Invest Clin 64(3): 308 - 316, 2023 https://doi.org/10.54817/IC.v64n3a4

Corresponding author: Lizhong Sun. Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical

University, Beijing, PR China. E-mail: chonggong0260326@163.com

Effect of creatine kinase isoenzyme (CK-MB)

on early prognosis after off-pump coronary

artery bypass grafting.

Zifan Zhou, Longfei Wang, Jun Wang, Ningning Liu, Yongmin Liu and Lizhong Sun

Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University,

Beijing, 100029, PR China.

Keywords: coronary heart disease; beating coronary artery bypass grafting; myocardial

enzymes; early prognosis.

Abstract. This study aimed to analyze the effect of elevated creatine ki-

nase isozyme levels on early prognosis after off-pump coronary artery bypass

(OPCAB) grafting. Based on the levels of creatine kinase isoenzyme (CK-MB),

116 patients were divided into two groups: one with a mild increase (n=85)

and another group with a severe increase (n=31) in the enzyme. Clinical data,

changes in CK-MB levels at 12, 24, and 48 hours after surgery, changes in left

ventricular ejection fraction (LVEF) and left ventricular end-diastolic diameter

(LVESD) before surgery, and seven days and three months after surgery were

measured, and recorded. Also, the blood flow of the bridging vessel, vascular

resistance, the diameter of the anterior descending branch, and the diameter

of the distal target vessel were recorded during the operation (> 1.5 mm). A

decrease in the level of LVEDD was recorded in both groups after the operation

compared to the levels before. However, in the group with a mild increase in CK-

MB, the LVEF after the operation increased compared to before the operation

(p<0.05). The occurrence of angina pectoris 24 hours before surgery, high vas-

cular resistance during surgery, and diameter of distal target vessel > 1.5 mm

were related factors affecting the increase of CK-MB after surgery. The ratio of

these factors was higher in the severe increase group than in the mild increase

group (p<0.05). An increase in myocardial enzymes causes a slow recovery of

myocardial function, so it can be used as a critical biological index to reflect

the prognosis of patients.

Creatine kinase isozyme on prognosis after off-pump coronary artery bypass grafting 309

Vol. 64(3): 308 - 316, 2023

Efecto de la isoenzima de creatina quinasa (CK-MB) en el

pronóstico temprano después de un injerto de revascularización

coronaria sin circulación extracorpórea.

Invest Clin 2023; 64 (3): 308 – 316

Palabras clave: enfermedad cardiaca; injerto de revascularización coronaria con el

corazón latiendo; creatine kinase isoenzyme (CK-MB); pronóstico

temprano.

Resumen. Este estudio tuvo como objetivo analizar el efecto de los niveles

elevados de la isoenzima de creatina quinasa (CK-MB) en el pronóstico tempra-

no después de un injerto de revascularización coronaria sin circulación extracor-

pórea (OPCAB). Basados en el nivel de la isoenzima de creatina quinasa CK-MB,

116 pacientes fueron divididos en dos grupos: uno con un aumento leve de la

enzima (n=85) y otro grupo con un aumento severo (n=31). Los datos clínicos,

los cambios en los niveles de CK-MB a las 12, 24 y 48 horas posteriores a la ci-

rugía, los cambios en la fracción de eyección del ventrículo izquierdo (LVEF) y

el diámetro telediastólico del ventrículo izquierdo (LVESD) antes de la cirugía,

7 días y 3 meses después fueron medidos y registrados. Además, fueron registra-

dos el flujo sanguíneo del puente venoso, la resistencia vascular, el diámetro de

la rama descendente anterior y el diámetro del vaso diana distal durante la ope-

ración (> 1,5 mm). Se registró una disminución en el nivel de LVEDD en ambos

grupos después de la operación en comparación con antes de la operación. Pero

en el grupo con un ligero aumento, el nivel de LVEF después de la operación

aumentó en comparación con el de antes (p<0,05). La aparición de angina de

pecho 24 horas antes de la cirugía, la alta resistencia vascular durante la cirugía

y el diámetro del vaso diana distal > 1,5 mm fueron los factores relacionados

que afectaron al aumento de CK-MB después de la cirugía. La proporción de

estos factores fue mayor en el grupo del aumento severo que en el grupo del

aumento leve (p <0,05). Un incremento de las isoenzima de CK-MB provoca una

recuperación lenta de la función miocárdica, por lo que puede utilizarse como

un índice biológico crítico para reflejar el pronóstico de los pacientes.

