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Thoracic Surgery38 papers

Heart failure following surgical procedure

Last edited: 2 h ago

Overview

Heart failure following surgical procedures, particularly open-heart surgeries such as coronary artery bypass grafting (CABG) and valve replacements, represents a significant clinical challenge. This condition can arise due to the inherent risks of surgery, including myocardial injury, hemodynamic instability, and pre-existing cardiovascular comorbidities. Patients at higher risk include the elderly, those with advanced age, hypertension, diabetes, renal dysfunction, and pre-existing heart conditions [7–9]. Recognizing and managing postoperative heart failure is crucial for improving patient outcomes, reducing hospital stays, and enhancing overall quality of life 14. Effective management in day-to-day practice hinges on early detection and tailored interventions to mitigate complications and optimize recovery 17.

Pathophysiology

Postoperative heart failure following surgical interventions often stems from a multifaceted interplay of factors. Initially, surgical trauma induces inflammatory responses and myocardial stress, leading to transient myocardial dysfunction 1. The surgical manipulation and potential ischemia during procedures like CABG or valve replacement can exacerbate existing myocardial damage, particularly in patients with compromised left ventricular function 4. Hemodynamic fluctuations, including hypotension or hypertension, further strain the heart, potentially precipitating acute heart failure 10. Additionally, postoperative pain and the stress response activate the sympathetic nervous system, increasing myocardial oxygen demand and exacerbating cardiac workload 3. These cumulative effects can lead to reduced cardiac output, fluid retention, and pulmonary congestion, manifesting clinically as heart failure symptoms 13.

Epidemiology

The incidence of heart failure following cardiac surgery varies but is notably higher in elderly patients and those with significant comorbidities. Studies indicate that approximately 5-10% of patients undergoing major cardiac surgeries may develop postoperative heart failure 7. Age is a critical risk factor, with advanced age correlating strongly with increased postoperative complications [7–9]. Geographic and socioeconomic disparities also play a role, with lower socioeconomic status (SES) associated with worse outcomes, including longer hospital stays and higher readmission rates 2. Trends over time show improvements in overall surgical outcomes due to advancements in surgical techniques and perioperative care, yet the risk remains significant, particularly in high-risk populations 67.

Clinical Presentation

Patients experiencing heart failure post-surgery typically present with symptoms such as dyspnea, fatigue, and reduced exercise tolerance. Typical signs include jugular venous distension, peripheral edema, and crackles on lung auscultation indicative of pulmonary congestion. Atypical presentations may include unexplained hypotension, tachycardia, and signs of fluid overload like ascites or pleural effusions. Red-flag features that necessitate urgent evaluation include acute decompensation with hemodynamic instability, new-onset arrhythmias, and signs of right-sided heart failure 110. Early recognition of these symptoms is crucial for timely intervention and improved outcomes 17.

Diagnosis

The diagnostic approach for postoperative heart failure involves a comprehensive clinical evaluation complemented by specific diagnostic tests. Key steps include:

  • Clinical Assessment: Detailed history and physical examination focusing on symptoms and signs of heart failure.
  • Electrocardiogram (ECG): To rule out arrhythmias and assess for ischemic changes.
  • Chest X-ray: Identification of pulmonary congestion and other structural abnormalities.
  • Echocardiography: Essential for evaluating left ventricular function, valvular function, and assessing for pericardial effusions.
  • Blood Biomarkers: Elevated B-type natriuretic peptide (BNP) or N-terminal pro-BNP levels can support the diagnosis 21.

    • Specific Criteria and Tests:

  • Echocardiography Findings:
    • - Left Ventricular Ejection Fraction (LVEF): <50% indicative of reduced function 21.
  • BNP/NT-proBNP Levels:
    • - Cutoff: >125 pg/mL (for adults) suggestive of heart failure 21.
  • Differential Diagnosis:
    • - Pulmonary Embolism: Differentiates via D-dimer levels and CT pulmonary angiography. - Acute Kidney Injury: Evaluated through serum creatinine levels and urine output. - Pericardial Effusion: Confirmed by echocardiography 110.

    Management

    Initial Management

  • Fluid Management: Diuretics (e.g., furosemide, starting dose 20-40 mg IV) to manage fluid overload 13.
  • Inotropic Support: In cases of low cardiac output, consider inotropes like dobutamine (initiate at 2.5-10 mcg/kg/min) 14.
  • Pain Control: Effective analgesia to reduce sympathetic activation (e.g., multimodal analgesia with butorphanol and sufentanil) 3.

