This study reviewed 15 years of experience with emergency coronary artery bypass grafting (CABG) after unsuccessful percutaneous transluminal coronary angioplasty (PTCA) at a hospital in Australia. The study found that of over 4,000 PTCA procedures performed during that period, 74 patients (1.8%) required emergency CABG within 24 hours of PTCA failure. Compared to a matched group of 74 elective CABG patients, the emergency CABG patients had a higher rate of acute myocardial infarction (AMI) after the procedure (8.1% vs 2.7%) but similar low mortality rates (2 deaths vs none). With prompt and complete revascularization, outcomes for emergency CABG patients were not significantly

1. Emergency Surgery After Unsuccessful Coronary
Angioplasty: A Review of 15 Years’ Experience
Michael S. Barakate, FRACS, Paul G. Bannon, PhD, Clifford F. Hughes, AO, FRACS,
Matthew D. Horton, FRACS, Ann Callaway, MMgt, and Tara Hurst, MAStat
Cardiothoracic Surgical Unit, Royal Prince Alfred Hospital, Baird Institute for Heart and Lung Surgical Research, University of
Sydney, Sydney, Australia
Background. Emergency coronary artery bypass graft-
ing (CABG) is occasionally necessary for failed percuta-
neous transluminal coronary angioplasty (PTCA). The
aim of this study was to assess the outcome of patients
receiving emergency CABG after unsuccessful PTCA
over a 15-year study period.
Methods. From January 1982 through December 1996,
74 patients underwent emergency CABG after unsuccess-
ful PTCA (crash group). This group was compared with a
matched group of 74 patients having primary elective
CABG (control group).
Results. All 74 crash group patients were to have PTCA
of one coronary system. After PTCA failure, 58 patients
(78.3%) developed electrocardiographic changes of evolv-
ing acute myocardial infarction (AMI). The overall rate of
AMI was 8.1% for the crash group and 2.7% for the
control group. Two patients in the crash group died, with
no deaths in the control group. There was no significant
difference between mean in-hospital length of stay.
Conclusions. With prompt, aggressive, and complete
myocardial revascularization, patients who required
emergency CABG after PTCA failure had an outcome not
significantly different from that of patients having elec-
tive CABG.
(Ann Thorac Surg 2003;75:1400–5)
© 2003 by The Society of Thoracic Surgeons
mergency coronary artery bypass grafting (CABG) is
E occasionally necessary for failed percutaneous
transluminal coronary angioplasty (PTCA). Emergency
CABG after PTCA failure has a reported acute myocar-
dial infarction (AMI) rate of 8.9% to 51% and a mortality
rate of 3.8% to 14% [1–5]. In comparison, elective coro-
nary artery surgery is a relatively low risk procedure with
a reported mortality rate of 1.3% and an AMI rate of 5.4%
[6]. This study reports 15 years of experience in emer-
gency coronary bypass after angioplasty failure at the
Royal Prince Alfred Hospital (RPAH), from January 1982
through December 1996 by retrospective review. The aim
of this study was to assess the outcome of patients
receiving emergency CABG after unsuccessful PTCA. We
compared these outcomes with patients having primary
elective CABG.
Material and Methods
Over the 15-year study period 4,146 PTCA procedures
were performed at RPAH, and of these, 74 patients (1.8%)
required emergency CABG within 24 hours of PTCA
failure (crash group). Angiographic findings of PTCA
failure included acute arterial dissection and coronary
artery closure that could not be redilated. Clinical find-
ings associated with PTCA failure included persistent
chest pain, electrocardiograph (ECG) changes of evolving
myocardial infarction, persistent hypotension, unstable
arrhythmias, or cardiac arrest. Specific cardiac catheter-
ization data examined for the crash group included
degree of coronary artery disease (significant stenosis
was defined as greater than 50% reduction in luminal
diameter or estimated 75% reduction in cross-sectional
area), the cause of angioplasty failure, the culprit vessel,
and whether a reperfusion catheter was inserted in the
catheterization laboratory. Reperfusion catheters were
available from 1989 onward. The decision to use a reper-
fusion catheter was made by the cardiologist before
involvement of the cardiothoracic surgical unit.