Received: 15-01-2023 Accepted: 24-03-2023

INTRODUCTION

Coronary heart disease is caused by

blood flow obstruction caused by lumen

stenosis based on coronary atherosclerosis,

resulting in myocardial ischemia, hypoxia,

or necrosis. Early, the patients have typi-

cal chest pain and dyspnea after fatigue or

mood swings. If the obstruction cannot be

relieved for too long, the patient may have

cardiogenic shock at rest and even endan-

ger the patient’s life in severe cases

1,2

. In

recent years, the incidence of coronary heart

disease has increased and shows a younger

patients’ trend, and it has become a com-

mon disease seriously endangering people’s

health. Beating coronary artery bypass graft-

ing is a frequent clinical cardiac surgery. It

is of great value to improve the symptoms

of myocardial ischemia, angina pectoris, and

310 Zhou et al.

Investigación Clínica 64(3): 2023

cardiac pumping function; nevertheless, it

can cause mechanical damage to the heart

during the operation. Postoperative compli-

cations such as arrhythmia and cardiac in-

sufficiency often occur, so early detection of

myocardium damage after surgery is critical

for successful clinical treatment

3,4

. Creatine

kinase isoenzyme (CK-MB) exists mainly in

the myocardium but also in small amounts

in normal blood and tissues outside the

heart. When the myocardium is damaged, it

can be released into the blood immediately

and may be used in the clinic as a biomarker

to reflect the degree of myocardial injury

a CK-MB standard is needed to eliminate

between-method bias. Because the in vitro

expression of human creatine kinase gener-

ates three isoenzymes, CK-MM, CK-MB, and

CK-BB, it is important to establish an effec-

tive method to purify the isoform CK-MB

from the mixture. In this study, we aimed at

using tandem affinity purification (TAP. Re-

lated data show that early detection of myo-

cardial CK-MB after surgery can significantly

improve the occurrence of complications in

patients, which has an essential role in the

clinical treatment of coronary heart disease

. Therefore, by exploring the changes in

postoperative CK-MB levels in patients with

off-pump coronary artery bypass (OPCAB)

grafting, this study aims to analyze the im-

pact of elevated levels on early prognosis af-

ter this surgical procedure.

PATIENTS AND METHODS

General information

We selected 116 patients who under-

went OPCAB grafting in our hospital from

January 2018 to January 2019. The inclu-

sion criteria were as follows: 1) the age was

≤ 90 years old; 2) all patients in whom the

left internal mammary artery was used as

the bridging vessel during the operation and

bypass with the anterior descending branch;

3) ventricular ejection fractions > 50%; 4)

patients and their families knew and signed

a consent form. The hospital ethics commit-

tee approved this study. There were 86 males

and 30 females aged 40 to 86 years (mean

(63.58 ±7.69) years).

Operation method

The patient was in the supine position,

and endotracheal intubation and ventilator-

assisted ventilation were performed after

general anesthesia. After entering the chest

through the median sternal incision, the left

internal mammary artery was removed with

an intramammary retractor as a spare. The

skin of the leg was cut open to expose the

great saphenous vein from the 2cm above

the medial malleolus. After pericardiotomy

and suspension, the local myocardium to be

anastomosed was fixed with Octopus cardiac

fixator, the internal diameter of the anterior

descending branch was measured and re-

corded, and the distal end of the great saphe-

nous vein was anastomosed on the ascending

aorta with suture. After each arterial bridge

completed the kiss, the blood flow was mea-

sured and recorded by transient time flow.