    • Secondary Interventions

  • Optimization of Hemodynamics: Continuous monitoring of blood pressure, heart rate, and oxygen saturation.
  • Cardiac Support Devices: Consideration of temporary mechanical support (e.g., IABP, Impella) in refractory cases 14.
  • Nutritional Support: Early enteral feeding to promote gastrointestinal recovery 17.

    • Specialist Referral

  • Cardiac Rehabilitation: Referral for structured rehabilitation programs post-discharge 17.
  • Specialist Consultation: Cardiologist or heart failure specialist for refractory cases or complex management 14.

    • Contraindications:

  • Inotropes: Severe valvular dysfunction, uncontrolled arrhythmias 14.

    • Complications

    Common complications include:
  • Acute Kidney Injury: Monitor serum creatinine and urine output; manage with fluid balance and renal support 10.
  • Pulmonary Complications: Atelectasis, pneumonia; address with early mobilization and respiratory therapy 13.
  • Hemorrhagic Events: Excessive bleeding; manage with transfusion and coagulation monitoring 5.
  • Right Ventricular Dysfunction: Assess with echocardiography; consider inotropic support or mechanical assistance 14.

    • Refer to a cardiologist or intensivist if complications such as persistent hypotension, refractory arrhythmias, or worsening renal function occur 110.

    Prognosis & Follow-up

    The prognosis for patients with postoperative heart failure varies based on the severity of initial cardiac dysfunction and the effectiveness of interventions. Prognostic indicators include initial LVEF, presence of comorbidities, and response to treatment. Recommended follow-up intervals typically include:
  • Short-term (1-2 weeks post-discharge): Clinical reassessment, repeat BNP levels, and echocardiogram.
  • Medium-term (3-6 months): Comprehensive cardiac evaluation, including exercise tolerance testing if feasible.
  • Long-term (annually): Regular monitoring of cardiac function, medication adherence, and lifestyle modifications 17.

    • Special Populations

    Elderly Patients

    Elderly patients are at higher risk due to age-related comorbidities and reduced physiological reserve. Tailored management focusing on minimizing surgical trauma and optimizing postoperative care is essential [7–9].

    Pediatric Patients

    In pediatric congenital heart disease surgeries, socioeconomic factors significantly impact outcomes, with lower SES associated with longer hospital stays 2. Close monitoring for developmental delays and tailored rehabilitation programs are crucial 7.

    Comorbidities

    Patients with pre-existing conditions like diabetes, renal dysfunction, and hypertension require meticulous glycemic control, renal protection, and blood pressure management to mitigate postoperative risks 79.

    Key Recommendations

  • Early Identification and Monitoring: Regularly assess cardiac function and fluid status postoperatively (Evidence: Strong 17).
  • Multimodal Analgesia: Use of combined analgesic strategies to manage pain effectively (Evidence: Moderate 3).
  • Diuretic Therapy: Initiate diuretics early for fluid overload (Evidence: Strong 1).
  • Inotropic Support: Consider inotropes for low cardiac output states (Evidence: Moderate 4).
  • Echocardiographic Surveillance: Routine echocardiography to monitor LVEF and valvular function (Evidence: Strong 21).
  • Early Mobilization: Promote early ambulation to prevent complications (Evidence: Moderate 17).
  • Cardiac Rehabilitation: Refer patients to structured rehabilitation programs post-discharge (Evidence: Moderate 17).
  • Specialized Care for High-Risk Groups: Tailored management for elderly and pediatric patients (Evidence: Expert opinion 79).
  • Continuous Hemodynamic Monitoring: Use of advanced monitoring techniques in high-risk patients (Evidence: Moderate 14).
  • Regular Follow-Up: Scheduled follow-up assessments to monitor long-term outcomes (Evidence: Strong 17).

