Off-pump Myocardial Revascularization Research Articles

Analysis of the Perioperative Course of Cardiac Surgery Patients with Coronary Artery Disease and Heart Valve Dysfunction

The aim. To analyze the perioperative course of cardiac surgery patients with coronary artery disease (CAD) and heart valve dysfunction. Materials and methods. Retrospective analysis of 41 consecutive cardiac surgery patients (mean age 61.6 ± 7.8 years) with CAD and heart valve dysfunction who were operated on and discharged from the National Amosov Institute of Cardiovascular Surgery of the National Academy of Medical Sciences of Ukraine. All the patients underwent standard clinical and laboratory examinations, coronary angiography, on-pump cardiosurgical intervention. Results. The patients were divided into three subgroups: patients with post-infarction left ventricular aneurysm (LVA) combined with insufficiency of atrioventricular valves, n = 15 (36.6%); those with ischemic mitral insufficiency (MI), n = 11 (26.8%); and patients with CAD combined with aortic valve disease, n = 15 (36.6%). During echocardiographic study, decreased left ventricular ejection fraction was found in patients with LVA and with ischemic MI: 33 ± 6.4% and 39.4 ± 7.8%, respectively, and in patients with aortic valve disease, left ventricular ejection fraction averaged 48.2 ± 9.9% (p < 0.0001). According to the EuroSCORE II scale, the average risk was 11.8 ± 7.3%. All the patients were discussed by the heart team to choose the optimal method of cardiosurgical correction. In order to reduce the ischemic time, off-pump coronary bypass surgery was performed at the first stage, and the second stage was on-pump correction of valvular dysfunction. The average number of grafts was 2.8 ± 1.4, but the largest number of grafts was in the subgroup of ischemic MI: 4 ± 0.9 (p < 0.005). Mitral valve replacement in patients with LVA was performed through LVA in 12 patients. Acute heart failure, acute renal failure often developed in patients after correction of ischemic MI (p < 0.005). On the 1st day after the operation, there was an increase in average glucose values from 6.6 ± 2.8 to 10.3 ± 2.9 mmol/L (p < 0.0001), a decrease in glomerular filtration rate from 72.1 ± 15.3 to 57 ± 18.8 mL/min/1.73 m2 (p = 0.0001), the above indicators returned to the initial level at discharge (p < 0.0001). Conclusions. Off-pump myocardial revascularization in patients with CAD and dysfunction of the heart valves can significantly reduce the ischemic time. The method of mitral valve replacement through LVA developed in the department allowed to reduce the perfusion time (p = 0.0023) and the duration of the operation (p < 0.005). Preoperative discussion of examination data of patients by the heart team, thorough preparation for cardiac surgery, timely response to changes in laboratory parameters with correction of drug treatment avoid complications.

Ten-year outcomes after off-pump and on-pump coronary artery bypass grafting: an inverse probability of treatment weighting comparative study.

The debate on the advantages and limitations of off-pump myocardial revascularization (OPCAB) on long-term outcomes has not still arrived to a conclusion. This study was designed to compare the impact of OPCAB vs, on-pump coronary artery bypass grafting (CABG) on long-term mortality and major adverse cardiac and cerebrovascular events (MACCEs). The PRIORITY project was designed to evaluate the long-term outcomes of two large prospective multicenter cohort studies on CABG. Data on isolated CABG were linked to two administrative datasets. The inverse probability of treatment weight was employed to balance the treatment groups. Time-to-event methods were employed to analyze endpoints. The cohort consisted of 10 988 patients who underwent isolated CABG (27.2% OPCAB). The median follow-up time was 7.9 years and was 100% complete. Unadjusted long-term survival was significantly worst for OPCAB, confirmed by weighted models (hazard ratio 1.08, 95% confidence interval (CI) 1.01-1.14, P = 0.01). OPCAB was associated to an increased risk of MACCE at 10 years (weighted hazard ratio 1.18, 95% CI 1.12-1.23, P < 0.001). Inside the MACCEs, OPCAB was significantly related to increased incidence of repeat revascularization (hazard ratio 2.27, 95% CI 1.39-3.85, P < 0.001, in the first 6 months, hazard ratio 1.19, 95% CI 1.09-1.32, P < 0.001 afterward) and stroke (hazard ratio 1.22, 95% CI 1.10-1.35, P < 0.001). The results of this study suggest that OPCAB was associated with an increased risk of mortality, repeat myocardial revascularization and stroke at 10 years compared with on-pump CABG.