After the anastomosis of all bridges, the to-

tal time from the first to the last bridging

vessels was recorded, and heparin was neu-

tralized by protamine (1:1). The chest was

closed layer by layer, and a drainage tube was

placed in the pericardium and mediastinum.

After surgery, the patients entered the

extracardiac intensive care unit and were

continuously pumped with nitroglycerin for

24 hours. The changes in CK-MB levels were

monitored at 12 h, 24 h, and 48 h after the

operation. The patients whose highest value

of CK-MB was ≤ 5.31ng/mL were included in

the mild enzyme elevated group, and those

with values > 5.31ng/mL were included in

the severely elevated group. Patients were

followed for seven days postoperatively.

Observation index

1) General data of all patients on admis-

sion were collected. These included age, sex,

body mass index, hypertension, and diabetes

history, previous myocardial infarction, 24-

hour angina pectoris, and patients that had

Creatine kinase isozyme on prognosis after off-pump coronary artery bypass grafting 311

Vol. 64(3): 308 - 316, 2023

undergone percutaneous coronary interven-

tion (PCI). The blood flow of the bridge, vas-

cular resistance, the diameter of the ante-

rior descending branch, and the diameter of

the distal target vessel were recorded during

operation > 1.5mm.

2) Color Doppler echocardiography

(PHILIPS SONOS5500) was used to detect

the changes in the left ventricular ejection

fraction (LVEF) and left ventricular end-di-

astolic diameter (LVESD) before the opera-

tion and seven days and three months after

surgery.

Statistical method

Quantitative data of this study were ex-

pressed by (

sx ±

). The data of the mild and

severe elevated groups were compared with

the t-test. All the counting data were ex-

pressed by n (%). The χ² test tested the data

comparison between the two groups, and the

logistic regression analysis analyzed the relat-

ed factors affecting the increase of postopera-

tive CK-MB. p<0.05 was considered statisti-

cally significant. The IBM SPSS21.0 software

package analyzed the data of this study.

RESULTS

Preoperative general data between the two

groups

The incidence of angina pectoris 24

hours before operation in the severe eleva-

tion group was high (32.26%) when com-

pared with that in the mild elevation group

(9.41%), and the difference was statistically

significant (p<0.05). The two groups had

no significant difference in other data (p>

0.05). See Table 1.

Comparison of CK-MB levels between

the two groups during the perioperative

period

The levels of CK-MB in the two groups

were higher than that before the operation

(p<0.01), and the peak of CK-MB appeared 12

hours after surgery- The level of CK-MB in the

severe elevated group was higher than that in

the mild elevated group at each time point af-

ter the operation (p<0.05). See Table 2.

Table 1

Comparison of preoperative isoenzyme values between the two groups.

General data

Mild elevation

≤ 5.31ng/mL

(n=85)

Severe elevation

> 5.31ng/mL

(n=31)

t/χ² p

Age* 63.25±7.18 64.78±7.36 1.009 0.315

Gender (male/female) 63/22 23/8 0.001 0.993

BMI(kg/m

)* 23.67±3.12 24.55±3.29 1.325 0.188

Hypertension ** 59(69.41) 20(64.52) 0.251 0.617

Diabetes ** 35(41.76) 10(32.24) 0.761 0.383

Previous myocardial infarction ** 30(35.29) 9(29.03) 0.399 0.528

Previous PCI ** 7(8.24) 4(12.90) 0.576 0.448

Occurrence of angina pectoris 24 h

before **operation

8(9.41) 10(32.26) 9.044 0.003

LVEDD (cm)* 5.67±0.37 5.58±0.59 0.978 0.330

LVEF (%)* 53.12±5.16 53.54±5.31 0.385 0.701

sx ±

), **[n (%)].

312 Zhou et al.

Investigación Clínica 64(3): 2023

Comparison of operation between the two

groups

The proportion of patients whose di-

ameter of the anterior descending artery ≤

1.5mm and the diameter of the distal target

vessel > 1.5mm in the severe elevated group

were higher than those in the mild elevated

group (p<0.05). The vascular resistance in

the severe elevated group was significantly

increased compared with that in the mild el-

evated group (p<0.05). See Table 3.

