Multivessel Off-pump Coronary Artery Bypass Research Articles

Multi-vessel off-pump total endoscopic coronary artery bypass—pearls and pitfalls

Multi-vessel off-pump total endoscopic coronary artery bypass—pearls and pitfalls

Summary of the key steps in multi-vessel off-pump total endoscopic coronary artery bypass including selected pearls and pitfalls that facilitate the safe conduct of the operation.

Summary of the key steps in multi-vessel off-pump total endoscopic coronary artery bypass including selected pearls and pitfalls that facilitate the safe conduct of the operation.

The Impact of Hybrid Coronary Revascularization on Hospital Costs and Reimbursements

Hybrid coronary revascularization (HCR) combines a minimally invasive, left internal mammary artery-left anterior descending coronary artery (LAD) bypass with percutaneous intervention of non-LAD vessels for patients with multivessel coronary disease. The financial implications of HCR have not been compared with off-pump coronary artery bypass (OPCAB) through sternotomy. The contribution margin is a fiduciary calculation (best hospital payment estimate--total variable costs) used by hospitals to determine fiscal viability of services. From 2010 to 2011, 26 Medicare patients underwent HCR at a single United States institution and were compared with 28 randomly selected, contemporaneous Medicare patients undergoing multivessel OPCAB. All HCR patients underwent a robotic-assisted, sternal-sparing, off-pump, left internal mammary artery-LAD anastomosis plus percutaneous intervention to non-LAD vessels. A linear regression model was used to compare fiscal and utilization outcomes of HCR to OPCAB adjusted for hospital length of stay and The Society of Thoracic Surgeons Predicted Risk of Mortality score. On regression analysis controlling for overall length of stay and Predicted Risk of Mortality score, the contribution margin (+$8,771, p<0.0001) was greater for HCR than for OPCAB. Despite higher total cost for HCR compared with OPCAB (+$7,026, p=0.001), the total variable cost (+$2,281, p=0.07) was not significantly different. Best payment estimates (+11,031, p<0.0001) and Medicare reimbursements (+$8,992, p=0.002) were higher for HCR than for OPCAB, and there was a reduction in blood transfusion (-1.5 units, p<0.0001), ventilator time (-10 hours, p=0.001), and postoperative length of stay (-1.2 days, p=0.002) for the HCR group. Compared with OPCAB, HCR results in a greater contribution margin for hospitals. This may result from higher reimbursement as well as improved resource utilization postoperatively, which may offset more expensive procedural costs associated with HCR.

Myocardial Protection by Glucose-Insulin-Potassium in Acute Coronary Syndrome Patients Undergoing Urgent Multivessel Off-Pump Coronary Artery Bypass Surgery

Background The aim of this randomized and controlled trial was to investigate the effect of a glucose–insulin–potassium (GIK) solution on myocardial protection in acute coronary syndrome (ACS) patients undergoing urgent multivessel off-pump coronary artery bypass (OPCAB) surgery. Methods Sixty-six patients were randomly allocated either to receive 0.3 ml kg−1 h−2 GIK solution (potassium 80 mEq and regular insulin 325 IU in 500 ml of 50% glucose) or equivalent volume of normal saline (control) upon anaesthetic induction until 6 h after reperfusion. The primary endpoints were to compare the concentrations of creatine kinase-MB (CK-MB) and troponin-T between the groups after reperfusion. The secondary endpoints were to compare the incidences of postoperative troponin-T >0.8 ng ml−1 and myocardial infarction (MI) between the groups. Results Highest CK-MB [8.7 (4.4) vs 13.1 (7.9) ng ml−1, P=0.006] and troponin-T [0.20 (0.13–0.49) vs 0.48 (0.18–0.91) ng ml−1, P 0.8 ng ml−1 after reperfusion compared with the control group (3 vs 11, P=0.033). The incidence of postoperative MI was similar between the groups. Conclusions GIK administration in ACS patients undergoing urgent multivessel OPCAB significantly attenuated the degree of ensuing myocardial injury without complications related to glycaemic control. Clinical Trial Registry. URL: http://clinicaltrials.gov/ct2/show/NCT01384656?term=GIK+AND+OPCAB&rank=1 . Unique identification number NCT01384656.