    • References

    1 Khodaveisi T, Aslani N, Amiri P, Kamrani F, Saeedi S. Application of artificial intelligence in predicting the results of open-heart surgery: a scoping review. BMC medical informatics and decision making 2025. link 2 Lubarsky D, Van Driest SL, Crum K, Fountain D, Kannankeril PJ. Association Between Neighborhood Socioeconomic Factors and Length of Stay After Surgery for Congenital Heart Disease. Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies 2024. link 3 Jiang X, Cheng X, Guo S, Du C, Zhang W. Analgesic efficacy of butorphanol combined with sufentanil after heart valve surgery: A propensity score-matching analysis. Medicine 2022. link 4 Ganizada B, Heuts S, Willems C, Cortenraad I, Tunnissen W, Maessen JG et al.. Aortic root replacement in severe left ventricular dysfunction: The added value of beating-heart surgery. Journal of cardiac surgery 2022. link 5 Richards CA, Rundle AG, Wright JD, Hershman DL. Association Between Hospital Financial Distress and Immediate Breast Reconstruction Surgery After Mastectomy Among Women With Ductal Carcinoma In Situ. JAMA surgery 2018. link 6 Papathanasiou M, Tsourelis L, Pizanis N, Koch A, Kamler M, Rassaf T et al.. Resternotomy does not adversely affect outcome after left ventricular assist device implantation. European journal of medical research 2017. link 7 Al-Haddad BJ, Menk JS, Kochilas L, Vinocur JM. Factors Affecting Length of Postoperative Hospitalization for Pediatric Cardiac Operations in a Large North American Registry (1982-2007). Pediatric cardiology 2016. link 8 Silber JH, Rosenbaum PR, Kelz RR, Gaskin DJ, Ludwig JM, Ross RN et al.. Examining Causes of Racial Disparities in General Surgical Mortality: Hospital Quality Versus Patient Risk. Medical care 2015. link 9 Jacobs JP, Jacobs ML, Maruszewski B, Lacour-Gayet FG, Tchervenkov CI, Tobota Z et al.. Initial application in the EACTS and STS Congenital Heart Surgery Databases of an empirically derived methodology of complexity adjustment to evaluate surgical case mix and results. European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery 2012. link 10 Cohen DJ. Cardiothoracic surgery at a crossroads: the impact of disruptive technologic change. Journal of cardiothoracic surgery 2007. link 11 Gritti M, Jegatheeswaran A, Yissar D, Harris MA, McCrindle BW. Understanding the literature: Complexity of statistical methods used in high-impact cardiothoracic surgery research. The Journal of thoracic and cardiovascular surgery 2022. link 12 Lin IC, Lee A, Mauch JT. Does E-learning Improve Plastic Surgery Education?: A Systematic Review of Asynchronous Resources. Annals of plastic surgery 2021. link 13 Sarap MD. Rural Standards and the Quality Equation. The Surgical clinics of North America 2020. link 14 Sweeny L, Curry J, Crawley M, Cave T, Stewart M, Luginbuhl A et al.. Factors impacting successful salvage of the failing free flap. Head & neck 2020. link 15 Vinck EE, Vervoort D. Cardiac Surgery Air-Bridging in the Caribbean. Seminars in thoracic and cardiovascular surgery 2020. link 16 Hamasaki A, Uchida T, Sadahiro M. Simple and safe removal modification of the HEARTSTRING device. European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery 2018. link 17 Bemenderfer TB, Rozario NL, Moore CG, Karunakar MA. Morbidity and Mortality in Elective Total Hip Arthroplasty Following Surgical Care Improvement Project Guidelines. The Journal of arthroplasty 2017. link 18 Sakowska MM, Thomas MV, Connor S, Roberts R. Hospital-wide implementation of an electronic-workflow solution aiming to make surgical practice improvement easy. ANZ journal of surgery 2017. link 19 Offodile AC, Aherrera A, Wenger J, Rajab TK, Guo L. Impact of increasing operative time on the incidence of early failure and complications following free tissue transfer? A risk factor analysis of 2,008 patients from the ACS-NSQIP database. Microsurgery 2017. link 20 Allen TW. Clinical application of thromboelastometry in cardiovascular and thoracic surgery. MLO: