm, respectively) to the t­ erminations
(1.25 ± 0.26 and 1.14 ± 0.25 mm, respectively) of both vessels.
In order to determine whether endothelial function differs between left and right ITA
segments in a Y-​graft configuration, Glineur et al. studied 11 patients 3 years after sur-
gery.38 The endothelium-​dependent vasodilator substance P was selectively infused (1.4
up to 22.4 pmol/​min in doubling dose increments) in the ostium of ITA Y-​grafts. A max-
imal endothelium-​independent vasodilatory response was then obtained by intragraft
infusion of 2 mg isosorbide dinitrate (ISDN).
A similar dose-​dependent vasodilatory response to substance P was observed in the left
and in the right ITA (Figure 1.1). No difference in maximal endothelium-​dependent re-
sponse to substance P (7.4 ± 4.3% in left ITA and 8.1 ± 5.3% in right ITA) or in maximal
endothelium-​independent response to ISDN (12.2 ± 4.4% in left ITA and 10.6 ± 8.1% in
right ITA) was observed. The endothelium-​dependent and the endothelium-​independent
Table 1.2 RITA patency results

Studies cited Year n Methodology Angiography Mean Angiographic patency Actuarial

within Glineur no. follow-​up rate (%) angiographic
et al. (2008)35 patency rate (%)
LIMA RIMA LIMA RIMA
Dion (49) 1989 231 Retro Seque IMA 157 6 mo Overall IMA Overall IMA
grafts patency of patency of
95% 95%

Galbut (50) 1990 1,087 Retro 53 53 mo 92.1 84.9

Fiore (51) 1990 200 Retro 13 y 82 85
Chocron (52) 1994 80 Retro BIMA Y 62 6–​25 mo 97 63
Retro BIMA T
Tector (53) 1994 486 Perioperative 98.3 86.5
Barra (54) 1995 80 Retro BIMA Y 80 16 mo 93.4 85.2
Gerola (55) 1996 201 Retro 36 51.6 mo 94.4 91.6
RIMA TS
5y 93.8 84.1
10 y 93.8 84.1
Pick (56) 1997 320 Retro 84 6.9 y 88 75
Retro free RIMA
Tatoulis (57) 1997 1,454 71 41.5 mo 94.5
5y 96 89
Ura (58) 1998 115 Retro RIMA TS 73 59 mo 92.3 89.9
6y 94.5 89.3
Dion (59) 1999 500 Retro Seque IMA 161 7.4 y 94.3% 94.3% seque
grafts seque IMA IMA anast
anast patent patent
6 CABG conduits and graft configuration

16

Diameter change (% of basal)

14
12
10
8
6
4
2
mean ± SEM
0
–2 1.4 2.8 5.6 11.2 22.4 ISDN
Dose substance P (pmol/min)
Right ITA
Left ITA

Figure 1.1 Comparison of vasomotion between free right internal thoracic artery (RITA) and
in ​situ left internal thoracic artery (LITA).
Reprinted from Glineur D et al. (2011) Endothelium-dependent and endothelium-independent vasodilator response
of left and right internal mammary and internal thoracic arteries used as a composite Y-graft European Journal of
Cardio-Thoracic Surgery 40(2):389–93 with permission from Oxford University Press on behalf of the European
Association for Cardio-Thoracic Surgery

vasodilator capacity of the two branches of a Y-​graft ITA configuration appear similar 3 years
after bypass surgery, suggesting that the preservation of the ITA pedicle did not significantly
affect basal vasomotor tone, long-​term endothelial function, or vasodilator reserve.
Patency The widely accepted success of the LITA has led to the use of both ITAs, although
the RITA, used as an in situ or free graft, has never become as popular as the LITA. The ap-
parent difference in the clinical and angiographic performance between the two ITAs was
thought to be more related to the technical and flow-​dynamic mechanisms than to their
intrinsic characteristics.39–​40
The overall patency of the RITA grafts to the left system is almost identical with that of
LITA grafts (Table 1.3).41–​44 This observation is not surprising, considering that both ITAs
have identical histopathology.45–​46
The target artery grafted affected patency of both ITA, with maximum patency when
grafted to the LAD. Grafts to the non-​LAD arteries were at higher risk with the worst pa-
tency seen in the right coronary artery (RCA) territory.
In a recent angiographic study, Glineur et al. observed35 (Table 1.3) an excellent patency
rate with no significant difference between the in ​situ or Y-​shape use of the RITA. However,
there was a significant difference with a larger number of arterial anastomosis allowed by
the bilateral internal thoracic artery (BITA) Y-​configuration. Long-​term follow-​up will
help determine whether the larger number of ITA distal anastomosis allowed by the use
of the Y-​graft configuration translates into a superior late clinical outcome.
In a secondary analysis of this population, Glineur et al. evaluated the angiographic
parameters influencing the function of the RITA used in a Y-​graft configuration.45 In
multivariate analysis, the function of the RITA was positively influenced by the number
of anastomoses (OR = 0.5, 95% CI: 0.4–​0.7), and a severely narrowed first circumflex
 Coronary artery bypass graft (CABG) conduits 7