Off-Pump versus On-Pump Coronary Artery Bypass Grafting in Octogenarians: Comparison of Short-Term Outcomes and Long-Term Survival

Off-pump coronary artery bypass (OPCAB) has gained increasing acceptance with potential benefits for high-risk elderly patients. We report a surgeon's operative outcomes in octogenarians with an OPCAB program. Retrospective, intention-to-treat analysis of 97 consecutive octogenarians who underwent coronary bypass by a single surgeon between 1997 and 2001 before and after initiation of a multi-vessel OPCAB program was performed. OPCAB was attempted in all octogenarians. The OPCAB cohort had higher serum creatinine (OPCAB vs. pre-OPCAB: 1.30 ± 0.79 mg/dl vs. 1.08 ± 0.27, p = 0.04) and ejection fractions (52 ± 14% vs. 45 ± 11%, p = 0.02) than the pre-OPCAB cohort. The OPCAB group was more likely to require urgent/emergency surgery (63 vs. 40%, p = 0.04) and to have chronic renal insufficiency (18 vs. 3%, p = 0.05). After programmatic change to OPCAB, significant postoperative improvements were observed in the length of hospital stay (17 ± 19 vs. 8 ± 4 days, p < 0.01), duration of inotropic requirement (47 ± 70 vs. 18 ± 39 h, p < 0.04), duration of ventilator support (51 ± 54 vs. 16 ± 27 h, p < 0.01) and incidence of tracheostomy (16 vs. 3%, p < 0.02). In-hospital mortalities (3.2 vs. 2.7%), strokes (3 per group) and 5-year survival did not differ significantly (57 vs. 67%, p = 0.50, NS). Despite some higher preoperative risks, the OPCAB program demonstrated clinical benefits in octogenarians but no advantage in hospital-mortality or long-term survival.

No-Touch Aorta Off-Pump Coronary Bypass Operation: Arteriovenous Composite Grafts May Be Used as a Last Resort

Off-pump coronary artery bypass (OPCAB) operations with bilateral internal thoracic artery (BITA) or left internal thoracic artery (LITA) and radial artery (RA) in a Y-graft configuration achieves adequate myocardial revascularization while avoiding manipulation of the ascending aorta. The purpose of our study was to determine if saphenous veins can be used as composite grafts with the LITA as a last resort. Multivessel OPCAB without aortic manipulation was performed in 564 patients between February 2002 and October 2010. Patients receiving a LITA-vein composite graft (n = 62) were older and had more emergency procedures, renal insufficiency, peripheral vascular disease and therefore a higher logistic EuroSCORE predicted risk of mortality (all p < 0.001) than did patients who underwent BITA and LITA-RA grafts. Overall 30-day mortality was 1.1%: 6.5% in patients who received LITA-vein grafts and 0.5% in both total arterial groups (p = 0.001). Neurologic events occurred in 3.2%, 0.7%, and 0.5% of patients, respectively (p = 0.3). No patient who received a LITA-vein graft experienced perioperative myocardial infarction (MI). Patients in the total arterial graft groups had better 5-year survival (> 90%) and freedom from major adverse cardiovascular and cerebrovascular events (≥ 80%) than did patients who received LITA-vein grafts (74 ± 7.8% and 62.5 ± 8.1%, respectively). However there was no difference in the 3 groups with respect to freedom from MI and repeat revascularization. LITA-vein composite graft use is associated with a lower survival and higher complication rate, probably because of the higher patient risk profile. LITA-vein composite grafts may be used as a last resort in selected patients undergoing OPCAB operations without manipulation of the aorta when arterial grafts are not available or recommended.

Myocardial protection by glucose–insulin–potassium in acute coronary syndrome patients undergoing urgent multivessel off-pump coronary artery bypass surgery