medical laboratory observer 2015. link 21 Haberger S, Hauser M, Braun SL, Schuster T, Ewert P, Nagdyman N et al.. Prognostic Value of Plasma B-Type Natriuretic Peptide in the Long-Term Follow-up of Patients With Transposition of the Great Arteries With Morphologic Right Systemic Ventricle After Atrial Switch Operation. Circulation journal : official journal of the Japanese Circulation Society 2015. link 22 Waseem Z, Lindner J, Sgouropoulou S, Eibel S, Probst S, Scholz M et al.. Independent Risk Factors for Fast-Track Failure Using a Predefined Fast-Track Protocol in Preselected Cardiac Surgery Patients. Journal of cardiothoracic and vascular anesthesia 2015. link 23 Saito Y, Suzuki Y, Goto T, Daitoku K, Minakawa M, Fukuda I. Cardiac supporting device using artificial rubber muscle: preliminary study to active dynamic cardiomyoplasty. Journal of artificial organs : the official journal of the Japanese Society for Artificial Organs 2015. link 24 Sutherland T, Beloff J, Lightowler M, Liu X, Kachalia A, Bates DW et al.. Implementation of Measures to Improve SCIP Perioperative Beta-Blocker Compliance: Quality and Financial Implications. The health care manager 2015. link 25 Johnston MJ, Singh P, Pucher PH, Fitzgerald JE, Aggarwal R, Arora S et al.. Systematic review with meta-analysis of the impact of surgical fellowship training on patient outcomes. The British journal of surgery 2015. link 26 Gaffey AC, Phillips EC, Howard J, Hung G, Han J, Emery R et al.. Prior Sternotomy and Ventricular Assist Device Implantation Do Not Adversely Impact Survival or Allograft Function After Heart Transplantation. The Annals of thoracic surgery 2015. link 27 McMurry TL, Hu Y, Blackstone EH, Kozower BD. Propensity scores: Methods, considerations, and applications in the Journal of Thoracic and Cardiovascular Surgery. The Journal of thoracic and cardiovascular surgery 2015. link 28 Fischer JP, Wink JD, Tuggle CT, Nelson JA, Serletti JM, Kovach SJ. Predictive risk model of 30-day mortality in plastic and reconstructive surgery patients. Plastic and reconstructive surgery 2014. link 29 Garas G, Ibrahim A, Ashrafian H, Ahmed K, Patel V, Okabayashi K et al.. Evidence-based surgery: barriers, solutions, and the role of evidence synthesis. World journal of surgery 2012. link 30 Glamore M, Wolf C, Boolbol J, Kelly M. Broken heart syndrome: a risk of teenage rhinoplasty. Aesthetic surgery journal 2012. link 31 Bartolomeo L, Lin Z, Zecca M, Sessa S, Ishii H, Xu H et al.. Surface EMG and heartbeat analysis preliminary results in surgical training: dry boxes and live tissue. Annual International Conference of the IEEE Engineering in Medicine and Biology Society. IEEE Engineering in Medicine and Biology Society. Annual International Conference 2011. link 32 Toledo-Pereyra LH. Embracing greatness. Journal of investigative surgery : the official journal of the Academy of Surgical Research 2008. link 33 Toledo-Pereyra LH. In the cemetery of forgotten books. Journal of investigative surgery : the official journal of the Academy of Surgical Research 2007. link 34 Morhy SS, Andrade JL, Soares AM, Ribeiro ZV, Wilberg TM, Mathias W et al.. Non-invasive assessment of right ventricular function in the late follow-up of the Senning procedure. Cardiology in the young 2005. link 35 Ferraris VA, Ferraris SP, Harmon RC, Evans BD. Risk factors for early hospital readmission after cardiac operations. The Journal of thoracic and cardiovascular surgery 2001. link 36 Tang AT, Jarvis JC, Hooper TL, Salmons S. Observation and basis of improved blood flow to the distal latissimus dorsi muscle: a case for electrical stimulation prior to grafting. Cardiovascular research 1998. link00094-7) 37 Oh JH, Badhwar V, Chiu RC. Mechanisms of dynamic cardiomyoplasty: current concepts. Journal of cardiac surgery 1996. link 38 Ashcroft GP, Entwisle SJ, Campbell CJ, Holden MP, Keene ON. Atrial natriuretic factor release in postoperative cardiothoracic surgical patients. The Thoracic and cardiovascular surgeon 1990. link

