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Off-pump coronary artery bypass or "beating heart" surgery is a form of coronary artery bypass graft (CABG) surgery performed without cardiopulmonary bypass.
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- Early outcome after off-pump coronary artery bypass grafting: effect on mortality and stroke
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Sometimes the fatty type materials that collects to form a blockage or line on the walls of an artery may break loose during CABG procedure manipulation. Data analysis from beating heart surgery patients shows a significant reduction in the release of this debris with correspondingly lower stroke rates. The fatty emboli which cause brain damage are generated when the large artery from the heart aorta is manipulated and although these are reduced in most off-pump coronary bypass surgeries they are not eliminated because the aorta is still used as a site to attach some of the grafts.
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A growing number of OPCAB surgeons, however, are avoiding the aorta completely, known as "anaortic" or no-touch coronary bypass surgery, by taking all their grafts from sites other than the aorta e. Off-pump surgery can be more technically challenging. The technique has a steep learning curve , but with adequate training and experience, the quality of the anastomoses has been shown to be similar to on-pump results in surgeons with comparable experience. On February 18, , Amano Atsushi performed a successful off-pump coronary artery bypass operation on Emperor Akihito.
From Wikipedia, the free encyclopedia. Journal of the American College of Cardiology. Seminars in Thoracic and Cardiovascular Surgery.
Early outcome after off-pump coronary artery bypass grafting: effect on mortality and stroke
Yusuf et al. Serruys et al. While Hannan et al.
They both begin with the surgeon harvesting blood vessels from the leg, chest or the arm. The surgeon gains access to the heart using midline sternotomy. While the heart is stopped the surgeon performs the graft procedure by sewing one end of a section of a blood vessel over a tiny opening made in the aorta and the other end over a tiny opening made in the blocked coronary vessel, distal to its blockage.
With the grafting complete, the body is removed from the cardiopulmonary bypass machine and the heart is restarted Shekar, In off-pump CABG, the area around the blocked coronary artery is stabilized while the surgeon grafts the blood vessel on the pumping heart. But it gained popularity, as a variant of on-pump coronary artery bypass, due to its recently discovered effects of causing less inflammation, less morbidity and being more cost effective Hijazi, According to Robertson and colleagues , on-pump patients tend to have significantly higher frequencies of complete revascularization as compared to patients treated via Off-pump method These finding are supported by Ivanov et al.
Ivanov et al. Due to incomplete revascularization, Lattouf and colleagues have reported that patients requiring more than 3 grafts are more likely to be treated on-pump. Incomplete revascularization has traditionally been associated with increased mortality. In , Buda et al. This body of evidence supports the argument that incomplete revascularization caused by off pump bypass surgery could lead to increased mortality in off pump bypass surgeries as compared to on-pump surgeries.
Incomplete revascularization also leads to increased repeat procedures. On pump bypass is preferred to off-pump bypass in emergency situations. This makes sense, as loading an already ischemic heart with additional workload by performing Off-pump surgeries seems counterproductive. They also proved that using cardiopulmonary bypass CPB machines during emergency procedure lowers rates of recurrent angina, lessens symptoms of heart failure and decreases re-hospitalization frequency.
Though it was initially thought that using cardiopulmonary bypass machine increases the incidence of ischemic cerebral injury Knipp et al. Indeed, Hammon and colleagues have reported that neuropsychological deficits in patients undergoing ONCAB with single cross-clamping and minimal aortic manipulation is lower than those undergoing OPCAB.
They further hypothesized that mild hypothermia as obtained in on-pump surgeries could actually be beneficial for the brain. As Brown et al. Comparing the morbidity and mortality rate, both the off- and on-pump techniques yield very good results with very low mortality. However a much lower post operative morbidity with the off-pump operation is established.
The much higher morbidity in the on-pump bypass is seemed to be much attributable to cardiopulmonary bypass process itself Sabik et al. This is further supported by a research which shows that off-pump technique was associated with a much decreased risk-adjusted operative mortality from 2. The adoption of an off-pump procedure also decreased the risk-adjusted complication rate from Adding even more to this point a research highlighted that the patients who were treated off-pump had both lower complication rates 8.
The aforementioned facts therefore highlight the importance of OFCAB in reducing both mortality and morbidity and lesser post operation complications. CABG involvesa systemic inflammatory response associated with cytokine release and complement activation due to the fact that it is an invasive process. Another research showed that the serum levels of tumor necrosis factor-alpha were detected in higher amounts in patients with ONCAB. Therefore the much increased levels of the pro inflammatory cytokines in the ONCAB group could be the factor which causes more post op complications and mortality amongst patients.
Comparing patients with multiple co-morbidities, 4 studies were reviewed and patients were classified as being high risk if there was the presence of multiple preoperative co morbid factors. A significant number of patients in the ONCAB group had 3 vessel disease, severe heart failure symptoms and unstable angina.
However there were no significant differences to be accounted for almost all of the preoperative risk factors present. In about two researches, the number of grafts placed was found to be greater in the ONCAB group in comparison to the OFCAB group, but however the number of grafts was found to be alike in other studies. Mortality was found to be much higher in ONCAB group in one of the studies but however not much difference was found in the other 3 studies. In these studies, the postoperative blood loss, need for blood transfusion, arrhythmias, and ventilation time was found to be higher in the oncab group as compared to the ofcab group.
