Robotically enhanced coronary artery bypass surgery

Robotically enhanced telemanipulation surgery is a rapidly developing technique which enables totally endoscopic cardiac surgery with utmost precision and perfection on both beating heart and arrested heart. Between December 2002 and September 2006, 268 patients underwent robotically enhanced coronary artery bypass surgery using the da Vinci telemanipulation system. Fourteen patients underwent total endoscopic coronary artery bypass surgery. Of these 12 were performed on a beating heart and 2 on an arrested heart. Two-hundred and fifty-four patients had endoscopic takedown of the internal mammary artery followed by minimally invasive direct coronary artery bypass in 193 patients and left anterolateral thoracotomy in 61 patients. The internal mammary artery mobilization time was 36 min (28–76 min) and the left internal mammary artery to left anterior descending artery anastomosis time ranged from 20 to 36 min for the totally endoscopic coronary artery bypass patients. The right internal mammary artery of one patient was anastomosed to diagonal artery totally endoscopically. The mean internal mammary artery flow by Doppler measurement in patients undergoing minimally invasive direct coronary artery bypass was 58 ml min⁻¹. Seven patients required conversion to median sternotomy and coronary bypass surgery on the beating heart. The mean intensive care unit stay was 1.2 days and the mean hospital stay 4.5 days. There was one in-hospital mortality. All 14 patients who underwent total endoscopic bypass surgery had coronary angiography 3 months later which showed 100% patency in 13 patients. One patient had 50% anastomotic narrowing for which coronary angioplasty was performed in the same sitting. By using telematic technology, a complete endoscopic anastomosis is possible in both single vessels and suitable double vessel disease patients. The use of robotics is now extended to achieve complete myocardial revascularization by harvesting both the internal mammary arteries and making a small thoracotomy for direct anastomosis also.     

Risk-adjusted analysis of long-term outcomes after on- versus off-pump coronary artery bypass grafting

 Open in a separate windowOBJECTIVESRecent data suggested that off-pump coronary artery bypass (OPCAB) may carry a higher risk for mortality in the long term when compared to on-pump coronary artery bypass (ONCAB). We, therefore, compared long-term survival and morbidity in patients undergoing ONCAB versus OPCAB in a large single-centre cohort.METHODSA total of 8981 patients undergoing isolated elective/urgent coronary artery bypass grafting between January 2009 and December 2019 were analysed. Patients were stratified into 2 groups (OPCAB n = 6649/ONCAB n = 2332). The primary end point was all-cause mortality. Secondary endpoints included repeat revascularization, stroke and myocardial infarction. To adjust for potential selection bias, 1:1 nearest neighbour propensity score (PS) matching was performed resulting in 1857 matched pairs. Moreover, sensitivity analysis was applied in the entire study cohort using multivariable- and PS-adjusted Cox regression analysis.RESULTSIn the PS-matched cohort, 10-year mortality was similar between study groups [OPCAB 36.4% vs ONCAB 35.8%: hazard ratio (HR) 0.99, 95% confidence interval (CI) 0.87–1.12; P = 0.84]. While 10-year outcomes of secondary endpoints did not differ significantly, risk of stroke (OPCAB 1.50% vs ONCAB 2.8%: HR 0.51, 95% CI 0.32–0.83; P = 0.006) and mortality (OPCAB 3.1% vs ONCAB 4.8%: HR 0.65, 95% CI 0.47–0.91; P = 0.011) at 1 year was lower in the OPCAB group. In the multivariable- and the PS-adjusted model, mortality at 10 years was not significantly different (OPCAB 34.1% vs ONCAB 35.7%: HR 0.97, 95% CI 0.87–1.08; P = 0.59 and HR 1.01, 95% CI 0.90–1.13; P = 0.91, respectively).CONCLUSIONSData do not provide evidence that elective/urgent OPCAB is associated with significantly higher risks of mortality, repeat revascularization, or myocardial infarction during late follow-up when compared to ONCAB. Patients undergoing OPCAB may benefit from reduced risks of stroke and mortality within the first year postoperatively.     