This paper reports all the patients for whom the
surgeons were called. Patients who required salvage
techniques in the catheterization laboratory were not the
focus of this paper. Coronary artery stenting was intro-
duced at our institution in 1994. Stenting did not make a
major impact until 1995 with the introduction of second-
generation stents. GpIIbIIIa inhibitors were not available
at our institution until 1998, well after this study was
completed. The fact that there were only approximately 5
patients each year who required emergency CABG after
PTCA failure represents the skill of our cardiologists and
not the use of salvage techniques.
During the study period 11,909 patients underwent
primary elective CABG and had been entered in a
prospective database. From this database a matched
group of 74 patients (control group) was selected by
computer search. Further patient data were obtained
from the hospital’s cardiology reporting system, the car-
diothoracic unit’s clinical reporting system, medical
Accepted for publication Dec 12, 2002.
Address reprint requests to Dr Hughes, Cardiothoracic Surgical Unit,
Level 8, Page Chest Pavilion, Royal Prince Alfred Hospital, Missenden Rd,
Camperdown, NSW 2050, Australia; e-mail: clifford.hughes@
email.cs.nsw.gov.au.
© 2003 by The Society of Thoracic Surgeons
Published by Elsevier Science Inc
0003-4975/03/$30.00
PII S0003-4975(02)05026-9
CARDIOVASCULAR

2. records, and the surgeons’ records. Control group data
were matched to the crash group data for the year of
operation, the number of coronary systems diseased, and
number of bypass grafts performed. We then checked
that there were no statistically significant differences in
preoperative risk factors. Preoperative risk factors as-
sessed for the two study groups included left ventricular
ejection fraction, coexisting valvular heart disease, diabe-
tes mellitus, obesity, previous stroke, preexisting chronic
renal impairment, chronic obstructive pulmonary dis-
ease, peripheral vascular disease, and family history of
ischemic heart disease. Patients who had previous CABG
were excluded from both groups. Preoperative compari-
son is shown in Table 1.
Statistics
Comparison between the crash and control groups was
performed using the SPSS statistical software package
(SPSS Inc, Chicago, IL). Fisher’s exact tests were calcu-
lated for two-by-two tables. Mann-Whitney U tests were
calculated for continuous data, as appropriate.
Results
Emergency surgery was necessary in 74 patients having
PTCA (1.8%). The PTCA failure rate leading to emer-
gency CABG was 4.2% over the first half of the study
(January 1982 to June 1989) and was 1.3% over the latter
half of the study (July 1989 to December 1996 inclusive).
Comparisons of preoperative criteria studied are shown
in Table 1. Of the 74 crash CABG patients, all were
intended to have angioplasty of one system, usually a
single culprit vessel. The angiograms had been reported
before intervention, and on review of these reports it was
found that 47 of 74 patients (63.5%) had significant
stenosis of one coronary system, 19 of 74 (25.7%) had
two-system disease, and 8 of 74 (10.8%) had three-system
disease. Two patients had significant left main stem
disease. Details regarding coronary arteries diseased,
coronary systems grafted, mean cardiopulmonary bypass
(CPB) times, and number of distal anastomoses per-
formed for both study groups are shown in Table 2.
PTCA failures were due to arterial dissection with or
without complete occlusion in 40 patients (54%) and
complete occlusion without dissection in 34 patients
(46%). Vessels intended to be dilated were the left ante-
rior descending in 39 patients (52.7%), the right coronary
artery in 26 patients (35.1%), and the left circumflex in 9
patients (12.2%). Only 1 patient had two-vessel dilatation
for disease of the left anterior descending and first
diagonal arteries. GpIIbIIIa inhibitors were not available
at our institution until 1998. Intraaortic balloon pumps
(IABP) were not inserted preoperatively. A coronary
artery stent was inserted in 3 patients (4%), indicated by
arterial dissection in 2 and acute arterial closure in 1
Table 1. Comparison of Preoperative Characteristics by
Patient Group
Age (years)
Mean 59.7 61.7 NS
Range
Female sex
37.3–80.8
18 (24%)
41.6–76.8
20 (27%) NS
Duration of angina (months)
Mean
Range
Previous MI
28.3
1–240
38 (51%)
38.4
1–240
33 (45%)
<0.05
NS
Unstable angina before PTCA 53 (72%) n/a
Family history of IHD 24 (32%) 15 (20%) NS
Valvular heart disease 1 (1%) 2 (3%) NS
Diabetes 12 (16%) 7 (9%) NS
Smoking history 34 (46%) 56 (76%) <0.01
Hypertension 34 (46%) 19 (26%) <0.02
Hyperlipidemia 28 (38%) 37 (50%) NS
Obesity 30 (41%) 27 (36%) NS
Previous stroke 7 (9%) 8 (11%) NS
Creatinine >150 SI units 0 1 (1%) NS
Chronic airways limitation 1 (1%) 5 (7%) NS
Peripheral vascular disease 7 (9%) 6 (8%) NS
Venous disease 3 (4%) 7 (9%) NS
Ejection fraction
Mean 0.68 0.64 NS
Range 0.35–0.88 0.26–0.87
Variable
Crash
Group
(n = 74)
Control
Group p
(n = 74) Value
IHD = ischemic heart disease; MI = myocardial infarction; n/a =
not applicable; NS = not significant; PTCA = percutaneous trans-
luminal coronary angioplasty; SI = system international.