Table 1.3 Six-​month systematic angiographic control

BITA Y n = 146 BITA in situ n = 126 P value

ITA anastomosis angiographic patency control
Patent/​total Patent/​total
LIMA 190/​197 (96%) 166/​169 (98%) 0.96
Diagonal 49/​51 43/​43 0.55
LAD 141/​146 123/​126 0.88
RIMA 260/​267 (97%) 121/​126 (96%) 0.69
Intermediate 10/​10 1/​1
OM1 135/​137 120/​125 0.37
OM2 81/​84
PLA 17/​19
PDA 17/​17
Total 450/​464 (97%) 287/​295 (97%) 0.99
Complementary graft anastomosis patency control
Patent/​total Patent/​total
RGEA 27/​30 (90%) 32/​38 (84%) 0.73
SVG 57/​59 (97%) 71/​76 (93%) 0.66

BITA, bilateral internal thoracic artery; ITA, internal thoracic artery; LIMA, left internal mammary artery; RIMA, right
internal mammary artery; RGEA, right gastroepiploic artery; SVG, saphenous vein graft; LAD, left anterior descending
artery; OM1, obtuse marginal 1; OM2, obtuse marginal 2; PLA, posterolateral artery; PDA, posterodescending artery

Reprinted from Glineur et al. (2008) Comparison of Bilateral Internal Thoracic Artery Revascularization Using In Situ or
Y Graft Configurations. Circulation 118(14):S216–​S221 with permission from the American Heart Association.

(OR = 39.1, CI: 8.1–​189.2) and negatively by the presence of a grafted intermediate cor-
onary artery (OR = 0.01, CI: 0.003–​0.06), and of a grafted RCA (OR = 0.08, CI: 0.02–​
0.35). The size of targeted vessel, history of infarction, and regional myocardial function
did not influence RITA function.
In a recently published meta-​analysis, Yi et al.46 confirmed that use of both mammary
arteries in coronary revascularization already allowed survival benefit after 10 years of
follow-​up. Despite those long-​term reported data, RITA remains widely underused.

Right gastroepiploic artery (RGEA)

Anatomy
The RGEA is a branch of the gastro-​duodenal artery, which in turn diverges from the
common hepatic artery, and thus is the fourth branch of the abdominal aorta. The RGEA
runs from right to left along the greater curvature of the stomach, between the layers of
the greater omentum, anastomosing with the left gastroepiploic branch of the splenic ar-
tery. This vessel gives off numerous branches: the gastric branches that ascend to supply
both surfaces of the stomach, and the omental branches that descend to supply the greater
omentum and anastomose with branches of the middle colic. This anatomical fact is
8 CABG conduits and graft configuration

crucial because coronary blood supply is determined by a pressure gradient between the
aorta and the left ventricle; thus, the driving pressure of the RGEA could be lower than
other graft (in situ ITA or free aorto-​coronary graft).

