Off-pump coronary artery bypass grafting (OPCABG) is a surgical revascularization technique where grafts are anastomosed to coronary arteries to bypass occlusions without using cardiopulmonary bypass. As a result, the typical considerations for “on-pump” CABG (atrial cannulation, aortic cannulation, aortic cross-clamping, cardioplegia, suspension of mechanical ventilation, etc.) are not performed. Instead, surgeons fix a suction device to the ventricular apex to manipulate the heart. Additionally, the target coronary artery is immobilized with an epicardial stabilization device while the rest of the heart continues to beat around it. The video shows the Urchin® Evo heart positioner which provides effective positioning and visualization of the anastomotic sites.
As a cardiac anesthesiologist, I utilize much less heparin for these cases, but often have a myriad of hemodynamic challenges to cope with as surgeons operate. Because I can’t rely on cardiopulmonary bypass, I’m responsible for maintaining the hemodynamics which can be compromised by variable venous return, arrhythmias from cardiac manipulation, and ineffective forward flow due to the heart not being in its natural position.
Propensity matched studies and retrospective reviews have shown that OPCABG has less morbidity/mortality, transfusions, stroke, renal failure, hospital length of stay, and time receiving mechanical ventilation. Some of these findings have also been shown in randomized trials and meta-analyses. Still, the major benefit may be in high risk patients. For example, patients with highly calcified “porcelain” aortas may benefit from the no-touch technique inherent to OPCABG (no aortic clamp, no aortic cannulation).
Drop me a comment with your experience regarding OPCABG!
