The future of off-pump coronary artery bypass grafting: a North American perspective

Abstract

Off-pump coronary artery bypass graft (OPCAB) is currently performed routinely in a minority of specialized centers and in many more centers, utilized only when a porcelain aorta mandates a no-touch aortic technique. The OPCAB literature can be summarized as follows: (I) large-scale randomized trials in relatively low risk patients that include surgeons with a range of experience demonstrating no consistent beneficial differences in major cardiovascular and cerebrovascular outcomes but lower transfusion rates and shorter length of stay, tempered by some reports of higher rates of incomplete revascularization and lower rates of long term graft patency; (II) smaller randomized controlled trials (RCTs) from highly specialized programs demonstrating equivalent or superior outcomes with OPCAB and similar completeness of revascularization and graft patency; and (III) observational data from large databases demonstrating a consistent benefit of OPCAB, especially in higher-risk patient subsets. Our rationale for OPCAB remains that if complete and precise revascularization can be safely and routinely accomplished, then the patient should benefit by avoiding the morbidities that can be attributed to aortic cannulation/clamping, cardiopulmonary bypass (CPB), hemodilution, hypothermia and global myocardial ischemia/cardioplegia.We further believe that OPCAB procedures should emphasize the use of arterial grafts to optimize long term patency and minimize aortic manipulation to limit the risk of stroke. Moving forward, the off-pump surgical community and specialty societies must address the challenge of training surgeons and their teams to master this technically demanding procedure. Furthermore, OPCAB opens the door to minimally-invasive surgical revascularization via hybrid coronary revascularization (HCR). A large NIH-funded RCT is currently underway to determine whether hybrid revascularization can offer a superior alternative to multi-vessel percutaneous coronary intervention for patients with low SYNTAX score and proximal LAD disease.

Long‐term survival in triple‐vessel disease: Hybrid coronary revascularization compared to contemporary revascularization methods

“…An HCR strategy for patients with TVD is associated with similar long‐term survival and FREEDOM from MACE to traditional CABG or multivessel PCI. HCR should be considered a feasible option for select patients with TVD, for those with intermediate SYNTAX scores and appropriate coronary anatomy, a proposal echoed by others, 23,31 presuming that a low residual SYNTAX score can be attained.…”

“…Similarly, the low perioperative stroke rate observed in our sternotomy CABG cohort may not necessarily be translatable to other patient populations, given that we perform the majority of these cases "off-pump," a practice pattern not currently adopted by most surgical centers in the United States. 31 Despite our center's surgical experience, only 100 patients were treated with HCR, which reflects our selectiveness of the revascularization strategy.…”

Short-Term and Mid-Term Clinical Outcomes Following Hybrid Coronary Revascularization Versus Off-Pump Coronary Artery Bypass: A Meta-Analysis

“…However, the major shortcoming of no-touch OPCAB is its greater technical requirement so that it is not applicable for every surgical team or every patient. 33 Nevertheless, further investigations should be still carried out to compare no-touch OPCAB and HCR.…”

Use of OPCAB in Czechia 2010-2015: Have we learned any lessons?

“…As mentioned above, OPCAB has gone through a period of great expectations (in the 1980s and 1990s), a period of sober judgment at the beginning of the 21st century, and now the slight skepticism we are experiencing today. According to some authors, the interest in OPCAB is typical for all new technologies, so called "Hype-cycle": Currently we are leaving "Trough of Disillusionment" [25] (see Fig. 1).…”