Coronary Artery Surgery

 

Despite improvements in medical and percutaneous therapy, ischemic heart disease caused by atherosclerotic coronary artery disease still represents one of our biggest challenges – the single largest killer of Americans. Among other indications, surgical revascularization (in combination with medical therapy) remains a Class Ia American Heart Association recommendation for asymptomatic patients or those with stable and unstable angina who have significant left main obstruction, left main equivalent (proximal LAD + proximal circumflex), and 3-vessel obstruction (especially with EF<50%).

The traditional surgical approach of coronary artery bypass grafting (CABG) utilizes a cardiopulmonary bypass machine to divert blood away from the heart and lungs allowing the surgeon to precisely connect coronary arteries with new conduits supplying the myocardium with enhanced blood flow. These bypass conduits perfuse areas of the heart that were previously flow limited. Although the traditional CABG operation is performed nationally with a 2-3% mortality and average hospital length of stay of less than 7 days, mechanisms of improving safety and speed of recovery have been actively pursued. An innovative alternative strategy to the traditional CABG procedure is to perform this procedure without the heart-lung machine on a beating heart: Off-pump CABG or OPCAB.

Technology advancements in heart stabilizing devices and miniature temporary shunts substantially diminish the challenges of a beating heart approach. Prospective randomized trials have observed that OPCAB appears as safe as the traditional CABG and retrospective studies suggest that OPCAB may be safer with fewer procedure related deaths and complications. A beating heart strategy is associated with fewer blood transfusions, decreased ventilator dependence, less renal failure, fewer strokes, and shorter hospitalization. Our surgical experience suggests that OPCAB should be discussed with all patients receiving CABG. However, certain patients will likely benefit and should be offered OPCAB including patients that are older and frail, suffer from chronic obstructive pulmonary disease, have had a prior stroke or neurologic event, and have renal insufficiency. As such, in our current practice, we perform OPCAB in 30-40% of patients requiring operative revascularization.