Logistic regression analysis of the related

factors affecting the increase

of postoperative CK-MB

Logistic regression analysis showed that

the incidence of angina pectoris 24 hours be-

fore surgery, vascular resistance, and distal

target vessel diameter > 1.5mm were related

factors affecting the increase of postoperative

CK-MB (p<0.05). See Table 4.

Comparison of cardiac function between

the two groups before and after surgery

The level of LVEF three months after

the operation in the mild elevated group was

significantly higher than before surgery (p

<0.05). In comparison, the level of LVEF at

seven days and three months after operation

in the severe elevated group was not signifi-

cantly different from that before operation

(p>0.05)- In contrast, the level of LVEDD

seven days and three months after operation

in the mild elevated group was significantly

lower than that before operation (p<0.05).

The level of LVEDD at three months after op-

eration in the severely elevated group was de-

creased than before (p<0.05). See Table 5.

DISCUSSION

Currently, the clinical treatment of

coronary heart disease is mainly by drug

treatment, surgical treatment, and interven-

tional stent treatment. Generally, different

treatment schemes are chosen according to

the severity of the patient’s condition. Tradi-

tional coronary artery bypass grafting is per-

formed under cardiopulmonary bypass, and

the long-term typical rate of vascular anas-

tomosis is high, as well as safety and effec-

tiveness. However, cardiopulmonary bypass,

cardiac arrest, and myocardial ischemia-

reperfusion can cause systemic inflamma-

tory reactions and multiple organ function

damage, seriously endangering the life and

health of patients

. In recent years, OPCAB

surgery has entered a new period. During the

operation, the anastomosis can be complet-

ed while maintaining the independent blood

flow of the coronary artery and the beating

heart, which reduces myocardial ischemia-

reperfusion injury. Although the ascending

aorta is not blocked during OPCAB grafting,

the operation itself can cause myocardial

ischemia-reperfusion injury during the anas-

tomosis. Its effect on the prognosis of pa-

tients has become the focus of clinical schol-

Table 2

Comparison of CK-MB levels between the two groups during the perioperative period.

Time

Mild elevation

≤ 5.31ng/mL

(n=85)

Severe elevation

> 5.31ng/mL

(n=31)

t p

Before operation (ng/mL) 0.93±0.54 0.90±0.53 0.266 0.791

12h after the operation (ng/mL) 2.26±0.85 10.77±12.77 6.153 <0.001

24h after the operation (ng/mL) 1.28±0.63 6.49±8.15 5.924 <0.001

48h after the operation (ng/mL) 0.86±0.49 2.57±1.52 9.199 <0.001

Values expressed as

sx ±

Creatine kinase isozyme on prognosis after off-pump coronary artery bypass grafting 313

Vol. 64(3): 308 - 316, 2023

Table 3

Comparison of surgery data between the two groups.

Operation condition

Mild elevation

≤ 5.31ng/mL

(n=85)

Severe elevation

> 5.31ng/mL

(n=31)

t/χ² p

Internal mammary artery bridge flow (mL/min) * 30.12±13.58 29.58±17.11 0.135 0.788

Great saphenous vein bridge flow (mL/min) * 21.19±10.65 22.02±11.47 1.252 0.627

Vascular resistance (mmHg/mL/min) * 4.11±0.92 6.03±1.48 5.451 0.003

Diameter of

the anterior

descending

branch

≤1.5mm ** 6(7.06) 7(22.58) 5.500 0.019

1.75~2.0 mm ** 60(70.59) 18(58.06) 1.617 0.203

≥2.25 mm ** 19(22.35) 6(19.35) 0.121 0.728

Diameter of the

distal target

vessel

≤1.5mm** 65(76.47) 17(54.84) 5.130 0.024

>1.5mm** 20(23.53) 14(45.16) 5.130 0.024

sx ±

), or **[n (%)].

