Off-Pump Coronary Revascularization: Operative Technique

Abstract

Off-pump coronary artery bypass grafting can be performed in most patients undergoing surgical myocardial revascularization. The selection of patients for off-pump surgery is dependent on the surgeon’s knowledge and comfort with the techniques of off-pump revascularization. Early in a surgeon’s experience with off-pump revascularization, it is best to select patients with normal left ventricular size and function, relatively large epicardial coronary arteries free of diffuse calcific atherosclerosis, and coronary artery disease limited to the left anterior descending and right coronary artery systems. As the surgeon gains experience and confidence with off-pump techniques, patients with decreased left ventricular function, enlarged hearts, and coronary artery disease of the circumflex system may be performed off-pump. When the surgeon has mastered the techniques of off-pump coronary surgery, nearly all patients presenting for coronary revascularization may be considered, including those with severe left main coronary artery stenosis, poor left ventricular function, and intramyocardial coronary arteries. Relative contraindications to off-pump myocardial revascularization include patients with severely enlarged and dysfunctional hearts, mitral insufficiency, or small and diffusely diseased coronary arteries. Patients with hemodynamic instability and those with chest anatomy that prevents rightward displacement of the heart, such as pectus excavatum or previous left pneumonectomy, should not be selected for off-pump revascularization. Similar to on-pump coronary artery bypass grafting, off-pump myocardial revascularization is a complex operation composed of many steps. The operative steps of off-pump coronary artery revascularization are (1) incision and conduit preparation; (2) patient positioning; (3) target vessel exposure; (4) target vessel stabilization; (5) target vessel hemostasis and ischemia prevention; (6) construction of anastomoses; and (7) closure. Off-pump myocardial revascularization has the potential benefit of lowering the risk of coronary surgery by eliminating cardiopulmonary bypass and ascending aortic manipulation. The use of in situ and composite arterial grafts for coronary revascularization avoids the need for ascending aorta manipulation to construct proximal anastomoses. In this article, the techniques used in off-pump, multivessel coronary artery bypass grafting with in situ and composite arterial grafts is illustrated. Using these techniques of coronary artery exposure and stabilization, off-pump coronary revascularization can be performed safely and accurately in the majority of patients presenting for surgical revascularization. Whether off-pump revascularization lowers the risk of surgical revascularization has been a highly debated and controversial issue in coronary surgery during the last decade. Off-pump revascularization has the potential for lowering the risk of coronary surgery by eliminating cardiopulmonary bypass, and all arterial off-pump revascularization using in situ and composite grafts has the potential to further reduce risk by eliminating the need for aortic manipulation.