The aim of this randomized and controlled trial was to investigate the effect of a glucose-insulin-potassium (GIK) solution on myocardial protection in acute coronary syndrome (ACS) patients undergoing urgent multivessel off-pump coronary artery bypass (OPCAB) surgery. Sixty-six patients were randomly allocated either to receive 0.3 ml kg(-1) h(-2) GIK solution (potassium 80 mEq and regular insulin 325 IU in 500 ml of 50% glucose) or equivalent volume of normal saline (control) upon anaesthetic induction until 6 h after reperfusion. The primary endpoints were to compare the concentrations of creatine kinase-MB (CK-MB) and troponin-T between the groups after reperfusion. The secondary endpoints were to compare the incidences of postoperative troponin-T >0.8 ng ml(-1) and myocardial infarction (MI) between the groups. Highest CK-MB [8.7 (4.4) vs 13.1 (7.9) ng ml(-1), P=0.006] and troponin-T [0.20 (0.13-0.49) vs 0.48 (0.18-0.91) ng ml(-1), P<0.0001] values after reperfusion were significantly lower in the GIK group compared with the control group. The area under the curve of serially measured troponin-T was also significantly smaller in the GIK group compared with the control group [0.83 (0.43-1.81) vs 0.46 (0.31-1.00), P=0.036]. Significantly fewer patients in the GIK group showed troponin-T >0.8 ng ml(-1) after reperfusion compared with the control group (3 vs 11, P=0.033). The incidence of postoperative MI was similar between the groups. GIK administration in ACS patients undergoing urgent multivessel OPCAB significantly attenuated the degree of ensuing myocardial injury without complications related to glycaemic control. Clinical Trial Registry. URL: http://clinicaltrials.gov/ct2/show/NCT01384656?term=GIK+AND+OPCAB&rank=1. Unique identification number NCT01384656.

Does off-pump coronary artery bypass grafting negatively impact long-term survival and freedom from reintervention?

Recently published evidence has raised concerns about worse late mortality and increasing need for reintervention after off-pump coronary artery bypass grafting. We undertook this study to assess the impact of off-pump coronary artery bypass grafting on survival and freedom from reintervention at 10 years. From January 2002 to December 2002, 307 consecutive patients who had isolated multivessel off-pump coronary artery bypass grafting at our institution were compared to a control group of 397 patients that underwent multivessel on-pump coronary artery bypass grafting during the same period. In addition, univariate and risk-adjusted comparisons between the two groups were performed at 10 years. Kaplan-Meier survival was similar for the two cohorts. After adjusting for clinical covariates, off-pump coronary artery bypass grafting did not emerge as a significant independent predictor of long-term mortality (Hazard Ratio 0.91; 95% Confidence Interval 0.70–1.12), readmission to hospital for cardiac cause (Hazard Ratio 0.96; 95% Confidence Interval 0.78–1.10), or the need for reintervention (Hazard Ratio 0.93; 95% Confidence Interval 0.87–1.05). Off-pump coronary artery bypass grafting compared with on-pump coronary artery bypass grafting does not adversely impact survival or freedom from reintervention at a 10-year follow-up.

Deep Pericardial Traction Suture versus Vacuum-Assisted Apical Suction to Expose the Posterior Wall of the Heart in Off-Pump Coronary Artery Bypass: A Prospective, Randomized Study

Displacement of the heart to expose the posterior vessels during off-pump coronary artery bypass (OPCAB) may cause hemodynamic instability. Deep pericardial traction suture (DPTS) and vacuum-assisted apical suction (VAS) with the Starfish positioning device help to provide good exposure without relevant hemodynamic changes. Our aim was to compare these two methods in patients undergoing multivessel OPCAB. We prospectively randomized 20 patients undergoing multivessel OPCAB to the use of VAS or DPTS. The Octopus device was used in both groups to stabilize the target vessel. Hemodynamic parameters, including venous oxygen content (SvO(2)), cardiac index (CI), central venous pressure (CVP), mean arterial pressure (MAP), pulmonary artery pressure (PAP), and pulmonary capillary wedge pressure (PCWP), were measured before grafting (baseline), after heart positioning, and during performance of peripheral anastomoses. Perioperative data for the two groups were similar. During exposure of the lateral wall, there were fewer hemodynamic changes in the DPTS group (increase in CVP) than in the VAS group (increases in CVP, PAP, and PCWP); the CVP was significantly higher in the DPTS group (P < .05). During exposure of the posterior wall, significant hemodynamic changes occurred only in the DPTS group (increase in PCWP). Values for all other parameters were similar, including anastomosis time, graft flow, postoperative myocardial enzymes, and inotropic support. Heart positioning during OPCAB with either VAS or DPTS is a safe and effective maneuver for exposure of coronary arteries. In our study, the use of the VAS device produced less hemodynamic impairment during exposure of the lateral and posterior walls.