Table 2. Extent of Coronary Artery Disease and Operative
Data
Arteries diseased
Right coronary artery 34 29 NS
Left anterior descending artery 52 62 NS
Left circumflex artery 23 18 NS
Left main artery 2 1 NS
Coronary systems grafted
One 47 47
Two 19 19
Three 8 8
Mean systems grafted 1.5 1.5 NS
Cardiopulmonary bypass time (min)
Mean 52.2 57.2
Range 26–104 25–111 NS
Distal anastomoses
One 28 22
Two 25 29
Three 12 12
Four 5 7
Five 2 4
Six 1 0
Seven 1 0
Mean number 2.1 2.2 NS
NS = not significant.
Variable
Crash Control
Group Group p
(n = 74) (n = 74) Value
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3. patient. Of these 3, the patient with acute arterial closure
sustained an AMI but made a good recovery after emer-
gency CABG. The remaining 2 patients did well without
complication after emergency CABG. A reperfusion cath-
eter was inserted in 24 crash group patients (32%). For
details regarding outcomes after emergency CABG after
unsuccessful PTCA with and without reperfusion cathe-
ter usage see Figure 1.
Angioplasty failure was accompanied by angina in 63
patients (85%), and ECG changes of evolving myocardial
infarction in 58 patients (78%). Hemodynamic instability
occurred in 24 patients (33%) after the procedure, with
prolonged hypotension in 13 patients (18%), and unstable
ventricular arrhythmias in 8 patients (11%). Cardiopul-
monary resuscitation was required for 3 patients (4%)
with evolving AMI and shock who were transported
directly to the operating theater. These 3 patients were
massaged onto CPB, fortunately all of whom survived.
The average time from termination of the PTCA to
commencement of CPB was 3 hours 22 minutes for 59
patients (80%) in whom the decision to operate was made
in the catheterization laboratory. After emergency CABG
the AMI and mortality rates for these patients were 4 of
59 (6.8%) and 2 of 59 (3.4%) respectively. For the remain-
ing 15 patients time from termination of PTCA to com-
mencement of CPB ranged from 6 to 24 hours. These
patients had all developed intractable angina pectoris
and signs of evolving myocardial infarction that necessi-
tated emergency operative revascularization. After emer-
gency CABG the AMI rate for these patients was 2 of 15
(13.3%) with no mortality. The overall mortality rate for
the crash group was 2 of 74 (2.7%).
Crash group patients received St. Thomas II cardiople-
gic solution (crystalloid buffered with bicarbonate with-
out additives; Mayne Pharma, Melbourne, Victoria). This
was administered antegrade through the aortic root in 65
patients. Nine patients received cardioplegia through
other means: retrograde through the coronary sinus in 2,
antegrade and retrograde in 2, antegrade and retrograde
and down the grafts in 1, and antegrade and down the
grafts in 4 patients. These 9 patients were operated on
over the last 7 years of the study (1991 to 1996 inclusive)
and none of these patients suffered myocardial infarction
or died.
There was no significant difference in the CPB times of
the two groups. Although single system angioplasty was
initially intended for all patients, at operation the average
number of systems grafted was 1.5 (see Table 2). The left
internal mammary artery (LIMA) was used for bypass
grafting in 25 patients (34%) in the crash group (4
sustained AMI, with no mortality) and 51 patients (69%)
in the control group (2 sustained AMI, with no mortality).