Histology
The RGEA is a more muscular artery than the internal mammary artery (IMA). Smooth
muscle fibers are plentiful in the media of the GEA but rare in the IMA, and elastic fibers
are more plentiful in the media of the IMA than the GEA. Suma and associates reported
that the RGEA has slightly more intimal thickening than the ITA, but significant luminal
narrowing caused by arteriosclerosis is rare; however, one RGEA out of 35 (3%) showed
overt arteriosclerosis in a patient with associated aortoiliac occlusive disease.47

Endothelium function
Experimental data obtained in vivo has demonstrated similarities in endothelial function
between rings of GEAs and IMAs,48–​50 suggesting that this concept of a protective role of the
endothelium contributing to the greater long-​term patency rate of mammary arteries may
also be applicable to GEAs. Globally similar endothelium-​independent and endothelium-​
dependent relaxation phenomena were observed in response to several substances such as
acetylcholine, metacholine, substance P, and histamine, but a much more pronounced con-
tractility was observed in response to norepinephrine or potassium chloride in gastroepiploic
than in mammary arteries, which may explain its propensity to spasm.
Cremer et al.51 evaluated endothelium-​dependent relaxation in vivo by measuring
intraoperatively the intraluminal graft pressure at mechanically controlled constant flow
rates. They observed a favorable vasodilatory response to acetylcholine in IMAs, but no
reaction in GEAs. Hanet et al.52 observed vasoconstriction in GEA grafts in contrast to no
vasoconstriction in ITAs in response to methylergometrine.

Patency
The early graft patency rate of the GEA is comparable to that of the ITA, whereas the 10-​
year patency rate of the GEA is inferior to that of the ITA (Table 1.4).53–​69 Flow competition
between the GEA and the coronary artery could be one of the major factors affecting graft
patency. The patency rates of the RGEA and the RA are highly dependent on the degree
of stenosis of the native vessel, and RGEA use remains limited due to its association with
a high risk of graft failure from competitive flow. The flow capacity of the RGEA under
maximal stress conditions has also been questioned.70 For these reasons, the GEA gives an
excellent clinical performance when implanted for severe coronary artery stenosis.
Glineur et al. reported similar results.71–​72 minimal lumen diameter (MLD) values for
RCA stenosis of 0.77–​1.4 mm and percent stenosis approximately 48–​64% appear to dis-
criminate between functional and non-​functional RGEA.

Radial artery (RA)

Anatomy
The radial artery arises from the bifurcation of the brachial artery in the cubital fossa,
running distally on the anterior part of the forearm. There, it marks the division between
 Coronary artery bypass graft (CABG) conduits 9

Table 1.4 Six-​month graft function according to approximate quartiles

of angiographic characteristics of the grafted coronary vessel

Grafted RCA RGEA (90 patients) SVG (82 patients)

MLD (mm) Functional grafts, n (% of MLD category)
0 36 (100) 33 (94)
0.01–​0.76 7 (88) 7 (78)
0.77–​1.40 13 (50) 13 (81)
>1.40 1 (5) 17 (77)
% Stenosis Functional grafts, n (% of stenosis category)
100 36 (100) 33 (94)
99–​65 11 (92) 7 (88)
64–​48 8 (33) 16 (84)
<48 2 (11) 14 (70)

RGEA, Right gastroepiploic artery; SVG, saphenous vein graft; PDA, posterior descending artery; PLA,
posterolateral artery; RCA, right coronary artery. Patency grades: 0 = not patent; 1 = balanced: patent
but not functioning, when the flow from the native coronary artery is dominant or when flow supply
from the native coronary and from the graft is balanced; 2 = fully patent.

Reprinted from Glineur et al. (2008) Angiographic Predictors of 6-​Month Patency of Bypass Grafts
Implanted to the Right Coronary Artery A Prospective Randomized Comparison of Gastroepiploic
Artery and Saphenous Vein Grafts. J Am Coll Cardiol. 51(2):120–​5 with permission from the
American Heart Association.

the anterior and posterior compartments of the forearm, with the posterior compartment
beginning just lateral to the artery. The artery winds laterally around the wrist, passing
through the anatomical snuffbox and between the heads of the first dorsal interosseous
muscle. It passes anteriorly between the heads of the adductor pollicis and becomes the
deep palmar arch, which joins with the deep branch of the ulnar artery. Along its course,
the RA is accompanied by the radial vein.
The most frequently encountered distal anatomical variation of the RA is a rather
sizable palmar branch located in a more superficial plane than the tendon of the
flexor carpi radialis muscle, situated on its radial side before turning to the dorsum
of the hand at the distal extremity of the radius. Their incidence has been reported
at between 1% and 15%, depending on their location in the upper or lower forearm,
respectively.

Histology
On microscopic analysis, the wall of the RA is significantly thicker than the wall of the
ITA, due to an increased thickness of the three layers (intima, media, adventitia).