冠状动脉硬化性心脏病合并左锁骨下动脉严重狭窄非体外循环下同期手术的临床经验

目的探讨非体外循环冠状动脉旁路移植同时主动脉-锁骨下动脉旁路治疗冠状动脉硬化性心脏病(冠心病)合并锁骨下动脉重度狭窄的手术方法及效果.方法2003年1月～2004年5月,我院治疗须行冠状动脉旁路移植术同时合并左锁骨下动脉近端重度狭窄3例,术中先行主动脉-锁骨下动脉旁路,左乳内动脉获得满意的流量后,再行非体外循环冠状动脉旁路移植.结果手术时间210～340 min,平均283 min,出血量570～1 630 ml,平均963 ml.游离左乳内动脉后量杯测流量均＜5 ml/min,主动脉-锁骨下动脉旁路后量杯测流量均＞50 ml/min,乳内动脉远端与前降支吻合后流量仪测流量12～27 ml/min,平均20 ml/min.术后临床症状缓解,未发现冠脉-锁骨下动脉窃血综合征.3例随访3～6个月,平均5个月,无心绞痛发作.结论非体外循环冠状动脉旁路移植同时主动脉-锁骨下动脉旁路手术是治疗冠心病合并锁骨下动脉重度狭窄简单而有效的方法.     

Early and midterm outcome after off-pump coronary artery bypass grafting in patients with poor left ventricular function compared with patients with normal function

OBJECTIVE: As there are few reports on the clinical results of off-pump coronary artery bypass (OPCAB) in patients with poor left ventricular (LV) function, the safety and efficacy of OPCAB surgery in such patients remains unclear. METHODS: From January 2002 to May 2007, a total of 519 consecutive patients underwent isolated myocardial revascularization via OPCAB. We compared the early and midterm results of 79 patients with poor LV function [ejection fraction (EF) < 40%] with those of 319 patients with normal LV function (EF >or= 50%). Follow-up was completed in 96.2% of the patients. RESULTS: There were no significant intergroup differences in the number of grafts per patient or the rate of achievement of complete revascularization. No patient in either group was converted from off-pump to on-pump. The overall 30-day mortality was 1.0%. The mean follow-up was 3.0 +/- 1.3 years. Five-year freedom from death from all causes was 57.7% in the low-EF group and 83.6% in the normal-EF group. The rates of freedom from cardiac death were 73.2% and 93.7%, respectively; and the rates of freedom from the combined endpoint of cardiac death, myocardial infarction, repeat coronary intervention, and heart failure requiring treatment were 65.7% and 77.3%, respectively. CONCLUSION: OPCAB surgery in patients with poor LV function can be performed safely with the same quality in terms of the number of grafts and rate of complete revascularization as in patients with normal LV function. There are higher mortality and cardiac event rates in patients with poor LV function than those with normal LV function at the midterm evaluation after OPCAB.     

Early angiographic control of perioperative ischemia after coronary artery bypass grafting

Objective: To assess the impact of immediate angiography in patients with defined clinical and laboratory criteria of perioperative myocardial infarction after coronary artery bypass operation. Patients and methods: Between January 1999 and December 1999 2052 patients underwent coronary artery bypass grafting in our institution. Out of this cohort 131 (6.4%) patients met the criteria of perioperative myocardial ischemia, which was defined as: (a) increase in the isoenzyme ratio of creatinine phosphokinase (CK/CK-MB] above 10%; (b) ischemic electrocardiographic episodes (defined as a new onset of elevated ST-segment change lasting at least 1 min and involving a shift from baseline of greater than or equal to 0.1 mV of ST-depression and a new association of a postoperative Q; (c) recurrent episodes of, or sustained ventricular tachyarrhythmia as well as ventricular fibrillation; (d) hemodynamic deterioration despite adequate inotropic support. Results: Angiography was performed in 108 patients (5.3%, group A) whereas 23 patients (1.1%, group B) were immediately re-operated due to severely compromised hemodynamics. Angiographic results in group A showed regular grafts in 45 patients (2.2%); 63 patients (3.1%) had either an occlusion (n=41), incorrect anastomosis (n=29), graft stenosis (n=14), graft spasm (n=6), displaced graft (n=6), poor distal run-off (n=5) or incomplete revascularization (n=2). In group A 43 patients underwent a re-operation (34 patients) or an early angioplasty (nine patients). Due to poor coronary artery status no intervention was performed in the remaining 20 patients with angiographic findings. Operative findings in group B showed graft occlusion in ten patients (43.5%), incorrect anastomosis in five patients (21.7%), bleeding, stretched graft, venous graft spasm and displaced graft in one patient (4.3%) each, and no patho-morphological finding in 4 patients (17.4%). Thirty-day mortality rate was ten patients in group A (9.3%), all of them with angiographic findings, as opposed to nine patients (39.1%) in group B. Conclusion: ST-change and elevated CK/CK-MB enzyme ratio is highly indicative for possible graft failure and should be followed early angiographic control to assess the need for reintervention.     