The average number of distal anastomoses for patients in
the crash group was 2.1 (range, 1 to 7), and for the
matched control group was 2.2 (range, 1 to 5). During the
same period the average number of distal anastomoses
was 4.1 per patient for those who underwent primary
coronary revascularization at our unit.
Differences in morbidity for the crash group between
the first and second half of the study and comparison
with the control group are shown in Table 3. For the crash
group over the first half of the study there was a higher
rate of low cardiac output, postoperative hemorrhage
greater than 1.5 L, myocardial infarction, and 30-day
mortality. There were no significant differences between
the two study groups in incidences of postoperative AMI
or 30-day mortality. In the crash group AMI developed in
6 patients, 2 of whom died. In the control group 2 patients
developed AMI, with no mortality. There were no signif-
icant differences in requirement for postoperative cat-
echolamines, reoperation for hemorrhage, nor the inci-
dence of postoperative arrhythmias. There was no
significant difference between mean in-hospital length of
stay.
Comment
The reported incidence of emergency CABG after PTCA
failure ranges from 0.32% to 7% [1–5, 7]. Emergency
CABG after PTCA failure is now required infrequently,
however, owing to increased operator experience in
PTCA techniques and intracoronary stent usage [4, 7].
The consequences of PTCA failure can be serious and
include AMI and death. The international literature in-
dicates that the patient immediately enters a higher risk
group after PTCA failure, with reported mortality rates
for subsequent emergency CABG of 3.8% to 14% [1–5]. In
contrast, the 30-day mortality in this series was 2 of 74
(2.7%). The explanation for this is multifactorial and
demands a multidisciplinary approach to management
after PTCA failure. In our experience the key factors in
achieving a satisfactory outcome include simultaneous
Fig 1. Details regarding outcomes after emer-
gency coronary artery bypass graft (CABG)
surgery after unsuccessful percutaneous trans-
luminal angioplasty (PTCA) with and with-
out reperfusion catheter usage. (AMI = acute
myocardial infarction despite emergency
CABG; h = hours; LIMA = left internal
mammary artery usage at CABG; m = min-
utes; OR = operating room.)
1402 BARAKATE ET AL
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4. resuscitation and management in the catheterization
laboratory, minimizing the time to surgical revasculariza-
tion (with the operating rooms in the same building as
the catheterization laboratory in our hospital), and com-
plete myocardial revascularization at surgery.
In the present study the overall rate of emergency
CABG after PTCA failure was 1.8%, with a rate of 4.2% for
the first half of the study period compared with 1.3%
during the latter half. The cause of PTCA failure in the
present study was arterial dissection (54%) and acute
arterial occlusion (46%), and these are the most com-
monly reported reasons for PTCA failure necessitating
emergency CABG [1–3, 8–11]. Other reported indications
for emergency surgery include arterial spasm and arte-
rial perforation into the pericardial cavity [1, 10–12].
More recently stent complications have been reported as
the cause of PTCA failure in as many as 37% of cases [4].
When PTCA failure causes coronary artery damage,
surgical options for that artery may be difficult depend-
ing upon the extent of the injury (ie, coronary artery
dissection). As a result of the failure 33% of patients in
this series were in critical condition before surgery. That
is consistent with 25% to 38% of patients in other re-
ported series being unstable before emergency CABG
after PTCA failure [2, 5, 8], highlighting the high risk
involved in operating in these circumstances.
Our devised policy was to get the patient to the
operating room and on CPB as quickly as possible. For
the crash group the AMI rate was 6.8% for those in whom
the decision to operate was made in the catheterization
laboratory, compared with 13.3% for those patients held
until intractable angina pectoris and signs of evolving
myocardial infarction developed (see Results). The re-
ported risk of AMI and death is proportional to the
duration of myocardial ischemia [1, 4, 5] and it was our
surgical aim to minimize the time to revascularization.
Measures to decrease ischemia may be used after PTCA
failure [2]. The use of reperfusion catheters after PTCA
failure has been shown to help reverse the ECG changes
seen and reduce the incidence of AMI [7, 12–14]. In our
experience reperfusion catheter usage resulted in a
longer delay to the commencement of CPB (4 hours 6
minutes versus 3 hours 18 minutes) and subsequently
higher AMI (12.5% versus 5.3%) and mortality (4.2%
versus 2.6%) rates for those patients in whom the deci-
sion to operate was made in the catheterization labora-
tory (see Fig 1). Reperfusion catheter use after unsuccess-
ful angioplasty may delay time to operative
revascularization and lead to a false sense of security,
potentially resulting in worse outcomes. This area needs
further investigation.