Feasibility, safety, and efficacy of multivessel off-pump coronary artery bypass grafting in diabetics

Feasibility, safety, and efficacy of multivessel off-pump coronary artery bypass grafting in diabetics

A Haemodynamic Study during OPCAB Surgery Using a New Multi-Suction Cardiac Positioner

Displacement of the heart is necessary to expose the target vessel for distal anastomosis to achieve successful multivessel off-pump coronary artery bypass (OPCAB) grafting. In addition to complete revascularisation of the heart, a main challenge during the operation is to maintain haemodynamic stability during this procedure. A new heart positioner (Tentacles) was tested. In a prospective clinical study we used the Tentacles device in 50 patients scheduled for multivessel OPCAB procedures and investigated the haemodynamic effects during displacement of the heart and while performing the anastomoses to the anterior, lateral and posterior wall. The following haemodynamic parameters were investigated: mean arterial blood pressure (MAP), cardiac index (CI) and stroke volume index (SVI). The incidence of myocardial ischaemia was monitored by transoesophageal echocardiography (TEE) and by ST-segment analysis in the electrocardiogram (ECG). The Tentacles device permitted rapid, secure and excellent exposure of the lateral and posterior wall of the heart. During exposure of the anterior wall there was a small decrease in MAP (77 ± 10 vs.71 ± 9 mmHg, P = 0.02) in combination with an increase in the CI (3.0 ± 0.7 l vs. 3.1 ± 0.8 l/min/m2, P = 0.03). When the lateral and posterior walls of the heart were exposed, the SVI decreased significantly (36 ± 11 and 38 ± 8 mL/m2, P < 0.01 and P = 0.04, respectively) compared to baseline (44 ± 11 mL/m2) while CI and MAP remained stable. The amount of norepinephrine administered during displacement of the heart was significantly higher in all three positions (0.05 ± 0.05, 0.06 ± 0.05 and 0.04 ± 0.03 µg/kg/min, P < 0.01) compared to the physiological position (0.02 ± 0.02 µg/kg/min). Sinus rhythm was maintained throughout the operation. Neither significant changes of the ST-segment in the ECG nor incidences of wall motion abnormality in TEE were observed. Six hours postoperatively the troponin I concentration was 11.7 ± 4.3 ng/mL. The Tentacles device provided excellent access in multivessel OPCAB surgery. Haemodynamic stability was maintained in all patients; however additional catecholamine support was used when the heart was displaced. This was the case when carrying out an anastomosis on the anterior, lateral, or posterior wall.

10-Year Follow-Up of Off-Pump Multivessel Coronary Artery Bypass Grafting

On-pump total arterial grafting is associated with improved long-term outcomes compared to conventional grafting using left internal thoracic artery and saphenous vein grafts, but there are no data to confirm the same for off-pump total arterial grafting. We assessed the impact of off-pump total arterial grafting on medium-term outcomes. From September 1998 to September 2008, 580 consecutive patients who had off-pump multivessel arterial grafting only were compared with a control group of 806 patients undergoing off-pump coronary artery bypass with internal thoracic artery and saphenous vein grafts, performed by the same surgeon. Perioperative data were collected prospectively. Medium-term univariate and risk-adjusted comparisons between the 2 groups were carried out. After adjusting for clinical covariates, total arterial grafting did not emerge as a significant independent predictor of medium-term mortality, readmission to hospital, or the composite outcome of death and readmission. At medium-term follow-up, off-pump total arterial grafting, despite being a safe and effective myocardial revascularization strategy, offered no mortality or morbidity benefits.

Current Practice and Outcomes of Off-pump Multivessel Coronary Artery Bypass

Outcomes of off-pump multivessel coronary artery bypass were compared with those of the on-pump procedure. From July 2001 to June 2006, 3,637 patients with multivessel coronary disease underwent off-pump coronary artery bypass, and 3,586 patients had on-pump coronary artery bypass in our center. The rates of operative mortality, permanent stroke, renal failure and perioperative myocardial infarction were significantly lower in the off-pump group, and these patients required fewer blood transfusions, shorter durations of ventilatory support, and shorter hospital stays. However, the patients who underwent on-pump coronary artery bypass were considered more high-risk and tended to have more complex procedures.

