"On" or "off" pump coronary artery bypass grafting-Is the last word out?

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Abstract

A glance at the history of the development of Coronary Artery Bypass Surgery (CABG) throws up the interesting finding that the first milestones were without cardiopulmonary bypass (CPB) support. Off-pump CABG (OPCAB), having predated On-pump surgery, has had a roller coaster ride for want of a clean, still and bloodless field, culminating in the introduction of CABG on CPB (On-pump) by Favaloro in 1967. This develop-ment profoundly " democratised " the CABG procedure in that now a broad number of surgeons could achieve better and reproducible results with considerably more optimum oper-ating conditions. The initial enthusiasm for On-pump CABG gradually gave way to concerns regarding its safety, especially with regard to complications arising from CPB, and not CABG per se. Foremost of these relate to microembolic showering during manipulation of the aorta and neurocognitive dysfunction. In addition, CPB triggers a whole-body inflam-matory response caused by contact activation of the comple-ment cascade. This leads to multiple organ dysfunction affecting the kidneys, liver, lungs, brain and heart itself. 1 Studies published over a decade and a half ago questioned the safety of On-pump CABG. The proportion of patients recovering without any complication was found to be only 64.3%. 2 In addition, health insurance data and data from clinical studies showed that 10.2% did not leave the hospital within 14 days after the operation and 3.6% of the patients were discharged to a non-acute care facility. 3 These and other observations, pari passu with the development of mechanical and pharmacological organ stabilizers and intracoronary shunts, resurrected OPCAB in the early 1990s. As regards surgical technique, the actual suture anasto-mosis of the vessels follows the same technique both in On-and Off-pump surgery. The difference is that unlike On-pump surgery, where the heart is arrested by means of cardioplegia, in Off-pump surgery the area of interest is kept immobile with the help of organ stabilizers while the anastomosis is being performed. Pharmacologic agents like short-acting beta-blockers (e.g. Esmolol) or Adenosine are used in conjunction with these mechanical stabilizers to achieve the goal of a relatively motionless field. Exposure of the heart is aided by retraction devices like the " Starfish " , which lift up the apex from the pericardial cavity (Table 1). Retraction can also be achieved by means of folded sponges placed in the pericardial sac to lift the heart, or by pericardial hitching sutures. Distal coronary perfusion is maintained by means of flexible intra-coronary shunts introduced into the coronary vessel prior to commencement of the anastomosis (Fig. 1). Although these devices are designed for one-time use, they may be reused after ETO sterilization. This assumes importance as far as cost-containment in a country like India is concerned, giving a further fillip to Off-pump surgery. Numerous large observational studies and small random-ized controlled trials (RCT) have been published in the past 18 years suggesting benefits from OPCAB. Among these are, a reduction in stroke, duration of post-operative ventilation, need for reoperation, bleeding, wound infection, renal failure, post-operative length of stay 4 and decreased atrial fibrillation

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Yadava, O. P., & Kundu, A. (2013, March). “On” or “off” pump coronary artery bypass grafting-Is the last word out? Indian Heart Journal. https://doi.org/10.1016/j.ihj.2013.02.008

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