Other techniques reported to successfully decrease the
rate of AMI in this setting include the use of the IABP,
intracoronary nitroglycerin, and coronary stenting. Per-
cutaneous CPB may minimize myocardial damage after
unsuccessful PTCA but only when the patient regains a
stable cardiac rhythm [15]. In the early experience IABP
use meant an open procedure under difficult nonsterile
circumstances and our view was that the risk outweighed
the benefit of urgent CABG once the patient crashed.
Since the advent of percutaneous IABP this is now
possible in the catheterization laboratory but use should
not delay transfer to the operating room and institution
of CPB. Our experience has shown that IABP use (along
with new techniques) is not critical provided there is no
delay with prompt operative revascularization after un-
successful PTCA.
Table 3. Differences in Morbidity for the Crash Group Between the First and Second Half of the Study and Comparison
Between the Whole Crash and Control Groups
Clinical Variables
Crasha
Group
January 1982
to June 1989
(n = 22)
Crasha
Group
July 1989 to
December 1996
(n = 52)
Crash Group
Totalb
(n = 74)
Control Group
Totalb
(n = 74)
Intra-aortic balloon pump use 1 (4.5%) 0 1 (1%) 1 (1%)
Low cardiac output 2 (9.1%) 3 (5.8%) 5 (7%) 1 (1%)
Prolonged ventilation (>48 hours) 1 (4.5%) 2 (3.8%) 3 (4%) 3 (4%)
Required dialysis 0 0 0 1 (1%)
Required catecholamines 2 (9.1%) 4 (7.7%) 6 (8%) 7 (9%)
Hemorrhage >1.5 L 4 (18.2%) 5 (9.6%) 9 (12%) 6 (8%)
Reoperation for hemorrhage 0 2 (3.8%) 2 (3%) 1 (1%)
Permanent neurologic injury 1 (4.5%) 0 1 (1%) 0
Wound infection 0 1 (1.9%) 1 (1%) 0
Myocardial infarction 3 (13.6%) 3 (5.8%) 6 (8%) 2 (3%)
Atrial fibrillation on discharge 1 (4.5%) 0 1 (1%) 1 (1%)
Ventricular tachycardia (requiring cardioversion) 0 1 (1.9%) 1 (1%) 1 (1%)
Thirty-day mortality 1 (4.5%) 1 (1.9%) 2 (3%) 0
In-hospital length of stay
Mean (days) 10.1 9.1 9.4 8.3
Range 4–21 3–57 3–57 4–27
a
There were no significant differences in postoperative variables between the first and second halves of the study for patients in the crash group.
were no significant differences in postoperative variables between the whole crash and control group.
b
There
1403
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5. Ischemic time has been defined differently in previous
reports, making comparison difficult. Parsonnet and col-
leagues [1] reported time for transit from the catheteriza-
tion room to the operating room for 59 of 67 patients (88%
of their study group) averaging 26 minutes, with 8 pa-
tients (12%) held for observation until sudden accelera-
tion of symptoms and signs. In the post-PTCA group the
rate of AMI was 28% and mortality of 12% [1]. Greene
and colleagues [2] reported the time for revascularization
from angioplasty failure to when the patient came off
bypass. This time averaged 3 hours 4 minutes for 53
patients, with an AMI rate of 51% and a mortality rate of
3.8% [2]. Borkon and colleagues [5] reported 73 of 91
patients (80%) went directly from the catheterization
room to the operating room without specifying the actual
time while the remaining 18 patients (20%) had develop-
ment of symptoms within 24 hours after PTCA that
necessitated emergency CABG. The AMI rate was 29%
with a mortality rate of 12.1% [5]. The differences in
outcomes between these studies may in part be ex-
plained by a different method of estimating ischemic
time, which may inaccurately reflect the actual duration
of myocardial ischemia. Therefore we recommend stan-
dardization of reported ischemic times. We have em-
ployed the time from the onset of ischemia (by clinical
and angiographic features) to the commencement of
CPB. The time for onset of CPB was a consistently
reported time point for all patients and represents the
point at which the myocardium was rested.
