Off-pump and minimally invasive direct coronary artery bypass graft surgery: Outcomes
- David M Holzhey, MD, PhD
David M Holzhey, MD, PhD
- University of Leipzig
- Heart Center
- Section Editors
- Edward Verrier, MD
Edward Verrier, MD
- Section Editor — Cardiac Surgery
- Professor of Surgery
- University of Washington School of Medicine
- Gabriel S Aldea, MD
Gabriel S Aldea, MD
- Section Editor — Cardiac Surgery
- Professor of Surgery
- University of Washington
Standard coronary artery bypass graft surgery (CABG) employs a midline incision through the sternum, placement of the patient on cardiopulmonary bypass, and arrest of the heart with cardioplegia. This approach allows for optimal exposure of the coronary arteries and a motionless (non-beating) heart, both of which optimize the suturing of the distal anastomoses of the bypass.
This approach may contribute risk during certain clinical scenarios. For example, patients requiring a repeat CABG are at risk of damage to a previously placed left internal mammary bypass graft during a repeat sternotomy and patients with calcified aortas may be at increased risk of cerebral embolization with cross-clamping of the aorta during cardiopulmonary bypass.
This topic will discuss clinical outcomes after off-pump and minimally invasive direct CABG, two approaches that have been be evaluated as potential approaches to decrease some of the risks of standard CABG. Complications of CABG using any technique, technical issues related to minimally invasive CABG, and minimally invasive approaches to valvular surgery are discussed separately. (See "Early noncardiac complications of coronary artery bypass graft surgery", section on 'Prevention of complications' and "Minimally invasive coronary artery bypass graft surgery: Definitions and technical issues" and "Minimally invasive aortic and mitral valve surgery".)
Off-pump coronary artery bypass graft surgery (OPCAB) refers to CABG without the use of cardiopulmonary bypass. The major rationale for this procedure, which is also called “beating heart surgery,” is to avoid the morbidity associated with cardiopulmonary bypass (induction of a systemic inflammatory response, activation of platelets) and of cross-clamping the aorta (risk of stroke or systemic embolization).(See "Minimally invasive coronary artery bypass graft surgery: Definitions and technical issues", section on 'General principles' and "Embolism from aortic plaque: Thromboembolism".)
All surgeons performing OPCAB must be competent with the on-pump technique. The off-pump technique is technically more challenging and requires additional training. It has been chosen by some practitioners for high-risk patients with contraindications to conventional CABG, such as those with extensive ascending aortic atheromatous or calcific changes that might preclude safe aortic instrumentation. A potential disadvantage of off-pump surgery is the difficulty of performing distal anastomoses on a beating heart; this might lead to incomplete revascularization if exposure of the back of the heart is challenging or decreased graft patency because of suboptimal conditions during the construction of the distal anastomosis.
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