off pump coronary artery bypass

1. OPCAB
OFF-PUMP CORONARY ARTERY BYPASS GRAFTING SURGERY…….
(Presented by Suprakash Sarkar)

2. Introduction
 Off-pump coronary artery bypass graft surgery is a form of
CABG(coronary artery bypass graft) surgery performed without
CPB(heart-lung machine) as a treatment for coronary heart disease.
 During most bypass surgeries, the heart is stopped & a heart-lung
machine takes over the work of the heart lungs.
 When a off-pump CABG is performed , the heart is still beating while
the graft attachments are made to bypass a blockage. It is also known
as “Beating Heart surgery”.

3. Indications
• Coronary artery disease requiring surgical revascularization
• High risk or contraindications for cardiopulmonary bypass and aortic
cross-clamping
• Severely atheromatous or heavily calcified aorta
• Aortic disease with risk of dissection, rupture or embolization
• Patients who can not tolerate PTCA & don’t response well to drug therapy
• Hemodynamic instability
• Impaired left ventricular function
• Acute myocardial infarction
• History of transient ischemic attacks or cerebrovascular accidents
• Impaired renal function or need for dialysis in patients with chronic renal
failure
• Patients who refuse blood transfusions

4. Contraindication
s
• Infection
• Bleeding
• Irregular heart rhythms
• Blood clots leading to stroke or heart attack
• Complications from anesthesia
• Kidney failure
• Congenetal bleeding disorder
• Valvular Heart disease

5. OPCAB tissue stabilization &heart positioning devices
Genzyme Immobilizer
utilizes a stabization platform & silastic vessel loops.
The Medtronic Octopus4 tissue stabilizer & starfish2 heart
positioner utilize vacuum suction to stabilize & position the
heart.
Illustrates silastic snares that are looped around the target
coronary vessel & then fixed to a small immobile plate , thus
directly immobilizing the target vessel.

6. OPCAB Demands
Exposure of posterior lateral wall of the heart.
Stabilization of target area.
Visualization Occlusion of the Coronary artery or Shunt.
Stable Hemodynamics.

7. Pre Operative Assessment
• For optimization of diabetes, hypertention, reactive airway & other
coexisting morbidities.
• To alley anxiety related to the procedure.
• Preoperatative assessment of the carotid arteries.
• Essential Investigation to be done : Coagulation profile, Lipid profile,
Electrolytes, Blood Grouping & Serology, Renal & Liver function tests,
CXR, ECG, Echo, USG abdomen(elderly males), PFT.

8. Intra Operative Monitoring
• ECG – lead ii & V5 – well visualized “P” wave & QRS
complex prior to commencing the surgery.
• SpO2, ETCO2
• Temperature Monitoring
• Urinary output monitoring
• Invasive blood pressure (IBP) monitoring – by radial or
femoral artery.

9. Pulmonary Artery Catheter
•Usually placed via the right internal jugular vein.
•Indication:-
•Ejection Fraction <0.4
•Significant abnormality of the left ventricular
wallmotion.
•LVEDP > 18 mm Hg at rest.
•Recent Ml & unstable angina.

10. Transesophageal echocardiography (TEE)
• Advantages:-
• Identify myocardial ischemia early by detecting regional wall
motion abnormalities.
• Assess left ventricular dysfunction intra operatively.
• Assessing the improvement in myocardial function after the
completion of revascularization.
• Disadvantage:-
• Inability to image the required part of the heart during
grafting.

11. Arterial Blood Gas Test
(ABG)
• Check for severe breathing and lung problem such as Asthma , Cystic
Fibrosis, Chronic obstructive pulmonary disease or obstructive sleep apnia.
• Check how treatments for lung problems are working
• Check whether you need extra oxygen or other help with breathing.
• Check your acid-base balance. You can have too much acid in your
body from kidney failure, a severe infection, specific toxic ingestions,
or complications of diabetes.

12. Steps OF OPCAB
• Position : Supine
• Anaesthesia : General Anaesthesia with Endotracheal tube.
• Incision : Median sternotomy
Procedure
Surgical skin prepare (shaving,draping,dressing) is done.
A vertical incision is given at the center of the chest.
Chest is opened via median sternotomy.
Thoracotomy is done creating a 6-8 inch incision.

13. Chest Retractor Sternum Saw

14. The grafts are being hervested.
Blood vessels can be as graft from leg(saphenous vein) ,internal mammary artery ,radial artery.
After thoracotomy a incision is given to pericardium to reveal the beating heart.
After hervesting patient is given heparine to prevent blood clots
Then a stabilizer is attached to stabilize the desired place.
A perfusionist must be present there to connect the CPB if any emergency situation occurs.
After this the reserved graft is anatomose to the coronary artery with 70 polipropiine suture.

15. Pericardium is properly closed with suture.
Chest tubes are placed in the mediastinum & plural space to drain blood from and around heart & lungs.
After completing instrument counting sternum is closed with alluminium wire & the incisions are closed with suture.
Clossure of every incision is done.
Dressing is done.
OPCAP successfully performed

16. Complications
• Embolism
• Infection
• Accute pain
• Hypothermia
• Fluid electroite imbalance
• Cardiac temponant
• Dysrythmia
• Injury to nerve
• Hypertention or Hypotention

17. Any Question?

18. THANK YOU……