Coronary artery and graft spasm after off-pump coronary artery bypass grafting

We report a case of a 52-year-old man with severe coronary artery and graft spasm after triple-vessel off-pump coronary artery bypass grafting. Emergent coronary angiography was performed to identify the location and severity of the spasm. Intracoronary injections of several vasodilators failed to relieve the spasm. Observational treatments including intra-aortic balloon pump and inotropic drugs to increase coronary flow were performed until the spasm resolved. The patient recovered and was discharged. A follow-up coronary angiography revealed patent native coronary artery and bypass grafts without evidence of residual spasm.     

Pulmonary oxygen transfer deficits of diabetic origin in patients undergoing coronary artery bypass grafting

The objective of this study was to determine the effects of a diabetic disposition on pulmonary gas exchange by examining 72 patients who underwent coronary artery bypass grafting (CABG), using the arterial/alveolar oxygen tension ratio [(a/a)Po ₂] as a criterion. Patients were divided into a diabetic (DM) group and a nondiabetic (non-DM) group. The postoperative blood gases and hemodynamic data measured when the blood glucose level was at a maximum on the day of CABG were used as the postoperative pulmonary gas exchange indices, and the physicians who managed these patients were unaware of this study. The preoperative (a/a)Po ₂ ratio was 0.66±0.03 (SE) in the DM group and 0.78±0.02 in the non-DM group (P<0.01), while the postoperative ratios were 0.42±0.03 and 0.52±0.03, respectively (P=0.01). The correlation coefficient (r) for regression analysis of the relation between the postoperative Pao ₂/Fio ₂ ratio and the postoperative (a/a)Po ₂ ratio was 0.99 in the DM group (P<0.01) and 0.88 in the non-DM group (P<0.01). The r values of the relation between (a/a)Po ₂ and (a-a)Po ₂ were –0.68 (P<0.00) and –0.84 (P<0.01), while those for the respiratory index were –0.87 (P<0.01), and –0.93 (P<0.01), respectively. Thus, pulmonary oxygen transfer was compromised before and after CABG in the DM group compared to the non-DM group. Moreover, the Pao ₂/Fio ₂, being the simplest pulmonary gas exchange index to calculate, was a reliable substitute for the (a/a)Po ₂ ratio during the early postoperative management of CABG patients.     

1110例冠状动脉搭桥术的早期结果

目的　回顾性总结１９９６ 年１ 月以来１１１０ 例冠状动脉搭桥术（ＣＡＢＧ） 的近期疗效,介绍冠心病搭桥术的体会和经验。　方法　体外循环下行ＣＡＢＧ１０４８ 例,非体外循环ＣＡＢＧ６０ 例。心肌保护均采用冷血含钾停跳液,体外循环时间１１５ ±３５ 分钟,主动脉阻断时间７２ ±２４ 分钟,单支搭桥１１０ 例,２ 支搭桥１４５ 例,３ 支搭桥４１５ 例（３７－３ ％） ,４ 支搭桥或４ 支以上４３９ 例（３９－５％） 。搭桥材料：左乳内动脉７５１ 例,大隐静脉８７７ 例,桡动脉１０１ 例,全动脉化７２ 例。合并手术：室壁瘤切除１１２ 例,室壁瘤折叠１４ 例,左室成形５ 例,瓣膜手术４８ 例,室间隔穿孔修补术５ 例。　结果　住院死亡９ 例,死亡率０－８１％ 。其余患者痊愈出院,心绞痛基本缓解。术后并发症：低心排１１ 例,主动脉球囊反搏７例,围术期心肌梗塞２ 例,脑部并发症３ 例,二次开胸止血４ 例。　结论　选择好靶血管和充分血管化是冠状动脉搭桥术的关键。另外要重视围术期处理。     

Massive coronary spasm of the native coronary system after coronary artery bypass grafting: Two patients with different outcomes

We report the cases of two patients who developed a massive spasm of the native coronary system in the immediate postoperative period, following a coronary artery bypass grafting operation with different outcomes. The first patient was hemodynamic stable and it was manifested as ischemic electrocardiographic changes in different leads (ST elevation or depression). He was treated with intracoronary and intravenous administration of nitroglycerin and calcium channel blocker and had a favorable outcome. The second patient died due to multiorgan failure and hemorrhagic shock, after the implantation of a central venoarterial extracorporeal membrane oxygenation.     

