Off Pump CABG Anesthetic and Surgical Consideration

Introduction and background: Off pump cardiac coronary artery bypass graft (OPCABG) reached its peak usage at around 25% in 2004. Since then, there has been a decline in use of this technique to a level much below its peak. In contrast, the OPCABG's percentage of total coronary artery bypass graft (CABG) surgery is much higher in Brazil, India (over 90%), Japan (over 60%), China and many other Asian countries. However, its application is still being debated for several decades. OPCABG is technically demanding both for anesthesiologists and surgeons, but since it is still widely used there is continuing need to contrast its results and benefits with conventional bypass. This review will look at the technique, challenges, and literature related to off pump surgery, and will specifically address effects on graft patency, inflammatory response, neurological and cognitive deficits, early discharge, long-term survival and quality of life. Also reviewed will be anesthetic and surgical techniques and results for offpump, minimally invasive, and robotic surgery. Methods and results: This was review was accomplished by a comprehensive retrieval of literature published over last two decades by Pubmed and Google Scholar. A systematic search was done to look for publications featuring a large number of cases. The goal of the inclusion criteria was to derive information from articles published in major anesthesia and surgical journals. In order to make this review comprehensive, articles describing history, evolution of off-pump surgical technique, graft patency, and early and late outcome data were included. Published meta-analyses were also reviewed to find utcome differences between off-pump and on-pump coronary bypass surgery regarding rates of atrial fibrillation, neurological deficit, and cognitive deficit. Also reviewed is literature on robotic minimally invasive techniques providing complete revascularization with or without coronary angioplasty and intracoronary stents performed in the cardiac catheterization laboratory. Publications or reviews from the early years of off-pump surgery (1990-2000) were mostly not included; primarily because the technique has significantly evolved in the past decade as a result of the development of new surgical and anesthetic devices and significantly increased experience amongst the providers with stated techniques. Some references were included to provide a historical basis of the technique. For example, early off-pump surgery primarily involved a 1-2 vessel coronary bypass grafting to the leftanterior descending coronary artery and/or its diagonal branch. Currently used equipment nd devices used to facilitate surgery were not available. In contrast, the current goal in the majority of modern OPCABG surgery is to achieve complete revascularization of all the diseased coronary arteries. This may include revascularization performed by the catheterization laboratory prior to or immediately after off-pump surgery Conclusion: This review concludes that most of the studies showed reduced length of stay, operative morbidity and mortality. There has been consistent evidence showing decreased incidence of bleeding and coagulopathy in patients who had off -pump coronary bypass surgery compared to on-pump surgery. There is also some evidence of a decreased incidence of neurological complications and cognitive dysfunction following off-pump coronary bypass surgery, especially when aorta is not manipulated. Also, off-pump bypass will continue to be the indicated technique when cannulation of the aorta is contraindicated.