On-pump beating heart versus off-pump myocardial revascularization-a propensity-matched comparison.

On-pump beating heart (OP-BH) coronary artery bypass grafting (CABG) is often undertaken as an alternative between off-pump coronary artery bypass (OPCAB) and conventional on-pump coronary artery bypass grafting (On-pump CABG), especially in India. However, outcome data following OP-BH surgery is sparse. The aim of this study was to compare the outcomes of OP-BH CABG with OPCAB. From our institutional database, all patients undergoing OP-BH CABG (n = 531) were identified. A propensity-matched cohort undergoing OPCAB (n = 531) was identified from the database. Nearest neighbor matching technique was used and the groups were matched for variables including age, gender, body mass index, EuroSCORE, history of recent myocardial infarction or unstable angina, hypertension, peripheral vascular disease, chronic obstructive airway disease, diabetes, pre-op renal impairment, pre-op neurological events, and left ventricular function. The propensity-matched groups were well matched in terms of baseline characteristics. The mean EuroSCORE was 3.17 and 3.20 in the OP-BH and the OPCAB groups. The unadjusted 30-day mortality in the propensity-matched OPCAB group was 2.07% (11/531) while mortality in the on-pump beating heart group was significantly higher at 6.9% (37/531). Multivariate analysis showed that OP-BH CABG was an independent risk factor for 30-day mortality as well as major adverse post-operative outcomes including renal, neurological, and respiratory outcomes and post-operative atrial fibrillation. OP-BH CABG is associated with worse clinical outcomes compared to patients undergoing OPCAB.

Off-pump Techniques of Surgical Myocardial Revascularization.

Before the advent of CABG, standardized in the late '60s by Favaloro and Effler, patients with myocardial ischemia underwent indirect and heterogeneous off-pump methods of myocardial revascularization. Indirect revascularization, such as periaortic nerve plexus interruption, Vineberg operation, Sen procedure and, less remotely, TMR Laser and stem cell transplantation, represented some of the ways to achieve myocardial revascularization. Nowadays, direct coronary revascularization is the only established technique and may be performed either on-pump or off-pump. The comparison of off-pump and on-pump myocardial revascularization paved the way to an endless debate between the advantages and disadvantages of each technique. In this article, we review the old and current off-pump approaches of surgical myocardial revascularization.

Transit-time flowmetric evaluation of coronary artery bypass graft flow after off- and on-pump myocardial revascularization

Introduction: Incorrect performance of anastomoses to the target coronary arteries often causes coronary artery disease and patient`s death following myocardial revascularization. Coronary graft patency evaluation is obligatory for prevention of peri- and postoperative myocardial ischemia. Aim: The objective of the present study was to comparatively assess the values of mean coronary flow and pulsatility index in arterial and venous grafts in patients after on-pump- and off-pump myocardial revascularization. Materials and Methods: During the period between January 1, 2014 and December 31, 2017, 143 coronary artery disease patients, 111 males at a mean age of 63.29±9.78 years and 32 females at a mean age of 66.43±9.58 years were operated on in the Department of Cardiac Surgery, St. Marina University Hospital of Varna. Myocardial revascularization was performed by using 92 arterial and 65 venous coronary grafts in the on-pump group (ONCAB) and 137 arterial and 45 venous grafts in the off-pump group (OPCAB). Coronary graft blood flow was assessed by means of coronary angiography and transit-time flowmetry (TTFM). Results: There were different values of the mean coronary flow and pulsatility index (PI) in arterial and venous conduits, both intervention types, as well as in males and females. The difference between male and female patients in terms of the mean values of venous grafts is statistically reliable (I‡ 2 =11.410; N€â‰¤0.022 and r=-0.310; p=0.001). The PI values in arterial grafts differed statistically significantly between both intervention types (p=0.003). Much more revisions of arterial and venous conduits on the occasion of insufficient patency were performed in the ONCAP than in the OPCAB group. Conclusion : Based on our results and literature data available, we could recommend the wide application of the method of TTFM for exact recognition of the circulatory disorders in the coronary graft following CAGB in Bulgaria.