Early and late outcome after coronary artery bypass surgery in diabetic patients

OBJECTIVE: To determine the impact of diabetes on outcome after coronary artery bypass surgery. DESIGN: We matched 866 diabetic patients with non-diabetic controls in regards to gender, age, left ventricular ejection fraction, body mass index, presence of unstable angina and history of myocardial infarction, and day of surgery. The 30-d mortality and morbidity were evaluated with univariate analysis and survival and freedom from cardiac death were assessed with the Kaplan-Meier method. RESULTS: Follow-up time was 69+/-37 months. The 30-d mortality was 2.0% in the diabetic group and 1.0% in the non-diabetic group (p=0.15). Postoperative morbidity did not differ between groups. Cumulative 5- and 10-year survival rates were 89 and 71% in diabetics and 94 and 84% in non-diabetics (p=0.001). During follow-up, there was no difference between groups in regards to repeat revascularization. CONCLUSIONS: The 30-d mortality was equally low in diabetic and non-diabetic patients with severe coronary artery disease. However, long-term survival was significantly lower in the diabetic group than in the non-diabetic group.     

Impact of gender on 10-year outcome after coronary artery bypass grafting

Open in a separate window OBJECTIVESOur goal was to evaluate the impact of gender on the 10-year outcome of patients after isolated coronary artery bypass grafting (CABG) included in the Italian nationwide PRedictIng long-term Outcomes afteR Isolated coronary arTery bypass surgery (PRIORITY) study.METHODSThe PRIORITY project was designed to evaluate the long-term outcomes of patients who underwent CABG and were included in 2 prospective multicentre cohort studies. The primary end point of this analysis was major adverse cardiac and cerebrovascular events. Baseline differences between the study groups were balanced with propensity score matching and inverse probability of treatment. Time to events was analysed using Cox regression and competing risk analysis.RESULTSThe study population comprised 10 989 patients who underwent isolated CABG (women 19.6%). Propensity score matching produced 1898 well-balanced pairs. The hazard of major adverse cardiac and cerebrovascular event was higher in women compared to men [adjusted hazard ratio (HR) 1.13, 95% confidence interval (CI) 1.03–1.23; P = 0.009]. The incidence of major adverse cardiac and cerebrovascular event in women was significantly higher at 1 year (HR 1.31, 95% CI 1.11–1.55; P < 0.001) and after 1 year (HR 1.11, 95% CI 1.00–1.24; P = 0.05). Mortality at 10 years in the matched groups was comparable (HR 1.04, 95% CI 0.93–1.16; P = 0.531). Women have significantly a higher 10-year risk of myocardial infarction (adjusted HR 1.40, 95% CI 1.17–1.68; P = 0.002) and percutaneous coronary intervention (adjusted HR 1.32, 95% CI 1.10–1.59; P = 0.003).CONCLUSIONSThe present study documented an excess of non-fatal cardiac events after CABG among women despite comparable 10-year survival with men. These findings suggest that studies investigating measures of tertiary prevention are needed to decrease the risk of adverse cardiovascular events among women.     

左心室功能明显减退患者的冠状动脉旁路术

目的 探讨左心室功能明显减退患者的冠状动脉旁路移植术(CABG)的外科治疗效果。方法 回顾分析2000年12月至2002年12月对心肌梗死或长期慢性心肌缺血造成心室功能明显减退的45例冠心病患者进行CABG的相关资料。结果 42例联合应用左乳内动脉与前降支吻合。人均旁路移植3.3(1～5)支,无手术死亡。术后随访2～23个月,LVEF21.3％～65％,平均(42.7±5.9)％,与术前相比提高9％～24％(P<0.05);LVEDD55.2～64.6 mm,平均(54.7±3.8)mm。与术前相比,无明显变化(P>0.05);心绞痛完全消失39例,活动耐力增加。随访期间死亡2例。结论 左心室功能明显减退的冠心病患者,CABG手术成功率和近期效果满意,生活质量明显提高。术前合理选择病例、术中充分的再血管化和良好的围手术期处理是手术成功的关键。     

