Off-pump coronary artery bypass surgery: physiology and anaesthetic management †

Abstract

Increasing interest is being shown in beating heart (off-pump) coronary artery surgery (OPCAB) because, compared with operations performed with cardiopulmonary bypass, OPCAB surgery may be associated with decreased postoperative morbidity and reduced total costs. Its appears to produce better results than conventional surgery in high-risk patient populations, elderly patients, and those with compromised cardiac function or coagulation disorders. Recent improvements in the technique have resulted in the possibility of multiple-vessel grafting in all coronary territories, with a graft patency comparable with conventional surgery. During beating-heart surgery, anaesthetists face two problems: first, the maintenance of haemodynamic stability during heart enucleation necessary for accessing each coronary artery; and second, the management of intraoperative myocardial ischaemia when coronary flow must be interrupted during grafting. The anaesthetic technique is less important than adequate management of these two major constraints. However, experimental and recent clinical data suggest that volatile anaesthetics have a marked cardioprotective effect against ischaemia, and might be specifically indicated. OPCAB surgery requires team work between anaesthetists and surgeons, who must be aware of each other's constraints. Some surgical aspects of the operation are reviewed along with physiological and anaesthetic data.

Effect of Hydroxyethyl Starch 130/0.4 on Blood Loss and Coagulation in Patients With Recent Exposure to Dual Antiplatelet Therapy Undergoing Off-Pump Coronary Artery Bypass Graft Surgery

“…3-6 By avoiding CPB, off-pump coronary artery bypass surgery (OPCAB) is associated with less deterioration in coagulation and has been suggested as an alternative surgical technique to CPB in patients exposed to recent antiplatelet therapy, mitigating perioperative blood loss while maximizing ischemic benefit. [7][8][9][10] Colloids are often used in cardiac surgery because colloids are more efficient than crystalloids in maintaining intravascular volume and osmotic pressure, and improving microperfusion. 11- 16 Hydroxyethyl starch (HES) solutions, however, the most widely used synthetic colloids, cause adverse effects on coagulation that are mainly attributable to the mean molecular weight and degree of substitution.…”

Association of Carotid Arterial Circumferential Strain With Left Ventricular Function and Hemodynamic Compromise During Off-Pump Coronary Artery Bypass Surgery

“…1 In rare instances, an unacceptable condition requiring emergency on-pump conversion does occur, which increases perioperative morbidity and mortality. 3 Even if the surgery was completed successfully on a beating heart, significant hemodynamic instability during grafting tends to remain until the end of the surgery and leads to adverse postoperative consequences.…”

Effect of Tranexamic Acid on Transfusion Requirement in Dual Antiplatelet-Treated Anemic Patients Undergoing Off-Pump Coronary Artery Bypass Graft Surgery - A Randomized Controlled Study -

“…23 In the context of maximizing the ischemic benefit while minimizing the bleeding and transfusion risk conveyed by DAPT, OPCAB has been proposed as an alternative surgical revascularization technique. 8 Transfusion of allogeneic blood products carries risks far beyond the risk of disease transmission affecting the patient's outcome after cardiac surgery. 1 Despite efforts to reduce allogeneic blood transfusion, blood transfusion is still common in patients undergoing cardiac surgery, including OPCAB.…”

“…[4][5][6] In order to maximize the ischemic benefit and minimize the bleeding risk in patients receiving DAPT until shortly before surgery, off-pump CABG (OPCAB) has been proposed as an alternative technique of surgical revascularization. 7, 8 However, patients with preoperative anemia have a reduced red blood cell reserve that is likely to be depleted by operative intervention, even without the use of cardiopulmonary bypass (CPB). In addition, anemia per se has been demonstrated to be associated with reversible platelet dysfunction.…”