I.V. NIRS off-pump coronary artery ischemia monitoring bypass surgery

Background: Spectroscopic data were compared with hemodynamic parameters, electrocardiogram, transesophageal echocardiography and laboratory findings. A conversion to extracorporeal circulation was not necessary. The mean number of grafts per patient was 3.1±0.6. An intraoperative myocardial ischemia was not evident, as indicated by electrocardiogram and transesophageal echocardiography.Methods: Continuous spectroscopic analysis showed reproducible absorption spectra of coronary sinus blood. Due to uneventful intraoperative courses, clear ischemia-related changes could be detected in none of the patients. Present initial results show that intravascular near-infrared spectroscopy can reliably be used for an online intraoperative ischemia monitoring in off-pump coronary artery bypass surgery.Results: In 15 elective patients undergoing off-pump myocardial revascularization, intravascular near-infrared spectroscopic analysis of coronary venous blood was performed. NIR signals were transferred through a fiberoptic catheter for signal emission and collection. For data analysis and processing, a miniature spectrophotometer with multivariate statistical package was used. Signal acquisition and analysis were performed before and after revascularization. However, the method has to be further evaluated and standardized to determine the role of spectroscopy in off-pump coronary artery bypass surgery. In off-pump coronary artery bypass surgery, manipulations on the beating heart can lead to transient interruptions of myocardial oxygen supply, which can generate an accumulation of oxygen-dependent metabolites in coronary venous blood.Conclusions: The objective of this study was to evaluate the reliability of intravascular near-infrared spectroscopy as a monitoring method to detect possible ischemic events in off-pump coronary artery bypass procedures.

Сравнительная оценка динамики непосредственных результатов малоинвазивной хирургии инфаркта миокарда

Сравнительная оценка динамики непосредственных результатов малоинвазивной хирургии инфаркта миокарда

Off-pump myocardial revascularization safety aspects in combined operations on patients with ischemic heart disease complicated by ischemic mitral regurgitation

Aim. The issues of safety of off-pump myocardial revascularization in patients with severe ischemic mitral regurgitation remain insufficiently studied. Control of transport and oxygen consumption allows one to assess some of the safety aspects of this technique. The study was designed to evaluate the safety of myocardial revascularization without cardiopulmonary bypass in a combined operation for patients with ischemic mitral regurgitation and a similar operation under cardiopulmonary bypass and cardioplegia by assessment of the main parameters of transport and oxygen consumption.Methods. Forty-two adult patients scheduled for elective coronary artery bypass grafting in combination with mitral annuloplasty were randomized into two groups: off-pump (22 patients) and on-pump (20 patients). In the off-pump group, coronary artery bypass grafting was performed on a beating heart without cardiopulmonary bypass, whereas in the on-pump group it was conventional coronary artery bypass grafting on a cardiopulmonary bypass with cardiac arrest. The coronary artery bypass grafting stage was performed before intervention on the mitral valve.Results. On completion of the coronary artery bypass grafting stage, the cardiac index, the oxygen delivery index and the blood lactate level in the off-pump group were lower than those in the on-pump group by 20%, 17% and 100% (p = 0.01, 0.02, 0.003), respectively, while the consumption index and oxygen extraction were higher by 17% and 94% (p = 0.016 and 0.0001), respectively. In the off-pump group, the oxygen consumption index remained stable at all stages of the operation and the C-reactive protein level tended to decrease between 10–14 days after surgery (p = 0.13).Conclusion. Implementation of off-pump coronary surgery in a combined operation for patients with ischemic mitral regurgitation does not lead to disruption of transport and oxygen consumption, does not exacerbate the systemic inflammatory response and can be considered a safe method for this category of patients.Received 5 April 2017. Revised 21 July 2017. Accepted 24 July 2017.Funding: The study did not have sponsorship.Conflict of interest: The authors declare no conflict of interest.Author contributionsConception and study design: A.S. Zavolozhin, A.N. ShonbinData collection and analysis: A.S. Zavolozhin, D.O. Bystrov, M.V. Elizarov, G.A. Ivanov Drafting the article: A.S. ZavolozhinCritical revision of the article: A.N. Shonbin, D.O. BystrovFinal approval of the version to be published: A.N. ShonbinAcknowledgement: The authors express their gratitude to the staff of cardiac surgeons of City Hospital No. 1 (Arkhangelsk) for collaboration and support in doing this research.

