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Key Concepts

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  • Team approach

    • Although all cardiac operations require a multidisciplinary approach, this is especially true for off-pump coronary artery bypass grafting (CABG). Close and clear communication with the anesthesiologist is critical for the safe performance of the procedure. Similarly, the nursing staff should be included in the dialogue so that it can anticipate each step in the operation and prepare instruments, shunts, and sutures as necessary and in a timely fashion.

  • Minimization of risk

    • Off-pump CABG has the potential to reduce morbidity and mortality significantly. However, if done improperly, it can lead to higher complication rates. This is best avoided by minimizing potential intraoperative risk at every possible step.

  • Reengineering

    • To achieve optimal results with this technique, it must be realized that this procedure is not just a CABG performed without the assistance of cardiopulmonary bypass. Instead, it requires a complete reengineering of the operative technique and physiologic concepts, including optimizing oxygen supply and demand and maintaining hemodynamic stability before, during, and after cardiac manipulation.

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Introduction

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This will focus on the surgical technique that we feel provides the most effective and safe method of off-pump coronary revascularization.

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Off-pump coronary artery bypass (OPCAB) has been practiced to some degree for many years, but it has regained popularity only recently with the development of devices that allow for superb exposure and stabilization of the anastomotic area. This technology continues to develop and improve over time. With the spectrum of patients presenting with coronary disease becoming more complex and higher risk, surgeons have been looking for surgical options that may reduce complications. OPCAB has this potential because it avoids cardiopulmonary bypass (CPB) and the associated morbidity.

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OPCAB is not simply the standard coronary bypass operation performed without the assistance of CPB. Rather, it is a concept whose primary goal should be the reduction of morbidity and mortality. The technical result should be identical to that for a standard coronary artery bypass graft (CABG) operation: the same number, location, and quality of anastomoses. Further, OPCAB must be a reproducible technique, allowing it to be taught to other surgeons and incorporated into the training of cardiothoracic surgical residents. This aspect is something that has been studied in a scientific fashion at Gasthuisberg Hospital in Belgium. There are now objective data to support this technique, which can be safely taught to residents and can also be used to retrain established surgeons.1 Ideally OPCAB should be applicable to the entire spectrum of patients. In Leuven, a practical algorithm is used to determine whether a particular patient has a bypass performed with or without CPB (Fig. 28-1). Obviously, for any patient in extremis, receiving cardiac compressions, or with malignant arrhythmias, emergent institution of CPB is lifesaving and necessary. In this patient subset, the authors perform CABG on CPB, but with a beating heart to minimize further ischemia. In more stable patients, the next branch ...

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