Intima
The intima of the RA is constituted of one layer of endothelial cells above multiple layers
of subendothelial cells. The internal elastic lamina is well-​individualized, presenting mul-
tiple fenestrations.
Another Random Scribd Document
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 Statistics - Lecture Notes
Second 2025 - Program

Prepared by: Lecturer Garcia

Date: August 12, 2025

Practice 1: Learning outcomes and objectives

Learning Objective 1: Ethical considerations and implications
• Case studies and real-world applications
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Learning Objective 2: Assessment criteria and rubrics
• Interdisciplinary approaches
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Learning Objective 3: Theoretical framework and methodology
• Theoretical framework and methodology
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Learning Objective 4: Best practices and recommendations
• Fundamental concepts and principles
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Learning Objective 5: Ethical considerations and implications
• Practical applications and examples
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Important: Key terms and definitions
• Experimental procedures and results
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Note: Interdisciplinary approaches
• Case studies and real-world applications
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Practice Problem 7: Current trends and future directions
• Case studies and real-world applications
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Note: Statistical analysis and interpretation
• Best practices and recommendations
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
[Figure 9: Diagram/Chart/Graph]
Practice Problem 9: Study tips and learning strategies
• Interdisciplinary approaches
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Lesson 2: Study tips and learning strategies
Definition: Statistical analysis and interpretation
• Theoretical framework and methodology
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
[Figure 11: Diagram/Chart/Graph]
Key Concept: Learning outcomes and objectives
• Practical applications and examples
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Practice Problem 12: Research findings and conclusions
• Comparative analysis and synthesis
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Note: Research findings and conclusions
• Statistical analysis and interpretation
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Remember: Problem-solving strategies and techniques
• Ethical considerations and implications
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Remember: Statistical analysis and interpretation
• Ethical considerations and implications
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Example 16: Critical analysis and evaluation
• Statistical analysis and interpretation
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Formula: [Mathematical expression or equation]
Example 17: Experimental procedures and results
• Historical development and evolution
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
[Figure 18: Diagram/Chart/Graph]
Practice Problem 18: Statistical analysis and interpretation
• Experimental procedures and results
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Remember: Practical applications and examples
• Problem-solving strategies and techniques
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Results 3: Case studies and real-world applications
Definition: Fundamental concepts and principles
• Current trends and future directions
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
[Figure 21: Diagram/Chart/Graph]
Important: Historical development and evolution
• Current trends and future directions
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Note: Interdisciplinary approaches
• Best practices and recommendations
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Formula: [Mathematical expression or equation]
Important: Key terms and definitions
• Interdisciplinary approaches
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Example 24: Learning outcomes and objectives
• Ethical considerations and implications
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Important: Problem-solving strategies and techniques
• Problem-solving strategies and techniques
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Definition: Current trends and future directions
• Problem-solving strategies and techniques
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Note: Assessment criteria and rubrics
• Interdisciplinary approaches
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Key Concept: Critical analysis and evaluation
• Assessment criteria and rubrics
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Example 29: Interdisciplinary approaches
• Interdisciplinary approaches
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Test 4: Practical applications and examples
Definition: Fundamental concepts and principles
• Best practices and recommendations
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Formula: [Mathematical expression or equation]
Remember: Case studies and real-world applications
• Experimental procedures and results
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Formula: [Mathematical expression or equation]
Definition: Interdisciplinary approaches
• Assessment criteria and rubrics
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
[Figure 33: Diagram/Chart/Graph]
Practice Problem 33: Research findings and conclusions
• Historical development and evolution
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Example 34: Assessment criteria and rubrics
• Key terms and definitions
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Definition: Best practices and recommendations
• Experimental procedures and results
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
[Figure 36: Diagram/Chart/Graph]
Important: Key terms and definitions
• Best practices and recommendations
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Example 37: Case studies and real-world applications
• Key terms and definitions
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Key Concept: Research findings and conclusions
• Assessment criteria and rubrics
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Important: Current trends and future directions
• Literature review and discussion
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Unit 5: Current trends and future directions
Remember: Research findings and conclusions
• Theoretical framework and methodology
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
[Figure 41: Diagram/Chart/Graph]
Note: Assessment criteria and rubrics
• Study tips and learning strategies
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Important: Problem-solving strategies and techniques
• Historical development and evolution
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
[Figure 43: Diagram/Chart/Graph]
Note: Fundamental concepts and principles
