For treating hemodynamic instability during off-pump coronary artery bypass, we recommend intraaortic balloon pump insertion as the preferred bail-out method rather than conversion to cardiopulmonary bypass.
Heparin infusion maintains a steady target ACT level and avoids peaks and troughs associated with bolus doses. Lower level of anticoagulation using continuous heparin infusion does not increase ischemic complications. This is the first ever study of use of heparin infusion during OPCAB. We may conclude that heparin infusion is a safe anticoagulation strategy for OPCAB.
The OPCAB technique is still evolving. Low-volume centers have higher rates of conversion to CPB. Hypotension due to an impaired left ventricular function can be successfully treated by using an IABP. Although blood loss can be managed with BTs, use of a cell saver helps to reduce the number of BTs. We conclude that our technique of total arterial OPCAB using a cell saver can be safely performed in a low-volume center.
Objective Off-pump coronary artery bypass grafting in patients with left ventricular dysfunction has proven to be advantageous. However, it carries risk of emergency conversion to cardiopulmonary bypass. We have successfully used an intra-aortic balloon pump to prevent such conversion. The objective of the present study was to evaluate if intravenous nicorandil infusion reduces the incidence of intraoperative intra-aortic balloon pump insertion. Methods Consecutive cases of isolated off-pump coronary artery bypass surgery performed by a single surgeon were studied. Patients were divided into two groups. The first group did not receive nicorandil, and the second group received intraoperative nicorandil infusion (started in the operating room after central line insertion). Results A total of 375 patients were included in the study. Four patients in the non-nicorandil group and the patients in nicorandil group were on preoperative intra-aortic balloon pump and hence excluded from the study. After routine use of nicorandil infusion, incidence of intra-aortic balloon pump insertion during off-pump coronary artery bypass surgery decreased from 12.4% (21/169) to 2.9% (6/206). Conclusions Nicorandil infusion significantly (P = 0.007) reduced the incidence of intra-aortic balloon pump insertion in our series. In patients with left ventricular dysfunction (ejection fraction ≤ 30%), this difference (P = 0.008) assumes a special significance as off-pump bypass surgery is considered high risk in this subset. Nicorandil is an inexpensive drug, and the reduction in cost of surgery by avoiding intra-aortic balloon pump insertion is an added advantage. The use of nicorandil infusion during off-pump coronary artery bypass may result in favorable patient outcomes by reducing invasive intra-aortic balloon pump insertion during off-pump coronary artery bypass grafting.
Background Off-pump Coronary Artery Bypass Grafting (OPCAB) reduces the complications related to use of cardiopulmonary bypass. However the effects of using aortic side clamp during OPCAB is not eliminated if any graft is anastamosed to aorta. We describe here a simple technique of OPCAB using in-situ bilateral Internal Mammary Artery (IMA) as the only source of blood supply to the coronary grafts. Methods Every patient underwent preoperative assessment of bilateral subclavian artery. In our technique, one IMA was used to graft Left Anterior Descending Artery (LAD) and its branches. Other IMA was used to create a composite graft with Radial Artery (RA). This composite graft was used to revascularize the remaining coronary arteries. Results Out of 194 consecutive OPCABs performed, this technique of bilateral IMA was used in 138 patients. Conclusion The patency and efficacy of in-situ IMA graft for Coronary Artery Bypass Grafting (CABG) is well documented. Our simple technique using bilateral in situ IMA provides dual inflow and can be used in every possible coronary anatomy.
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