Effects of early vital capacity maneuver on respiratory variables during multivessel off-pump coronary artery bypass graft surgery*

Despite avoiding cardiopulmonary bypass, similar degrees of pulmonary impairment compared with on-pump coronary artery bypass surgery have been demonstrated in patients undergoing off-pump coronary artery bypass graft surgery (OPCAB) compared with on-pump coronary artery bypass surgery. To investigate the effects of an early vital capacity maneuver (VCM) on intrapulmonary shunt (Qs/Qt), oxygenation, and pulmonary outcome in OPCAB. Prospective, randomized, controlled, double-blind clinical trial. Cardiothoracic operating room and intensive care unit (ICU) of a university hospital. Fifty patients scheduled for OPCAB were randomized to treatment with VCM or none. After sternotomy, VCM was performed by inflating the lungs to 40 cm H2O and holding this pressure for 10 seconds. Qs/Qt, Pao2/Fio2 (P/F) ratio, and dynamic and static pulmonary compliances were measured before induction of anesthesia (T0), 15 minutes after tracheal intubation (T1), during Y-graft construction (T2), 15 minutes after completion of grafting (T3), 15 minutes after sternal closure (T4), and 3 hours after arrival at the ICU (T5). Qs/Qt was lower and P/F ratio was higher in the VCM group at T2 through T5. Pulmonary compliances were also higher in the VCM group at T4 and T5. Patients in the VCM group were extubated earlier. The beneficial effects of an early VCM on Qs/Qt persisted into the period of ICU care, with an improvement in P/F ratio and preserved pulmonary compliances, leading to a shorter time to extubation.

Off-Pump Coronary Artery Bypass in Severe Left Ventricular Dysfunction

The outcome of multivessel off-pump coronary artery bypass grafting in cases of severe left ventricular dysfunction was studied in 58 consecutive patients with ejection fraction < or =35% who were followed up for a median of 15 months. Patients with ejection fractions < or =25% (group 1) had the largest left ventricular dimensions preoperatively, with gradual increases during follow-up; those with ejection fractions of 26%-35% (group 2) had smaller preoperative ventricular dimensions, with left ventricular regression postoperatively. There was more improvement in ejection fraction in group 2 than group 1 (33% vs. 10%). Mitral regurgitation improved from moderate to mild in group 2; whereas in group 1, mild mitral regurgitation progressed to moderate or severe during follow-up. Ejection fraction was a predictor of more frequent use of intraaortic balloon pumping, longer duration of inotropic use, a higher mean pulmonary artery-to-systemic arterial pressure ratio, and increased postoperative drainage.

Effects of early vital capacity manoeuvre during multivessel off-pump coronary artery bypass surgery

Effects of early vital capacity manoeuvre during multivessel off-pump coronary artery bypass surgery

The effect of mannitol on oxygenation and creatine kinase MB release in patients undergoing multivessel off-pump coronary artery bypass surgery

Despite avoiding cardiopulmonary bypass, off-pump coronary artery bypass surgery is associated with reduction in PaO2 and postoperative respiratory compliance. Also, transient interruption of coronary flow is necessary during distal anastomoses and may impose ischemia-reperfusion myocardial injury. Mannitol is an osmotic diuretic with free radical scavenging properties, and we have evaluated the effects of mannitol on oxygenation and cardiac enzyme release in patients undergoing multivessel off-pump bypass surgery in a prospective, randomized, controlled, double-blind trial. Fifty patients were randomly allocated to receive either 20% mannitol 0.5 g/kg (n = 25) or normal saline 2.5 mL/kg (n = 25) during Y-graft construction. Pulmonary variables and serum sodium concentrations were measured 15 minutes after induction of anesthesia and sternum closure. Creatine kinase MB was measured before and after the operation. Intraoperative and postoperative fluid input and output, time to extubation, and intraoperative hemodynamic variables were also recorded. PaO2 after sternum closure was significantly higher in the mannitol group, with faster time to extubation and shorter length of stay in the intensive care unit. Intraoperative urine output was significantly greater in the mannitol group, without significant differences in fluid input, serum sodium concentration, and hemodynamic variables. Number of patients with a creatine kinase MB level more than 3 times the upper limit of normal was significantly higher in the control group. Mannitol could be safely used without adverse side effects in patients undergoing multivessel off-pump bypass surgery with beneficial effects in terms of preserving oxygenation, earlier extubation, and fewer patients with significant creatine kinase MB elevation.

