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Coronary Artery Bypass Surgery (CABG—Off-Pump CABG)

LIMA to LAD Radial to Diagonal Obtuse Marginal Position Radial to Distal RCA

All coronary revascularization patients are candidates for an off-pump CABG (OPCABG), the only contraindications being technical or the surgeon's level of comfort. So say the results of a recent study conducted by cardiothoracic surgeons from Columbia University Medical Center of NewYork-Presbyterian and St. Michael's Medical Center in Newark, NJ.

Coronary revascularization on the beating heart appears to be an attractive alternative to conventional CABG (CCABG), but has remained unproven and controversial. The study set out to compare outcomes of 268 consecutive unselected patients, one-half undergoing OPCABG surgery and the other half undergoing conventional revascularization, during a one-year period commencing July, 1998. Charts were reviewed for age, preoperative risk factors as per the STS criteria, operative findings, postoperative complications, ICU, and postoperative LOS.

The two groups of patients were well matched with similar ages (66.4±11.2 vs. 65.8±10, p=0.66) and preoperative ejection fraction (44±13 vs. 44±12, p=0.85). No hospital mortalities occurred in either group. There were five conversions from OPCABG to CCABG. A subgroup analysis of patients stratified by ejection fraction (<40% vs. >40%) and age (<65 years vs. >65 years) revealed no significant differences across both groups. An increase in chest tube output for the OPCABG group did not translate into an increased transfusion requirement.

"We were able to achieve completeness of revascularization, as shown by the same number of arteries bypassed in each group (3.9±1 in CCABG patients compared to 4.0±1.2 in OPCABG patients)," says one of the study's co-authors, Barry C. Esrig, MD, a cardiothoracic surgeon who practices at both Columbia University Medical Center and St. Michael's and is also Adjunct Assistant Clinical Professor of Surgery at Columbia University College of Physicians & Surgeons. Other significant data in consideration of the OPCABG procedure include shorter operating time, a decrease in ICU LOS days (2±4.0 in OPCABG patients compared to 3±5.4 in CCABG patients.) and fewer postoperative incidents of MI (2.2/OPCABG vs. 4.4/CCABG). Although no strokes were reported in either group, the OPCABG patients experienced fewer transient CNS incidents. Thus far, the short-term (six months to one year) follow-up has revealed no post-operative re-intervention.

Barry C. Esrig, MD, offers proof that OPCABG can achieve completeness of revascularization because all areas of the heart can be accessed, as evidenced by these photos.

Currently, 95% of the primary coronary revascularizations performed by some surgeons at Columbia University Medical Center and St. Michael's are done as OPCABG procedures. Although long-term graft patency results are yet unavailable, the prevailing view at both centers is that coronary revascularization can be safely performed on the beating heart with a decrease in LOS, no increase in short-term complications, and should be part of the surgeon's resources.