Previous reports have employed varied methods for
obtaining control groups to compare with patients un-
dergoing emergency CABG after unsuccessful PTCA [1,
2, 5, 8, 10, 12]. We chose a control group who underwent
elective CABG matched for the year of operation, the
number of coronary systems diseased, and number of
bypass grafts performed. We then checked that there
were no statistically significant differences in preopera-
tive risk factors as shown in Table 1. We were unable to
confirm the validity of the data for smoking history and
presence of hypertension because these factors were not
consistently measured over the study period. Smoking
history was not always reliably recorded in the emer-
gency situation. Year of operation was matched to ensure
that similar surgical techniques were performed. In this
way we have compared the outcomes of an emergency
procedure after unsuccessful PTCA intervention with a
similar but elective procedure. It is interesting to note
that the PTCA (crash) group had a significantly shorter
duration of symptoms before intervention was offered
(see Table 1). It is also interesting that except for 1, all
patients were intended to have single-vessel PTCA tar-
geting the culprit vessel. At surgery, however, an average
2.1 coronary grafts (range, 1 to 7) were performed after
PTCA failure (see Table 2). That compares with an
average of approximately two grafts per patient having
emergency revascularization after failed PTCA in the
international literature [1–3, 5, 8]. It is only because of
very aggressive and complete coronary artery surgery
that we have been able to achieve results that are
equivalent to planned surgery (see Table 3). We have not
addressed long-term outcomes in this paper. This study
specifically addresses the immediate results with aggres-
sive CABG. The long-term outcomes in these circum-
stances would be complex but nevertheless of great
interest.
Recent data from Reinecke and colleagues [16] ana-
lyzed significant differences between survivors and non-
survivors of emergency CABG after failed PTCA. In their
study survivors were significantly younger (58.2 versus
65.4 years, p < 0.01), had greater mean body surface area
(1.93 m2
versus 1.73 m2
, p < 0.001), had lower mean
Cleveland score (7.06 versus 8.86, p < 0.001), more fre-
quently received complete operative revascularization
(80% versus 36%, p < 0.001), and had faster mean bypass
times (56 versus 91 minutes, p < 0.001). Furthermore this
paper stated that “non survivors were more frequently
female (64% versus 24%, p < 0.01), had a moderately or
severely reduced left ventricle (29% versus 9.4%, p <
0.05), more frequently required intensive treatment (car-
diocompression, defibrillation, IABP insertion etc., 93%
versus 33%, p < 0.001), and interestingly had faster mean
time from PTCA end to start of CABG (57 versus 94
minutes, p < 0.05)” [16]. In our series 6 patients sustained
AMI after PTCA failure and of these, 2 died. Of the
remaining 68 patients, none died. Although the relatively
small number of patients in our study who died pre-
cluded further analysis of mortality risk factors, reported
data indicates that the risk of death is greatest for those
who experience ongoing myocardial ischemia and AMI
despite surgical revascularization [1, 4, 5]. Other investi-
gators have found additional risk factors for mortality
including advanced age, low left ventricular ejection
fraction, multivessel disease, female sex, PTCA of unfa-
vorable stenoses, multiple vessel PTCA, and prior CABG
[5, 8, 10, 17, 18].
In summary, this series reports a low rate of AMI
(8.1%) and death (2.7%) for patients who underwent
emergency CABG after PTCA failure, results that were
not significantly different when compared with those of a
matched group who underwent elective CABG (see Ta-
ble 3). These results compare well with reports from units
with onsite surgical backup [1, 2, 5] and certainly com-
pare favorably with those from units with offsite surgical
backup, which cite high mortality rates of 14% [4]. The
results in this series have been achieved by simultaneous
resuscitation and management in the catheterization
laboratory, minimizing the time to surgical revasculariza-
tion, and complete myocardial revascularization at sur-
gery. Our salvage rate highlights the need for a coordi-
nated effort between cardiac surgeons and invasive
cardiologists. The era of having an operating room open
with surgeons and a team “standing by” is over. Yet acute
closures and dissections do still occur. A system that
allows early admission of trouble, notification of surgeon
and operating room team, and a coordinated effort to get
the patient to the operating room and on bypass will
clearly give the best chances of survival.
1404 BARAKATE ET AL
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6. The authors thank the surgeons Matthew S. Bayfield, FRACS,
Bruce G. French, FRACS, Nick Hendel, FRACS, Brian C. Mc-
Caughan, FRACS, and Duncan S. Thomson, FRACS, for their
contribution to the clinical work that formed the basis for this
research.
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