OPCAB –vs- CABG???: The Big
Question
Obviously, the essential difference between OPCAB and CABG is that the heart-lung
machine is NOT needed with OPCAB and is needed with CABG. Though the objectives
of OPCAB and CABG are similar, eliminating the heart-lung machine alters the
procedure by which the end goal of cardiopulmonary bypass is achieved.
Conventional CABG is a widely used procedure with an excellent success rate, having an
intra-operative mortality rate of 1%. This procedure has been perfected by surgeons, and
therefore, complications during surgery rarely occur. It’s the potential for, and
prominence of, post-operative complications that have become a source of major
concern. Common post-operative complications are_________________________. As
posted on the ctsnet website, Ascione, Lloyd, Underwood et al. found that the
management costs of post-operative complications for CABG were significantly higher,
statistically, than for OPCAB. This technique is a universal treatment option which can
be successful for any patient.
Thus, the development of OPCAB. So far, 3396 OPCAB procedures have been
performed, according to the National Adult Cardiac Surgery Database. This
revolutionary procedure requires that cardiac surgeons and anesthesiologists go through
training to develop the skills necessary for the procedure. In other words, these surgeons
have to go to school all over again. Imperfect technique has forced surgeons to exclude
many patients. The techniques must be standardized.
MIDCAB nowadays this technique has largely been abandoned because it allows only
single vessel surgery, is technically demanding, and may lead to suboptimal results
The most recent data was discovered on www.ctsnet.org. 30% revascularization is done
on a beating heart. Money saved = reduced bed time and nurse care. Blood loss and
transfusion were less.
What changes is procedure is that, instead of stopping the heart_______________, the
heart is kept pumping and aortic cannulation and aortic cross-clamping is avoided. The
OPCAB procedure is relatively new (DATE) as compared with the conventional CABG
surgical procedures. However, the use of stabilizing and positioning devices (LINK)
allows stable and motionless access to the vessels on the backside of the heart while
minimizeing hemodynamic adverse effects.
This significantly reduces “morbidity, with marked decreases in (1) bleeding
complications and need for transfusion, (2) release of myocardial enzymes and other
biochemical markers of injury or inflammation, (3) postoperative intubation time, (4)
duration of intensive care stay, and (5) overall hospital stay without compromising
hospital mortality.” (http://www.arabmedmag.com/issue-15-012004/cardiology/main05.htm)
As can be imagined, there are several risks associated with physically stopping a patient’s
heart from beating and hooking the patient up to a heart-lung machine during CABG.
Some of these risks include… compliment activation……risks/difficulties in restarting
the heart beat………………… post operative complications
Where the surgeon and team lie on the OPCAB learning curve represents a key
determinant of intraoperative outcomes. According to an analysis by Brown and
coworkers,[17] patients undergoing OPCAB at "high-volume" centers exhibited
significantly lower major (cardiac, renal, bleeding, neurologic) complication rates and
were significantly more likely to be discharged directly home (80%) compared with
those seen at lower-volume institutions (66%; P = .001).
Difficulties with OPCAB insufficient scientific evidence of the advantage, effectiveness
and benefits of this operation over conventional CABG. Secondly, there is a huge
learning curve associated with this new and intricate procedure
known to cause a complex of systemic inflammatory responses and has been associated with
several adverse postoperative outcomes, including renal, pulmonary, neurologic, and
coagulopathic complications and even end organ dysfunction. (1) Surgeons driven to reduce both
the short-term and long-term morbidity associated with CPB find OPCAB to be an attractive
alternative. http://www.findarticles.com/cf_dls/m0984/3_125/114819640/p1/article.jhtml
Advantages/Disatvantages of OPCAB/CAB
OPCAB
CABG
Transit time flow measurement (TTFM) is used as a major tool for intraoperative quality
control in CABG. The aim of this study was to evaluate whether the results of TTFM can
be interpreted equally in off-pump CABG (OPCAB).
Mean flow rates in group A were 46±18.3 ml/min on IMA-grafts and 53±26.7 ml/min
on SV-grafts grafts. Mean flow rates in Group B were 25±13.6 ml/min on IMA-grafts
and 31±16.4 ml/min on SV-grafts. Postoperative mean Troponin-I concentration was
9±5.4 µg/l in group A and 2±1.3 µg/l in group B.
Conclusion: Flow rates were significantly lower in OPCAB compared to CABG with
CPB. Lower flow rates in OPCAB have not been followed by higher incidence of
postoperative ischemic events. A low value of mean flow is not “per se” an indicator
of an inadequate anastomosis. Especially in OPCAB it's important to consider flow
patterns, pusatile index, flow values and clinical findings simultaneously
As Major source of intraoperative brain injury