Table 4

Logistic regression analysis of the related factors affecting the increase of postoperative CK-MB.

Variable B SE

Wald statistic

quantity

p OR 95%CI

Constant -3.765 0.875 15.359 <0.001 0.022

Vascular resistance 0.785 0.452 3.467 0.001 1.452 0.725~4.154

Occurrence of angina pectoris

24 hours before the operation

1.033 0.332 6.564 0.011 3.128 1.207~7.365

Diameter of the anterior

descending branch≤1.5mm

0.688 0.428 2.211 0.127 2.113 0.663~6.280

Diameter of the distal target

vessel >1.5mm

0.402 0.153 5.610 0.015 1.461 1.063~2.142

Table 5

Comparison of cardiac function between the two groups before and after surgery.

Cardiac function Group Before the

operation

Seven days after

the operation

Three months after

the operation

LVEF (%) Mild elevation 53.12±5.16 53.84±5.13 57.48±5.01*

Severe elevation 53.54±5.31 54.63±5.22 54.32±6.15

LVEDD (cm) Mild elevation 5.67±0.37 4.73±0.35* 4.74±0.39*

Severe elevation 5.58±0.59 5.02±0.36 4.78±0.49*

Note: compared with pre-operation * p < 0.05

Values expressed as

sx ±

LVEF left ventricular ejection fraction; LVEDD left ventricular end-diastolic diameter.

314 Zhou et al.

Investigación Clínica 64(3): 2023

ars

8,9

we revised 400 patients; 200 received

on-pump CABG and 200 off-pump OPCAB

(OPCAB. OPCAB grafting consists of revas-

cularization of bridging blood vessels, which

can be improved by distal coronary artery

obstruction and stenosis, so myocardial isch-

emia-reperfusion injury will inevitably occur

after the operation

. Keeping a clear field

of vision for the operation during vascular

anastomosis will temporarily block the proxi-

mal vessels, resulting in temporary ischemia

of the muscles dominated by the distal end

of the artery. A significant decrease in blood

pressure during the operation can cause ar-

terial vasospasm and then cause myocardial

ischemic injury. If the patients do not move

in time after sorgery, it is easy to form coro-

nary or bridging vascular thrombosis, result-

ing in myocardial ischemic injury and a sig-

nificant increase of myocardial enzymes

CK-MB is a kind of myocardial enzyme

mainly present in cardiomyocytes’ cyto-

plasm. As an essential enzyme detection

index of myocardial injury, it has been paid

more and more attention in clinical practice

. The content of CK-MB in serum is mini-

mal. Generally, the cell membrane perme-

ability increases after myocardial injury, and

its level in the blood peaks after nine to 30

hours. Therefore, CK-MB detection is often

combined with clinical symptoms and car-

diac echocardiography to evaluate the sever-

ity of myocardial injury

the rats received

ISO subcutaneously at a dose of 100 mg/

kg for three days. In group III, rats received

ISO as group II and then GNPs (400 μg/kg/

day). In this study, by examining the post-

operative CK-MB level, the patients with the

highest value ≤ 5.31ng/mL were included

in the slightly elevated group (mild elevated

group) and those with levels > 5.31ng/mL

were classified as the significantly elevated

(severe elevated group). Based on the analy-

sis of the data of the two groups, it was found

that the peak level of CK-MB appeared 12

hours after the operation, and the level of

CK-MB in the severe elevated group was sig-

nificantly higher than in the mild elevated

group at each time point after surgery (p<

0.05). In addition, the Logistic regression

analysis results showed that the occurrence

of angina pectoris 24 hours before opera-

tion, high vascular resistance, and distal tar-

get vessel diameter > 1.5mm were related

factors affecting the increase of postopera-

tive CK-MB (p<0.05). The related data show

that the blood flow of the bridge is positively

correlated with the diameter of the distal

coronary artery. When there is stenosis or

obstruction of the distal vessel, the anasto-

motic site is not unobstructed and the blood

flow is small

. The positive correlation be-

tween the diameter of the distal target vessel

> 1.5mm and the increase of CK-MB may be

due to the decrease of blood flow caused by

a large vascular plaque load, which in turn

affects the increase of CK-MB level

each of

whom presented with a normal ECG and was

subjected to emergency coronary angiogra-

phy (CAG).