Endogenous stem cells in patients undergoing coronary artery bypass graft surgery

Considerable research efforts have recently been made towards the application of autologous stem cell therapy for cardiovascular regeneration. Patients with coronary artery disease undergoing surgery represent a potential target. As yet, this approach has failed to obtain satisfactory evidence in clinical studies. However, several observational studies have described mobilising effect of cardiac surgery on endogenous stem cells, although the mechanisms of this phenomenon and its clinical relevance are not defined. This article reviews available clinical data on the effect of cardiac surgery on endogenous stem cells and outlines some of the controversies in this area.     

非体外循环冠状动脉旁路移植术后低氧血症相关因素分析

目的分析非体外循环冠状动脉旁路移植术(Offpump coron aryartery bypass grafting,OPCABG)后低氧血症的影响因素。方法回顾性分析135例患者OPCABG术后并发低氧血症44例,对患者的年龄、性别、吸烟史、体质量、高血压、糖尿病、冠脉病变、术前心功能与低氧血症进行相关性分析。结果 CABG患者高龄、肥胖、长期大量吸烟及术前心功能底下与低氧血症有显著相关;性别、糖尿病、高血压、冠脉病变支数与CABG术后低氧血症发生率无明显相关性。结论 OPCAB术后低氧血症与多种因素有关,预防措施包括术前、术中、术后的各个阶段。     

Coronary artery spasm after off-pump coronary artery bypass grafting

BACKGROUND: Coronary artery spasm (CAS) in the immediate postoperative period has been recognized as a possible cause for perioperative myocardial ischaemia after off-pump coronary artery bypass grafting (CABG). It varies in severity and can be associated with circulatory collapse and death. The purpose of this study was to present our experiences on CAS after off-pump CABG and detail its management. METHODS: The case reports of three patients with similar clinical presentations of ischaemic heart disease who underwent CABG using an off-pump technique are reviewed. Severe manifestations of CAS in the immediate postoperative period with documented angiographic findings are presented. RESULTS: Three patients (two men and one woman) with angina pectoris were diagnosed with coronary artery disease using coronary angiography. The elective off-pump CABG was uneventful; however, severe manifestation of myocardial ischaemia with abrupt onset developed at the intensive care unit. All three patients underwent immediate coronary angiography to verify the diagnosis of CAS. Apart from intracoronary nitroglycerine infusion and medical support with inotropic agents, extracorporeal membranous oxygenation was carried out because of severe haemodynamic deterioration in one case, while support was required with intraaortic balloon pumping in another. All three patients made a full recovery. CONCLUSION: Coronary artery spasm can severely complicate the postoperative course for patients undergoing off-pump CABG, leading to myocardial ischaemia or infarction, life-threatening arrhythmias, persistent hypotension and even cardiac arrest. Early awareness and diagnosis of CAS with the establishment of appropriate management strategies may prevent its potentially lethal consequences.     

The clinical outcome of off-pump coronary artery bypass surgery in the elderly patients

Objective: There has been a body of evidence showing that off-pump coronary artery bypass (OPCAB) may reduce morbidity and mortality in the elderly patients. We reviewed our experience, retrospectively, on elderly patients aged 75 years and older who were operated on using the OPCAB technique. We compared their outcome to a similar group of elderly patients who were operated on using conventional coronary artery bypass grafting (CABG) with cardiopulmonary bypass (CPB) during the same period of time. Methods: Registry data and patients' notes and charts were reviewed for 56 consecutive elderly OPCAB patients (age 78.5±3.5 years) and 87 consecutive CPB patients (age 77.2±2.4 years, P=0.01). Both groups had similar risk factor profiles: Parsonnet score 17.4±4.4 (OPCAB) versus 16.6±5.2 (CPB), P=0.19. We studied in detail their preoperative and postoperative data in order to compare the outcomes of both techniques. Results: The length of stay in the intensive therapy unit (ITU) was 35.4±52.9 h for OPCAB patients and 77.6±144.9 h for CPB patients (P=0.0008). No patient died within 30 days in the OPCAB group, whilst ten (11%) CPB patients (P=0.0066) died within 30 days. The incidence of serious complications (including pulmonary oedema, septicaemia, permanent stroke and renal dysfunction requiring haemofiltration or haemodialysis) was one (2%) in the OPCAB group and 11 (13%) in the CPB group (P=0.028). CPB patients required a significantly higher number ten (12%) of intra-aortic balloon pumps (IABP) inserted compared to only one patient (2%) in the OPCAB group who required IABP insertion (P=0.05). Nine (11%) CPB patients were re-operated on for bleeding compared to no OPCAB patient (0%) needing re-operation, P=0.011. Conclusions: Although the mean age of the OPCAB group was significantly higher than the CPB group, the OPCAB group showed a significant reduction in postoperative serious morbidity, ITU stay and mortality. We believe that such a conclusion may have some effect on the decision-making and cost-effectiveness when performing coronary bypass surgery on the elderly population.     