A New Multisuction Cardiac Positioner for Multivessel Off-Pump Coronary Artery Bypass Grafting

: To accomplish successful multivessel off-pump coronary artery bypass grafting, safe, reproducible, and effective exposure of all coronary territories is essential. For this purpose, we developed a new, simple, multisuction cardiac positioner. : This new cardiac positioner consists of 3 small independent suction cups and suction tubes made of silicone. Unlike an apical suction cardiac positioner, this positioner has no arm. The suction cups can be applied with negative pressure of 300 mm Hg to various surfaces of the ventricle, including not only the apex but also the lateral, inferior, and right ventricular walls, according to surgeon preference. We applied this positioner in 15 clinical multivessel off-pump coronary artery bypass procedures. : In all cases, all target vessels including those on the lateral or inferior wall were successfully exposed and grafted without hemodynamic compromise. Surgical exposure, especially on the lateral and inferior walls, was quite similar to that of conventional coronary artery bypass graft procedures performed during cardiopulmonary bypass. : The multisuction cardiac positioner provided reproducible and easy access in multivessel off-pump coronary artery bypass surgery. This simple, variable, and inexpensive cardiac positioner may be used as a new tool to aid in the performance of successful multivessel off-pump coronary artery bypass surgery.

A New Multisuction Cardiac Positioner for Multivessel Off-Pump Coronary Artery Bypass Grafting

A New Multisuction Cardiac Positioner for Multivessel Off-Pump Coronary Artery Bypass Grafting

Evolution of Off-Pump Coronary Artery Bypass Grafting over 15 Years

: Off-pump coronary artery bypass grafting for multivessel disease is an important alternative to conventional myocardial revascularization using cardiopulmonary bypass. The development of exposure and stabilization techniques has made this surgery simple, safe, and routine. Experience with the technique, its evolution, the learning curve, and the pitfalls is presented. : A retrospective analysis was made of 28,216 patients who underwent elective coronary artery bypass grafting over a 15-year period from January 1990 through December 2004. Isolated off-pump coronary artery bypass grafting was performed in 14,030 patients and on-pump coronary artery bypass grafting in 14,186 patients. The overall period was divided into 3 groups of 5 years each: group I (1990-1994), group II (1995-1999), and group III (2000-2004). Initially, off-pump coronary artery bypass grafting was performed selectively in high-risk patients (eg, atheromatous aorta, severe systemic impairment, chronic obstructive pulmonary disease, octogenarian). Recently (2000-2004), multivessel off-pump coronary artery bypass grafting has been performed electively in 96% to 98% of patients undergoing coronary artery bypass grafting. Patients' medical charts were reviewed for age, preoperative risk factors, operative findings, intraoperative conversion rate to cardiopulmonary bypass, postoperative complications, and length of hospital stay. : In the years 1990-1994 (group I), mostly high-risk cases and cases with left anterior descending coronary artery lesions were included for off-pump coronary artery surgery. In the years 1995-1999 (group II), patients with double and triple vessel disease presenting for coronary artery bypass surgery were accepted for off-pump surgery irrespective of preoperative risk factors. However, in the years 2000-2004 (group III), off-pump coronary artery bypass surgery was the first choice of approach for any patient presenting for coronary artery bypass surgery. The mean number of grafts was lower in off-pump cases than in on-pump cases in group I (2.0 ± 0.4 vs. 3.2 ± 0.80) and group II (2.6 ± 0.6 vs. 3.3 ± 0.4), whereas the mean number of grafts was higher in off-pump cases than in on-pump cases in group III (3.5 ± 0.2 vs. 3.4 ± 0.8). In groups I and II, the conversion to cardiopulmonary bypass was 5.2% and 5.9%, respectively. The conversion to cardiopulmonary bypass decreased to 1.7% in group III, which was statistically significant. Perioperative myocardial infarction was 5.2% in group I, 1.7% in group II, and 1.5% in group III. The difference between groups II and III was not statistically significant. Hospital mortality was higher in group I (5.2%) than in group II (1.2%) or III (1.1%). The difference between groups II and III was not statistically significant. Length of intensive care unit stay was 36 ± 8 hours in group I, 28 ± 7 hours in group II, and 20 ± 8 hours in group III. These differences were statistically significant. Length of postoperative hospital stay was 8 ± 2 days in group I, 7 ± 2 days in group II, and 5 ± 2 days in group III These differences were statistically significant. : As surgeons' experience matures, off-pump coronary artery bypass surgery permits total myocardial revascularization in virtually all patients with multivessel coronary artery disease. Despite a significant learning curve, evolution to routine off-pump coronary artery bypass with good patient outcomes can be achieved with careful patient selection during the "learning curve." The method is safe and reproducible, and patients benefit with shorter intensive care unit and hospital stays.