Off Pump Coronary Artery
Off pump surgery is not new
1964 - IMA as a graft Kolesov
Thoracotomy no CPB
1985 - Complete CABG Benetti
1995 - Minimally Invasive CABG Calafiore
no CPB Subramanian
1996 - First use of suction Borst
Stabilization device Grunderman
1997 - Multivessel suction Jansen
CABG / OPCAB
Cardiopulmonary Bypass (CPB)
Aortic Cross Clamp
Exposure of post, Lat wall of the heart.
Stabilization of target area.
Visualization Occlusion of the Coronary Ar.
Click here to watch
a short clip
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a short clip
- Intramyocardial Coronary Ar.
- Very small arteries ( <1m”m).
- Calcified arteries.
- Poor conduits.
- Huge hearts.
- Hemodynamic Instability/Ischemia.
- Cardiogenic shock.
Manipulation Haematologic coagulation Inflammatory
of Aorta disorders Response
WBC , Hg Bleeding post pump
Neurologic dysfunction PLT , IgG syndrome
Prolonged Ventilation Immunitiy Transfusion Fever
M Prolonged ICU + Hospital stay M
- Easy quick Meticulous anastomosis
Best choice of Anastomotic site.
Possibility of Ar. Reconstruction.
- Multiple grafts.
- Unloading of Ischemic or failing Heart.
- Less stress on the Surgeon (anesthetist).
-Difficult surgery Experienced surgeon
-Haemodynamic disturbances Experienced and very
(Organ insults) aware Anesthetist
- Inability to perform Hybrid procedure
complete re-vascularization (PCI +OPCAB)
- Patency rate Do as best as you can.
- Reduction of: - neurologic complications.
- cognitive disorders.
- Reduction of ventilation time and pulmonary complications
- Reduction of blood loss Less transfusions.
- Possible less inflammation ?
- Shorter I.C.U stay.
- Possible earlier discharge?
most OPCABG patients are old and with sev. comorbidities.
Mechanism of Neurocognitive Disorders in Heart Surgery.
- Cerebral Embolization (Micro/Macro).
- Aortic Atherosclerosis.
- Air/Fat Embolism.
- Haemdynamic fluctuations.
- Vasculopathy (Carotis, Brain)
- Systemic Inflammatory Reaction.
Only few prospective Randomized Trials
showed superiority of OPCAB Vs CABG.
1. Sedrakan - Stroke 2006
41 randomized trials – 50% reduction of stoke in OPCAB
2. Glenville – Ann. Thor. Surg. 2004
Elderly P. Stroke CABG – 3% OPCAB 1%
3. Mohr – Ann. Thor. Surg. 2003
16,184 p. Stroke CABG - 3.8% OPCAB 1.9%
1. Alamanni – Eur. J. Cardioth. Surg. 2007
No difference stroke rate
2. Lund – Ann. Thorac. Surg. 2005
No difference in long term cognitive function or MRI evidence of brain injury
On the Other Hand
Puskas – Ann. Thor. Surg. 2000
In series of 10,800 p. found 3 independent variables for prediction of stroke – age,
previous Tia, carotid bruit
In a large series of patients with high respiratory
ventilation time significantly
shorter after OPCAB
Reddy. Eur. J. Cardthor. Surg. 2006
Other Trials resulted in same conclusions.
Some large prospective randomized studies
revealed less myocardial injury after
Rastan – Eur. J Cardioth. Surg. 2005
Mechanism of inflammation on pump
Contact activation of Ischemia-Reperfusion Translocation of
immune system injury to brain, kidney endotoxins through
following exposure liver, heart, lung damaged mucosal
of blood to foreign bowel. barriers.
surfaces of pump.
Post pump disease
Not found correlation between clinical outcome and inflammation
response nevertheless strong evidence of cytokines cascade
-Wan – J. Thor. Card. Surg. 2004.
Intense inflammatory response – Interleukin 6, 8, 10, TNFα,
Vascular adhesion molecule 1,
-Luyten – Eur. J. Cardioth. Surg. 2005.
Systemic inflammation caused by oxidative stress due to ischemia generated
oxidative products which caused endogenous antioxidants.
WHO IS GUILTY?
PUMP? SURGERY ITSELF?
YET NOT CLEAR
Blood Loss + Transfusions
Clear evidence in reduction of blood loss in
Ascine – Eur. J. Cardioth. Surg. 1999
Clear evidence in reduction of transfusions
Puskas – Ann. Thor. Surg. 1998
Few prospective randomized studies
documented reduction of graft patency rate
– Parolari – Ann. Thor. Surg. 2005
Other large trials present similar patency in
OPCAB Vs. CABG
– Puskas – JAMA 2004
– Fukui – Ann. Thor. Surg. 2007
– Calafiore – Ann. Thor. Surg. 1999
– Jansen – J. Thor. Cardiovasc. Surg. 1998
An example of outcome between CABG Vs.
OPCAB is presented in substudy of
No. of patients 654 597
Mean no. of grafts 3.4 +1 2.9+1.2
Op. Mortality 1.7% 1.7%
Stroke 0.9% 0.7%
Reop. for bleeding 2.6% 1.0%
Prolonged Ventilation 10.0% 3.4%
Atrial Fibrillation 23.0% 15.0%
Transfusions needed 51.0% 35.0%
Hospital stay 7.5 d 6.2 d
Mortality 1 y 4.9% 4.6%
Myocardial Infarction 1y 1.0% 0.7%
Need for Re-vascularization 2.8% 4.1%
Ann. Thor. Surg. 2007
Innovations in OPCAB
- Possible to operate in patients with neoplastic
(Decrease in: inflammatory response, coagulopathy disorders,
immunity response and spreading of malignancy).
- Possiblity to perform in SEMI awake patient,
- Surgical comfort depends on experience.
- Hybrid Re-vascularization
(in the future to be performed at the same time, in the same place)
Who should benefit from OPCAB ?
A Very High Risk Patient With Severe