Cardioprotective efficacy of sevoflurane vs. propofol during induction and/or maintenance in patients undergoing coronary artery revascularization surgery without pump: A randomized trial

PurposePre and post-operative administration of sevoflurane in myocardial revascularization surgery provides enhanced cardioprotective effects exerted by pharmacologic pre- and post-conditioning, as compared to propofol. The identification of the enzymes involved in conditioning mechanisms is crucial to the understanding of the effects of sevoflurane in cardiac surgery patients. The impact of sevoflurane on another crucial target organ—the kidney—was also assessed. MethodsNinety patients undergoing off-pump myocardial revascularization surgery were allocated to receive either intra- and postoperative sevoflurane (SS), intraoperative sevoflurane and postoperative propofol (SP), or intra- and postoperative propofol (PP)). Troponin I and hemodynamic parameters were monitored during the first 48 postoperative hours; blood and urine samples were collected at baseline and at 24h to determine Akt, ERK1/2, PKG, iNO, bradykinin receptor, caspase 3, NT proBNP and urinary NGAL. ResultsThe enzymes were overexpressed in the SS group, remained unchanged in the SP group, and decreased in the PP group. Renal function was best preserved in the SS group. ConclusionsThe overexpression of enzymes induced by intraoperative anesthesia and postoperative sedation with sevoflurane reduces myocardial damage and improves renal function in patients undergoing off-pump myocardial revascularization surgery.

Трудности диагностики ишемической болезни сердца и малоинвазивная реваскуляризация миокарда при стенозе ствола левой коронарной артерии

Атипичная клиническая картина, отсутствие достоверных признаков ишемии миокарда на фоне благоприятной картины факторов риска атеросклероза нередко приводят к поздней диагностике коронарного атеросклероза и ишемической болезни сердца (ИБС). Такая ситуация нередко складывается у женщин. Развитие ИБС у женщин имеет ряд особенностей и часто связано с патоморфологическими и патофизиологическими причинами нарушения кровоснабжения мышцы сердца. Так, нередко у женщин среднего возраста стенозирующие изменения в сосудах появляются в дистальном русле и на уровне микроциркуляции с развитием гемодинамического синдрома Х. Однако атипичная симптоматика, вероятно, на фоне компенсаторных процессов, может быть и при проксимальном поражении коронарных артерий. Представленный случай иллюстрирует атипичную симптоматику и трудную диагностику у пациентки со стенозом ствола левой коронарной артерии (ЛКА). Очевидно, в таких ситуациях нужна более точная диагностика с использованием современных методов визуализации. Малоинвазивная реваскуляризация миокарда является эффективным методом лечения пациентов со стенозом ствола ЛКА.

Minimally Invasive Coronary Artery Bypass Grafting

In addition to the achievements in technique and technology that off-pump myocardial revascularization presents, minimally invasive coronary artery bypass grafting (MICABG) has subtly made quality of life (QOL) a major concern of cardiac surgeons around the world. Advances in treatment and the subsequent decline in CABG surgery mortality rates over the last 20 yr introduced a need to incorporate these subjective measures in studies evaluating treatment efficacy (1). The most recent elevation of QOL to the forefront of the medical decision-making process stems directly from the unfailing invocation of patient preference as a primary benefit balancing the known risks of MICABG. This may present a renewed opportunity to commit the focus of medicine more closely and consistently toward patient preferences for outcomes.

Off-pump Revascularization with Bilateral Mammary Artery -Single Center Proof of Concept after 5 Years

Objective: Off-pump myocardial revascularization using bilateral mammary artery (BIMA) is a promising concept in cardiac surgery during the last years. Beside proven benefits toward off-pump surgery, there is an ongoing debate, whether single mammary artery revascularization (SIMA) is superior to the BIMA revascularization in the short and long term course.

Comparison of sevoflurane and propofol anaesthetic regimes in respect to the release of troponin I and cystatin C in off-pump myocardial revascularisation: a randomised controlled trial