Similarly, peri-operative myocardial infarction was found to be lower in the OFCAB group in one study but was found not to be significantly different in the other 3 studies. However the infectious, renal, and neurological complications were found to be similar in all the studies. Therefore OFCAB can be done with a much lower mortality and morbidity in the selected groups of high-risk patients with multiple co morbid. OFCAB is a reasonable, and may even be a preferable, operative strategy for the high-risk group of patients.
Two studies were found which assessed the possibility that whether coronary revascularization surgeries in individuals with severely damaged atheromatous aorta could be performed using the off pump technique or not Sharony et al. Both the studies used the propensity matching in order to have same number of individual patients in the OFCAB and the ONCAB groups with similar preoperative characteristic and echocardiography findings of ascending aortic atheromatous disease. The incidence of stroke and mortality were found to be greater in the ONCAB groups in both the studies. The 1st study Sharony et al.
The second study Sharony et al. In both the studies three years follow up was done. One study showed an increased survival in the OFCAB group whilst the other showed no significant difference. These facts therefore help reinstate that patients who had severe atherosclerotic aortic disease and underwent OFCAB show a significantly lower prevalence of complication, strokes and in hospital mortality in comparison with the patients who underwent ONCAB.
For older patients, the off pump procedure yielded better prognosis and outcome in comparison with its ONCAB counterpart. This fact is supported by 2 researches, in which one study selected patients greater than 75 years of age whilst the other study focused on patients greater than 80 years of age. However the preoperative patient characteristics were similar in both the studies. However, kidney failure, myocardial infarction, reoperation for bleeding, operative mortality and wound infections were not found to be significantly different amongst the two types of procedures.
The aforementioned facts therefore help conclude that OFCAB procedure is much more beneficial when performed in elderly patients. For patients with acute myocardial infarction a research carried in Israel highlighted the efficacy of the OFCAB procedure for such patients. The research included patients who underwent CABG sometime soon after an acute myocardial infarction. All the patients who were a part of the research had similar pre operative characteristics and had the operation performed within one week after the occurrence of an acute myocardial infarction Locker et al.
However the mortality rate was not significantly different in patients operated more than 2 days after myocardial infarction. The incidence of late mortality was however found to be much lower in the traditional CABG group. Therefore the use of OFCAB procedure in emergency patients being operated within the first 2 days of the onset of symptoms has found to be much beneficial in comparison to its traditional counterpart.
Table 1 shows a summary of the advantages of each technique. To conclude we could say that short term morbidity and mortality is less in very high-risk patients with off-pump, possibly because the procedure is shorter. It would be right to say that shorter the procedure, the better, especially for older, sicker patients. The length of the procedure is significantly shorter with off-pump than on-pump. However we suggest that the technique used should depend on the ease of the surgeon doing the operation as both the methods seem almost equally efficient according to the review otherwise.
Certainly more data over large randomized trials is required before off pump superiority over on-pump can be firmly established.
chapter and author info
National Center for Biotechnology Information , U. Glob J Health Sci. Published online Mar Author information Article notes Copyright and License information Disclaimer. Tel: E-mail: moc. Received Dec 30; Accepted Feb Keywords: coronary artery bypass graft surgery, off pump, on pump, CABG.
Advantages of Off-Pump Comparing the morbidity and mortality rate, both the off- and on-pump techniques yield very good results with very low mortality. Conclusion Table 1 shows a summary of the advantages of each technique. Table 1 The main advantages of each technique. Advantages of ON Pump CABG 1 Leads to more complete revascularization 2 Leads to increased formation of distal anastomosis 3 Is a better option in emergency situations 4 Most surgeons are familiar with this form of CABG Advantages of Off Pump CABG 1 Decreased morbidity and mortality rates 2 Associated with decreased levels of post-CABG inflammatory cytokines 3 Reduces occurrence of post-surgical cerebral microemboli 4 Preferred option in high risk patients and those with severe atherosclerotic aortic disease 5 Preferred option in older patients i.
Open in a separate window. M, Shimony A, Eisenberg M. Eur Heart J. D, Taylor F. It is predicted that the majority of bypass surgeries will be done off-pump in the future.
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In the off-pump or beating heart technique, the coronary artery bypass is carried out while the heart continues to beat. The same type of sternum incision used in a traditional coronary artery bypass is used, but once the heart is exposed, a stabilizer is used instead of a heart-lung machine. The stabilizing device is made of stainless steel and plastic and uses suction pods to grasp the epicardium outer layer of heart tissue while the heart is repositioned and vascular repairs are made.
Known in the medical world as OPCAB off-pump coronary artery bypass , this technique may help patients avoid the inflammation and neurological deficits associated with the heart-lung machine. The procedure also may offer patients other important advantages:. Although patients are discharged sooner with off-pump surgery, the four-to-six-week healing time from the incision sternotomy is similar to that of conventional bypass surgery. Nearly all patients are candidates for off-pump as long as the surgeon specializes in the procedure and has sufficient experience.
All arteries on the heart can be reached with modern exposure techniques. A surgeon can bypass up to six vessels without relying on a heart-lung machine. For high-risk patients with cerebral vascular problems, pulmonary or kidney disease, bleeding disorders, as well as patients older than 70, off-pump surgery is an excellent option and offers significant advantages.