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96200713914PM_Off Pump Coronary Artery Bypass Grafting


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									Off Pump Coronary Artery
     Bypass Grafting
                Off pump surgery is not new

1964 - IMA as a graft              Kolesov
       Thoracotomy no CPB

1985 - Complete CABG                         Benetti
       no CPB

1995 - Minimally Invasive CABG      Calafiore
       no CPB                       Subramanian

1996 - First use of suction         Borst
       Stabilization device         Grunderman

1997 - Multivessel suction          Jansen
       Stabilization Device
Cardiopulmonary Bypass (CPB)
      Aortic Cross Clamp
           OPCAB Demands
Exposure         of post, Lat wall of the heart.

Stabilization   of target area.

Visualization   Occlusion of the Coronary Ar.
                 or Shunt.

Stable           Hemodynamics.
Click here to watch
a short clip
Click here to watch
a short clip
           Relative Contraindications

- Intramyocardial Coronary Ar.
- Very small arteries ( <1m”m).
- Calcified arteries.
- Poor conduits.
- Huge hearts.
- Hemodynamic Instability/Ischemia.
- Cardiogenic shock.
                                 Pump Morbidity
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
                              Cost Effectiveness
                  Pump Benefits

- 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).
                     OPCAB Obstacles

          Problems                 Solutions
-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.
                      OPCAB Benefit

- Reduction of: - neurologic complications.
                   - cognitive disorders.
                   - stroke.
- 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.
                Neurological Outcome

Mechanism of Neurocognitive Disorders in Heart Surgery.
- Cerebral Embolization (Micro/Macro).
- Aortic Atherosclerosis.
- Air/Fat Embolism.
- Haemdynamic fluctuations.
- Vasculopathy (Carotis, Brain)
- Systemic Inflammatory Reaction.
                         Neurological Outcome
              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
                Respiratory Outcome

In a large series of patients with high respiratory
risk :
         ventilation time significantly
         shorter after OPCAB

                              Reddy. Eur. J. Cardthor. Surg. 2006

   Other Trials resulted in same conclusions.
            Myocardial Outcome

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.

                             Activation of
                        inflammatory cascade

                         Post pump disease

Not found correlation between clinical outcome and inflammation
     response nevertheless strong evidence of cytokines cascade
     during pump.
-Wan – J. Thor. Card. Surg. 2004.
Intense inflammatory response – Interleukin 6, 8, 10, TNFα,
                                 Vascular adhesion molecule 1,
                                 complement activation.
-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
                 Graft Patency
Few prospective randomized studies
documented reduction of graft patency rate
– Parolari – Ann. Thor. Surg. 2005

Other large trials present similar patency in
–   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
                “Care Registry”
                              CABG               OPCAB
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

               Thank you.

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