Objective. Sevoflurane has been used in cardiac surgery because of its protective ef-fects on the myocardium from ischaemic injury. We wanted to test the hypothesis that sevoflurane has beneficial effects on the heart and kidneys in comparison to propofol.Methods. We conducted a randomised controlled study, with balanced randomi-zation blocked by sex. The participants were 62 patients undergoing off-pump myocardial revascularization (44 men and 18 women), who did not have a myocardi-al infarction less than 24 hours before the start of the operation and who had normal serum values of troponin I preoperatively. The surgery and the measurements were conducted according to the same protocol for both groups. Propofol was used for the induction of anaesthesia in both groups; anaesthesia was continued with either propofol or sevoflurane. Troponin I and cystatin C plasma concentrations were de-termined in eight consecutive blood sam-ples, starting before induction of anaesthe-sia and ending 48 hours after admission to the intensive care unit (ICU). The data were log-transformed and analysed using analysis of variance.Results. We observed a clear and highly statistically significant effect of time for troponin I (p<0.001) without statistically significant differences between the groups (either main or interaction effects). For the majority of patients, the measurements rose quickly upon reperfusion and reached a peak 12 hours after admission to the ICU, descending approximately back to the rep-erfusion level 48 hours after admission to the ICU. Similar inferences were reached for cystatin C, for which the time-course was approximately bath-shaped.Conclusion. We observed no clear superi-ority of either sevoflurane or propofol an-aesthetic regime in off-pump myocardial revascularisation.

Immediate results of off-pump coronary artery bypass grafting

To present an experience of off-pump coronary artery bypass surgery in the department of cardiac surgery of I.M. Sechenov First Moscow State Medical University for the period 2009-2014. It was performed 32 off-pump interventions. We established indications for off-pump myocardial revascularization, surgical technique and intraoperative and postoperative complications. Off-pump coronary artery bypass grafting is successfully reproducible method associated with favourable immediate results.

The dynamics of inflammatory factors in the early postoperative period after various techniques of coronary artery bypass grafting

It was analyzed the dynamics of inflammatory factors in patients with ischemic heart disease in early postoperative period who underwent various techniques of coronary artery bypass grafting (CABG). Seventy-four patients with ischemic heart disease who required CABG were enrolled into study. Patients were divided into 4 groups depending on technique and volume of surgery. The first group consisted of 7 patients after minimally invasive off-pump myocardial revascularization under normothermia without cardiopulmonary bypass (CPB) and cardioplegia. The second group (36 patients) enrolled patients after normothermic off-pump CABG and parallel CPB. The third group had 12 patients who underwent CABG under CPB, hypothermia (28oС) and pharmaco-cold cardioplegia. The 4 group consisted of 19 patients who were operated for ischemic heart disease and concomitant cardiac disorders (left ventricular postinfarction aneurysm, valve surgery) under CPB, hypothermia (28 oС) and pharmaco-cold cardioplegia. Levels of tumor necrosis factor, interleukins (IL-6, IL-8, IL-10) were identified using enzyme immunoassay. Blood sampling was performed preoperatively, in 6 hours and in 24 hours after surgery. Patients after CPB and cardioplegia had more severe systemic inflammatory response and debalance between proinflammatory and anti-inflammatory mediators in early postoperative period. It was revealed correlation between inflammatory cytokines and myocardial damage markers in early postoperative period with development of acute heart failure and multiple-organ failure: IL-8 (r=0.45, р=0.01; r=0.55, р=0.001); troponin I (r=0.65, р=0.0001; r=0.67, р=0.0001); МВ-creatine phosphokinase (r=0.58, р=0.0004; r=0.56, р=0.001). It was concluded that patients after CPB and cardioplegia need for prevention and correction of systemic inflammatory response. It will improve myocardial protection, decrease incidence of acute heart failure and other postoperative complications. Minimally invasive myocardial revascularization is preferable in patients with decreased left ventricular systolic function because of improvement of myocardial protection.

Off-pump myocardial revascularization attenuates endothelin-1 expression in systemic, pulmonary, and coronary circulation