This study showed that the improve-

ment degree and speed of LVEF and LVEDD

were different in patients with different lev-

els of CK-MB after OPCAB grafting. The level

of LVEF in patients with mild elevation was

significantly higher than that before the op-

eration and three months after the opera-

tion (p<0.05); the level of LVEDD in the

mild elevated group was significantly lower

than that before the operation at seven days

and three months after operation (p<0.05);

the level of LVEDD in severe elevated group

was significantly lower than that before op-

eration and three months after operation

(p<0.05). This finding suggests that the

higher the level of CK-MB after surgery, the

longer the duration, the more serious the

myocardial injury of patients, and the worse

the prognosis.

To sum up, angina pectoris attack, dis-

tal target vessel diameter > 1.5mm, and

elevated vascular resistance before beating

coronary artery bypass grafting can affect

the elevation of myocardial enzymes after

the operation, and the recovery of myocar-

dial function is slow in patients with signifi-

Creatine kinase isozyme on prognosis after off-pump coronary artery bypass grafting 315

Vol. 64(3): 308 - 316, 2023

cantly increased myocardial enzymes, which

can be used as an essential biological index

to reflect the prognosis of patients.

Funding

None

Competing Interests

The authors declared that they have no

competing interests.

Authors’ ORCID numbers

• Zifan Zhou (ZZ):

0000-0003-2456-6001

• Longfei Wang (LW):

0000-0002-8585-9054

• Jun Wang (JW):

0000-0002-9593-0803

• Ningning Liu NL:

0000-0002-7443-5168

• Yongmin Liu YL:

0000-0003-2699-6080

• Lizhong Sun (LS):

0000-0001-9751-9471

Authors’ Contribution

Conception and design: Z Z: Adminis-

trative support; LW: Provision of study ma-

terials or patients; ZZ, JW: Collection and

assembly of data; NL, YL: Data analysis and

interpretation; LS: Manuscript writing; All

authors: Final approval of manuscript.

REFERENCES

1. Emdin CA, Khera AV, Natarajan P, Klarin

D, Zekavat SM, Hsiao AJ, Kathiresan S.

Genetic association of waist-to-hip ratio

with cardiometabolic traits, type 2 diabe

tes, and coronary heart disease. J Am Med

Assoc 2017; 317(6): 626-634. https://doi.

org/10.1001/jama.2016.21042.

2. Frestad D, Prescott E. Vital exhaustion

and coronary heart disease risk: A syste

matic review and meta-analysis. Psycho-

som Med 2017; 79(3): 260-272. https://

doi.org/10.1097/PSY.0000000000000423.

3. Filardo G, Hamman BL, da Graca B,

Sass DM, Machala NJ, Ismail S, Pollock

BD, Collinsworth AW, Grayburn PA. Effi

cacy and effectiveness of on- versus off-

pump coronary artery bypass grafting: A

meta-analysis of mortality and survival.

J Thorac Cardiovasc Surg 2018; 155(1):

172-179.e5. https://doi.org/10.1016/j.

jtcvs.2017.08.026.

4. Smetkin AA, Hussain A, Fot E V., Zakha

rov VI, Izotova NN, Yudina AS, Dityateva

ZA, Gromova YV, Kuzkov VV, Bjertnæs LJ,

Kirov MY. Estimated continuous cardiac

output based on pulse wave transit time in

off-pump coronary artery bypass grafting:

a comparison with transpulmonary ther

modilution. J Clin Monit Comput 2017;

31(2): 361-370. https://doi.org/10.1007/

s10877-016-9853-5.

5. Zou L, Su W, Wang M, Huang W, Zhao H,

Zhang E, Jin J, Xu H, Xiao F. Characteri

zation of a functional recombinant human

creatine kinase-MB isoenzyme prepared

by tandem affinity purification from Es

cherichia coli. Appl Microbiol Biotechnol

2017; 101(14): 5639-5644. https://doi.

org/10.1007/s00253-017-8286-5.