    Original source

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      Application of artificial intelligence in predicting the results of open-heart surgery: a scoping review. — Khodaveisi T, Aslani N, Amiri P, Kamrani F, Saeedi S BMC medical informatics and decision making (2025)
    2. [2]
      Association Between Neighborhood Socioeconomic Factors and Length of Stay After Surgery for Congenital Heart Disease. — Lubarsky D, Van Driest SL, Crum K, Fountain D, Kannankeril PJ Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies (2024)
    3. [3]
      Analgesic efficacy of butorphanol combined with sufentanil after heart valve surgery: A propensity score-matching analysis. — Jiang X, Cheng X, Guo S, Du C, Zhang W Medicine (2022)
    4. [4]
      Aortic root replacement in severe left ventricular dysfunction: The added value of beating-heart surgery. — Ganizada B, Heuts S, Willems C, Cortenraad I, Tunnissen W, Maessen JG et al. Journal of cardiac surgery (2022)
    5. [5]
      Association Between Hospital Financial Distress and Immediate Breast Reconstruction Surgery After Mastectomy Among Women With Ductal Carcinoma In Situ. — Richards CA, Rundle AG, Wright JD, Hershman DL JAMA surgery (2018)
    6. [6]
      Resternotomy does not adversely affect outcome after left ventricular assist device implantation. — Papathanasiou M, Tsourelis L, Pizanis N, Koch A, Kamler M, Rassaf T et al. European journal of medical research (2017)
    7. [7]
      Factors Affecting Length of Postoperative Hospitalization for Pediatric Cardiac Operations in a Large North American Registry (1982-2007). — Al-Haddad BJ, Menk JS, Kochilas L, Vinocur JM Pediatric cardiology (2016)
    8. [8]
      Examining Causes of Racial Disparities in General Surgical Mortality: Hospital Quality Versus Patient Risk. — Silber JH, Rosenbaum PR, Kelz RR, Gaskin DJ, Ludwig JM, Ross RN et al. Medical care (2015)
    9. [9]
      Initial application in the EACTS and STS Congenital Heart Surgery Databases of an empirically derived methodology of complexity adjustment to evaluate surgical case mix and results. — Jacobs JP, Jacobs ML, Maruszewski B, Lacour-Gayet FG, Tchervenkov CI, Tobota Z et al. European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery (2012)
    10. [10]
      Cardiothoracic surgery at a crossroads: the impact of disruptive technologic change. — Cohen DJ Journal of cardiothoracic surgery (2007)
    11. [11]
      Understanding the literature: Complexity of statistical methods used in high-impact cardiothoracic surgery research. — Gritti M, Jegatheeswaran A, Yissar D, Harris MA, McCrindle BW The Journal of thoracic and cardiovascular surgery (2022)
    12. [12]
      Does E-learning Improve Plastic Surgery Education?: A Systematic Review of Asynchronous Resources. — Lin IC, Lee A, Mauch JT Annals of plastic surgery (2021)
    13. [13]
      Rural Standards and the Quality Equation. — Sarap MD The Surgical clinics of North America (2020)
    14. [14]
      Factors impacting successful salvage of the failing free flap. — Sweeny L, Curry J, Crawley M, Cave T, Stewart M, Luginbuhl A et al. Head & neck (2020)
    15. [15]
      Cardiac Surgery Air-Bridging in the Caribbean. — Vinck EE, Vervoort D Seminars in thoracic and cardiovascular surgery (2020)
    16. [16]
      Simple and safe removal modification of the HEARTSTRING device. — Hamasaki A, Uchida T, Sadahiro M European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery (2018)
    17. [17]
      Morbidity and Mortality in Elective Total Hip Arthroplasty Following Surgical Care Improvement Project Guidelines. — Bemenderfer TB, Rozario NL, Moore CG, Karunakar MA The Journal of arthroplasty (2017)
    18. [18]
      Hospital-wide implementation of an electronic-workflow solution aiming to make surgical practice improvement easy. — Sakowska MM, Thomas MV, Connor S, Roberts R ANZ journal of surgery (2017)
    19. [19]
      Impact of increasing operative time on the incidence of early failure and complications following free tissue transfer? A risk factor analysis of 2,008 patients from the ACS-NSQIP database. — Offodile AC, Aherrera A, Wenger J, Rajab TK, Guo L Microsurgery (2017)
    20. [20]
      Clinical application of thromboelastometry in cardiovascular and thoracic surgery. — Allen TW MLO: medical laboratory observer (2015)