Early and long-term results of coronary artery bypass grafting in dialysis patients

OBJECTIVE: We evaluated the surgical outcome of coronary artery bypass grafting in dialysis patients. METHODS: We retrospectively analyzed 25 consecutive dialysis patients requiring isolated coronary artery bypass grafting. Their mean age was 61.6 years and average dialysis duration 80.4 months. RESULTS: Eight patients (32%) had emergency or urgent surgery. The mean number of bypassed vessels was 3.3 +/- 1.2. Internal thoracic artery grafts were used in 19 patients and gastroepiploic artery grafts in 5. Two (8%) died during hospitalization and complications occurred in 11 (44%). No cerebral complications were observed. All survivors showed ameliorated symptoms and improved overall function. Of 14 late deaths, 5 were cardiac-related, with 2 involving obvious myocardial ischemic events. Actuarial survival, including hospital deaths, at 1 year was 70.9%, at 3 years was 43.5%, and at 5 years was 34.8%. Cardiac-death-free survival was 70.2% at 3 years and 70.2% at 5 years. CONCLUSION: Coronary artery bypass grafting in dialysis patients is associated with a higher incidence of complications but has acceptable surgical mortality and effectively relieves angina symptoms.     

Breast reduction surgery after coronary artery bypass grafting

Breast reduction surgery is a frequently performed procedure. Older patients presenting for this surgery may have previously undergone coronary artery bypass grafting with harvesting of one or both internal mammary arteries. This may compromise the blood supply to the breast. Limiting medial dissection during breast reduction surgery in these women is prudent to prevent breast necrosis. A case illustrating this is described.     

Mortality and morbidity among patients who undergo combined valve and coronary artery bypass surgery: Early and late results

Aim: To describe mortality and morbidity early and late after combined valve surgery and coronary artery bypass grafting (CABG) as compared with CABG alone. Patients and methods: All patients from western Sweden in whom CABG in combination with valve surgery or CABG alone was carried out in 1988–1991. Results: Among 2116 patients who underwent CABG, 35 (2%) had this combined with mitral valve surgery and 134 (6%) had this combined with aortic valve surgery, whereas the remaining 92% underwent CABG alone. Patients who underwent combined valve surgery and CABG were older, included more women and had a higher prevalence of previous congestive heart failure and renal dysfunction but on the other hand a less severe coronary artery disease. Among patients who underwent mitral valve surgery in combination with CABG the mortality over the subsequent 5 years was 45%. The corresponding figure for patients who underwent aortic valve surgery in combination with CABG was 24%. Both were higher than for CABG alone (14%; P<0.0001 and P=0.003, respectively). In a stepwise multiple regression model mitral valve surgery in combination with CABG was found to be an independent significant predictor for death but aortic valve surgery in combination with CABG was not. Among patients who underwent mitral valve surgery in combination with CABG and were discharged alive from hospital 77% were rehospitalized during the 2 years following the operation as compared with 48% among patients who underwent aortic valve surgery in combination with CABG and 43% among patients with CABG alone. Multiple regression identified mitral valve surgery in combination with CABG as a significant independent predictor for rehospitalization but not aortic valve plus CABG. Conclusion: Among patients who either underwent CABG in combination with mitral valve surgery or aortic valve surgery or CABG alone, mitral valve surgery in combination with CABG was independently associated with death and rehospitalization, but the combination of aortic valve surgery and CABG was not.