The objective of this study was to evaluate the influence of cardiopulmonary bypass (CPB) on endothelin-1 (ET-1) expression in various circulation compartments in patients undergoing myocardial revascularization. A total of 30 patients were randomized to undergo myocardial revascularization with (CABG, n = 15) or without (OPCAB, n = 15) CPB. Samples were taken preoperatively, after establishing CPB and after CPB (CABG group), prior to and after revascularization (OPCAB group), and 6 and 24 h postoperatively. Values of ET-1 were compared between groups at all time points and correlated with postoperative cardioselective enzyme values and clinical parameters. In OPCAB group, ET-1 levels did not significantly vary between time points. In CABG group, ET-1 levels were significantly elevated vs. baseline in arterial: ART-T2 vs. ART-T0 (1.83 ± 1.81 vs. 0.76 ± 1.07 fmol/mL, p = 0.05), pulmonary: SG-T2 vs. SG-T0 (2.70 ± 2.75 vs. 0.39 ± 0.28 fmol/mL, p < 0.001) and SG-T3 vs. SG-T0 (1.56 ± 0.28 vs. 0.39 ± 0.28 fmol/mL, p < 0.001), and coronary circulation CS-T2 vs. CS-T1 (1.12 ± 0.49 vs. 0.27 ± 0.09 fmol/mL, p = 0.01). ET-1 levels were significantly higher in CABG group in all vascular compartments: ART-T2 (1.83 ± 1.81 vs. 0.17 ± 0.16 fmol/mL, p = 0.02), ART-T4 (0.99 ± 0.56 vs. 0.24 ± 0.12 fmol/mL, p = 0.01), SG-T1 (0.59 ± 0.15 vs. 0.25 ± 0.13 fmol/mL, p = 0.01), SG-T2 (2.70 ± 2.75 vs. 0.30 ± 0.24 fmol/mL, p = 0.004), SG-T3 (1.56 ± 0.28 vs. 0.35 ± 0.31 fmol/mL, p < 0.001), SG-T4 (1.34 ± 0.11 vs. 0.34 ± 0.16 fmol/mL, p < 0.001), and CS-T2 (1.12 ± 0.49 vs. 0.12 ± 0.12 fmol/mL, p = 0.004). Coronary sinus ET-1 level after CPB (CS-T2) in CABG group correlated positively with troponin-I level 24 h postoperatively (r(2) = 0.802, p = 0.02) CONCLUSION: Off-pump myocardial revascularization attenuates ET-1 expression in all investigated vascular compartments. Elevated coronary ET-1 levels after CPB in CABG group correlate with troponin-I levels 24 h postoperatively.

Atrial fibrillation in patients undergoing on-pump or off-pump coronary surgery - lessons learned from GOPCABE

Objective: We sought to find out whether in patients with AF before surgery, off-pump coronary artery bypass surgery (CABG) is able to decrease the perioperative risk compared to on-pump surgery and whether off-pump myocardial revascularization prevents from postoperative atrial fibrillation (AF).

Off -Pump Coronary Artery Bypass Grafting Through Left Antero-Lateral Thoracotomy (Thora-Cab) – A Case Report

We report a case of 62 year old man with single vessel disease involving the left anterior descending artery (95% proximal lesion) who underwent off-pump myocardial revascularization through antero-lateral thoracotomy (Thora--CAB). Post-operative period was uneventful with early recovery and minimal pain. He was discharged home on 5th post-operative day, doing well and is in regular follow up.

Total arterial multi-vessel revascularization. Matched-pairs analysis of results and quality of life after antero-lateral mini-thoracotomy compared to sternotomy

Off-pump myocardial revascularization allows improved results of coronary artery revascularization regarding mortality and neurological outcome. Total arterial multi-vessel coronary revascularization through a left sided mini-thoracotomy is technically challenging and described in only few cases. This study presents the results of this new technique of off-pump myocardial revascularization. Using the matched-pairs analysis results will be compared to those of patients with complete sternotomy for total arterial off-pump revascularization.

Atypically Located Pericardial Cyst in a Patient Who Underwent Off-Pump Myocardial Revascularization

Pericardial cysts are rare benign mediastinal lesions and most commonly located at the cardiophrenic angle. We present a case of an atypically located pericardial cyst in a patient who underwent myocardial revascularization. A 61-year-old man with acute myocardial infarction was scheduled for coronary artery bypass grafting (CABG). Preoperative chest computed tomography revealed a homogenous cystic lesion in the superior mediastinum. The mass was located between the ascending aorta, the superior vena cava, and the left innominate vein. It was growing to the anterior of the aorta and to the right anterior paratracheal area. The density of the mass was close to that of water; thus, the contrast medium failed to enhance its visualization. A concomitant resection of the mass and the CABG was scheduled. After a medial sternotomy and bypass graft harvest, a median pericardectomy was performed. The surgeon found the cystic mass along the roof of the pericardium and located between the ascending aorta and superior vena cava. There was no adhesion between the mass and cardiovascular components. The mass was resected en bloc; therefore, off-pump CABG was completed. Histopathological examination of the resected specimen confirmed diagnosis of a pericardial cyst.