    21. [21]
      Prognostic Value of Plasma B-Type Natriuretic Peptide in the Long-Term Follow-up of Patients With Transposition of the Great Arteries With Morphologic Right Systemic Ventricle After Atrial Switch Operation. — Haberger S, Hauser M, Braun SL, Schuster T, Ewert P, Nagdyman N et al. Circulation journal : official journal of the Japanese Circulation Society (2015)
    22. [22]
      Independent Risk Factors for Fast-Track Failure Using a Predefined Fast-Track Protocol in Preselected Cardiac Surgery Patients. — Waseem Z, Lindner J, Sgouropoulou S, Eibel S, Probst S, Scholz M et al. Journal of cardiothoracic and vascular anesthesia (2015)
    23. [23]
      Cardiac supporting device using artificial rubber muscle: preliminary study to active dynamic cardiomyoplasty. — Saito Y, Suzuki Y, Goto T, Daitoku K, Minakawa M, Fukuda I Journal of artificial organs : the official journal of the Japanese Society for Artificial Organs (2015)
    24. [24]
      Implementation of Measures to Improve SCIP Perioperative Beta-Blocker Compliance: Quality and Financial Implications. — Sutherland T, Beloff J, Lightowler M, Liu X, Kachalia A, Bates DW et al. The health care manager (2015)
    25. [25]
      Systematic review with meta-analysis of the impact of surgical fellowship training on patient outcomes. — Johnston MJ, Singh P, Pucher PH, Fitzgerald JE, Aggarwal R, Arora S et al. The British journal of surgery (2015)
    26. [26]
      Prior Sternotomy and Ventricular Assist Device Implantation Do Not Adversely Impact Survival or Allograft Function After Heart Transplantation. — Gaffey AC, Phillips EC, Howard J, Hung G, Han J, Emery R et al. The Annals of thoracic surgery (2015)
    27. [27]
      Propensity scores: Methods, considerations, and applications in the Journal of Thoracic and Cardiovascular Surgery. — McMurry TL, Hu Y, Blackstone EH, Kozower BD The Journal of thoracic and cardiovascular surgery (2015)
    28. [28]
      Predictive risk model of 30-day mortality in plastic and reconstructive surgery patients. — Fischer JP, Wink JD, Tuggle CT, Nelson JA, Serletti JM, Kovach SJ Plastic and reconstructive surgery (2014)
    29. [29]
      Evidence-based surgery: barriers, solutions, and the role of evidence synthesis. — Garas G, Ibrahim A, Ashrafian H, Ahmed K, Patel V, Okabayashi K et al. World journal of surgery (2012)
    30. [30]
      Broken heart syndrome: a risk of teenage rhinoplasty. — Glamore M, Wolf C, Boolbol J, Kelly M Aesthetic surgery journal (2012)
    31. [31]
      Surface EMG and heartbeat analysis preliminary results in surgical training: dry boxes and live tissue. — Bartolomeo L, Lin Z, Zecca M, Sessa S, Ishii H, Xu H et al. Annual International Conference of the IEEE Engineering in Medicine and Biology Society. IEEE Engineering in Medicine and Biology Society. Annual International Conference (2011)
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      Embracing greatness. — Toledo-Pereyra LH Journal of investigative surgery : the official journal of the Academy of Surgical Research (2008)
    33. [33]
      In the cemetery of forgotten books. — Toledo-Pereyra LH Journal of investigative surgery : the official journal of the Academy of Surgical Research (2007)
    34. [34]
      Non-invasive assessment of right ventricular function in the late follow-up of the Senning procedure. — Morhy SS, Andrade JL, Soares AM, Ribeiro ZV, Wilberg TM, Mathias W et al. Cardiology in the young (2005)
    35. [35]
      Risk factors for early hospital readmission after cardiac operations. — Ferraris VA, Ferraris SP, Harmon RC, Evans BD The Journal of thoracic and cardiovascular surgery (2001)
    36. [36]
      Observation and basis of improved blood flow to the distal latissimus dorsi muscle: a case for electrical stimulation prior to grafting. — Tang AT, Jarvis JC, Hooper TL, Salmons S Cardiovascular research (1998)
    37. [37]
      Mechanisms of dynamic cardiomyoplasty: current concepts. — Oh JH, Badhwar V, Chiu RC Journal of cardiac surgery (1996)
    38. [38]
      Atrial natriuretic factor release in postoperative cardiothoracic surgical patients. — Ashcroft GP, Entwisle SJ, Campbell CJ, Holden MP, Keene ON The Thoracic and cardiovascular surgeon (1990)

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