6. Natsukawa T, Maeda N, Fukuda S, Yamaoka

M, Fujishima Y, Nagao H, Sato F, Nishi

zawa H, Sawano H, Hayashi Y, Funahashi

T. Significant association of serum adipo

nectin and creatine kinase-MB levels in ST-

segment elevation myocardial infarction. J

Atheroscler Thromb 2017; 24(8): 793-803.

https://doi.org/10.5551/jat.38232.

7. Zhou Y, Li J, Du S, Du X, Fu C, Cao C, Wang

Y. Cardiac rehabilitation knowledge in pa

tients with coronary heart disease in Bao-

ding city of China: A cross-sectional study.

Int J Nurs Sci 2017; 4(1): 24-28. https://

doi.org/10.1016/j.ijnss.2016.12.011.

8. Mahmoud AF, Adel M, Ali HF, Alkady H.

Does the off-pump coronary artery bypass

grafting affect the outcome in ischemic

cardiomyopathy? J Egypt Soc Cardio-Tho

racic Surg 2017; 25(1): 1-7. https://doi.

org/10.1016/j.jescts.2017.01.002.

316 Zhou et al.

Investigación Clínica 64(3): 2023

9. Karim MR, Ahmed T, Khurshid R, Moi-

nuddin S, Hasan MK. Preoperative aspirin

use and outcomes in off-pump coronary

artery bypass grafting surgery. Bangladesh

Hear J 2018; 33(1): 16-21. https://doi.

org/10.3329/bhj.v33i1.37019.

10. Mizuno T, Egi K, Sakai K, Oi K, Hachima

ru T, Makita T, Oishi K, Arai H. Minimally

circulatory-assisted on-pump beating co

ronary artery bypass grafting for patients

with complex conditions for off-pump sur

gery. Artif Organs 2017; 41(3): 233-241.

https://doi.org/10.1111/aor.12761.

11. Scarpino M, Lanzo G, Moretti M, Olivo

G, Amantini A, Grippo A. Delayed ce

rebral fat embolism occurring after off-

pump coronary artery bypass grafting.

Cardiol J 2018; 25(1): 155-57. https://doi.

org/10.5603/CJ.2018.0015.

12. Mavai M, Singh YR, Gupta RC, Mathur

SK, Bhandari B. Erratum to: Linear analy

sis of autonomic activity and its correlation

with creatine kinase-MB in overt thyroid

dysfunctions (Ind J Clin Biochem, (2018),

33 (2), (222-228), 10.1007/s12291-017-

0659-0). Ind J Clin Biochem 2018; 33(2):

229-230. https://doi.org/10.1007/s12291-

017-0700-3.

13. Ahmed SM, Abdelrahman SA, Salama

AE. Efficacy of gold nanoparticles aga

inst isoproterenol induced acute myocar-

dial infarction in adult male albino rats.

Ultrastruct Pathol 2017; 41(2): 168-185.

https://doi.org/10.1080/01913123.2017.

1281367.

14. Miao ZL, Hou AJ, Zang HY, Huang RG,

Zheng XQ, Lin HL, Wang W, Hou P, Xia

F, Li ZQ. Effects of recombinant human

brain natriuretic peptide on the prognosis

of patients with acute anterior myocardial

infarction undergoing primary percuta

neous coronary intervention: A prospecti-

ve, multi-center, randomized clinical trial.

J Thorac Dis 2017; 9(1): 54-63. https://

doi.org/10.21037/jtd.2017.01.15.

15. Lee JJ, Lee JH, Jeong JW, Chung JY.

Fragmented QRS and abnormal creatine

kinase-MB are predictors of coronary ar

tery disease in patients with angina and

normal electrocardiographys. Korean J

Intern Med 2017; 32(3): 469-477. https://

doi.org/10.3904/kjim.2015.123.