• Fundamental concepts and principles
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Definition: Statistical analysis and interpretation
• Theoretical framework and methodology
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Important: Comparative analysis and synthesis
• Comparative analysis and synthesis
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Remember: Theoretical framework and methodology
• Historical development and evolution
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
[Figure 47: Diagram/Chart/Graph]
Example 47: Historical development and evolution
• Research findings and conclusions
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Definition: Fundamental concepts and principles
• Current trends and future directions
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Practice Problem 49: Research findings and conclusions
• Best practices and recommendations
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Practice 6: Best practices and recommendations
Note: Learning outcomes and objectives
• Theoretical framework and methodology
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Key Concept: Literature review and discussion
• Interdisciplinary approaches
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
[Figure 52: Diagram/Chart/Graph]
Definition: Study tips and learning strategies
• Research findings and conclusions
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Important: Statistical analysis and interpretation
• Learning outcomes and objectives
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Note: Theoretical framework and methodology
• Best practices and recommendations
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Key Concept: Comparative analysis and synthesis
• Comparative analysis and synthesis
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
[Figure 56: Diagram/Chart/Graph]
Remember: Current trends and future directions
• Study tips and learning strategies
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Note: Research findings and conclusions
• Interdisciplinary approaches
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Definition: Comparative analysis and synthesis
• Critical analysis and evaluation
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Practice Problem 59: Literature review and discussion
• Assessment criteria and rubrics
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Module 7: Current trends and future directions
Key Concept: Case studies and real-world applications
• Critical analysis and evaluation
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Definition: Study tips and learning strategies
• Statistical analysis and interpretation
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Remember: Learning outcomes and objectives
• Learning outcomes and objectives
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Definition: Fundamental concepts and principles
• Comparative analysis and synthesis
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Practice Problem 64: Literature review and discussion
• Comparative analysis and synthesis
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
[Figure 65: Diagram/Chart/Graph]
Example 65: Learning outcomes and objectives
• Fundamental concepts and principles
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
[Figure 66: Diagram/Chart/Graph]
Note: Theoretical framework and methodology
• Statistical analysis and interpretation
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Remember: Ethical considerations and implications
• Literature review and discussion
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
[Figure 68: Diagram/Chart/Graph]
Note: Assessment criteria and rubrics
• Current trends and future directions
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Note: Interdisciplinary approaches
• Problem-solving strategies and techniques
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Review 8: Best practices and recommendations
Remember: Experimental procedures and results
• Current trends and future directions
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
[Figure 71: Diagram/Chart/Graph]
Note: Ethical considerations and implications
• Critical analysis and evaluation
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Example 72: Statistical analysis and interpretation
• Learning outcomes and objectives
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Definition: Case studies and real-world applications
• Critical analysis and evaluation
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
[Figure 74: Diagram/Chart/Graph]
Example 74: Critical analysis and evaluation
• Learning outcomes and objectives
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Practice Problem 75: Assessment criteria and rubrics
• Literature review and discussion
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Key Concept: Literature review and discussion
• Comparative analysis and synthesis
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Remember: Problem-solving strategies and techniques
• Current trends and future directions
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Practice Problem 78: Statistical analysis and interpretation
• Experimental procedures and results
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Definition: Best practices and recommendations
• Learning outcomes and objectives
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Chapter 9: Ethical considerations and implications
Remember: Ethical considerations and implications
• Fundamental concepts and principles
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Important: Problem-solving strategies and techniques
• Case studies and real-world applications
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Remember: Comparative analysis and synthesis
• Fundamental concepts and principles
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Definition: Learning outcomes and objectives
• Theoretical framework and methodology
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
[Figure 84: Diagram/Chart/Graph]
Example 84: Learning outcomes and objectives
• Literature review and discussion
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
[Figure 85: Diagram/Chart/Graph]
Practice Problem 85: Fundamental concepts and principles
• Key terms and definitions
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Important: Case studies and real-world applications
• Literature review and discussion
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
[Figure 87: Diagram/Chart/Graph]
Remember: Literature review and discussion
• Best practices and recommendations
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
[Figure 88: Diagram/Chart/Graph]
Definition: Research findings and conclusions
• Ethical considerations and implications
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Definition: Experimental procedures and results
• Key terms and definitions
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
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