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Should Off-Pump CABG Be Abandoned?

Wednesday, April 27, 2016

Should off-pump CABG be abandoned? Joseph Sabik of the Cleveland Clinic, Cleveland, Ohio, suggests that while off-pump CABG should not be completely abandoned, it should no longer be the default option. Dr. Sabik argues in favor of on-pump CABG becoming the first choice of cardiac surgeons, citing procedural outcomes, quality of revascularization, and long-term effectiveness.

This presentation was originally given during the SCTS Ionescu University program at the 2015 Annual Meeting of the Society for Cardiothoracic Surgery in Great Britain and Ireland. This content is published with the permission of SCTS. Please click here for more information on SCTS educational programs. 


Off pump coronary bypass surgery is best for worst candidates (e.g., severe LV dysfunction, CRF, severe DM with complications, advanced lung disease) of CABGs. OPCAB surgery should be done by very experienced surgeons ONLY! Complete revascularization and high quality anastomoses (both IMA and SVG) are possible in experienced hands.
11 users have voted.
On pump should be the default operation for the surgeon who can not perform a good off pump procedure. They are two different approaches but the main point is full and good quality revascularisation. It is driving formula one car or a family car, iti is up to the driver.
I agree that off pump surgery coronary by pass surgery should be done by very experimental surgeons. But also complete arterial revascularization is the gold standar technique, using the two mamary artery, independent of the age, diabetes, etc of the patients. Safenous vein is almost obsolete.
Randomized trials showed no benefit of OPCAB over On pump in patients who previously we thought could potentially benefit by avoiding pump such as those with poor LV function , old age and those with kidney impairment.
Although results are not in favour of OPCABG, we should know that in most of these TRIALS operating surgeons in OPCABG group are not as experienced as they should be therefore these results should not be taken as true. OPCABG , total arterial graft with no touch aorta technique can be done safely with very good quality anastomosis and provides very good results in short and long term. So, I do not agree that this technique should be abandoned at all. I agree that training surgeons performing OPCABG is long process, but this a problem which teaching hospitals should solve, abandoning a technique is not the solution.
12 users have voted.
OPCABG is here to stay. It is more challenging, it require skill and experience, but sometimes it is the only way to achieve a good result. Do you remember how we were facing a CABG operation on a patient with heavvy calcified aorta? It was a nightmare and now, off-pump gives us the solution. There is to be someone who can do it.
I am a great proponent of OPCAB and use this technique of myocardial revascularization in nearly 99% of cases, with a conversion rate of approximately 1%. I do perform bilateral pedicled IMA’s plus minus radial artery or vein grafts, or total arterial revascularization using LIMA-RIMA (Y) or LIMA-Radial (Y) or free radial graft to aorta. Although there are clinical trials showing suboptimal clinical outcomes of OPCAB as compared with ONCAB – to my view, the experience of the surgeons involved in these trials must be fully assessed. OPCAB requires additional skill and experience of the surgeons and without being personal, I would like to comment that nearly all patients can be submitted to OPCAB (except cardiac emergencies) , but all cardiac surgeons can not be asked to perform OPCAB. Further, for trainee surgeons, what I feel that on-pump CABG should be the procedure of choice (default procedure). Lastly, OPCAB is performed in hypercoagulable state; therefore, intra and postoperative management of coagulation status in particular to Activated Clotting Time (ACT) may be important for improving graft patency either in short or long term.
11 users have voted.
In my oppinion, our target should be "complete revascularization". If the surgeon can perform complete revascularization "safely", and he/she has a high ability for off-pump surgical technique, he/she can choice off-pump technique. Off-pump technique is not for only the patients with LV dysfunction, renal problems and etc. If you choose worse candidates for off-pump surgery, your outcome will be worse.
We started doing off pump coronary surgery in 1978 clearly the big limitation in this years to reproduce this operation was the no existence of technology basically for achieve complete revascularization if was necessary; after we and others developed The technology; Started the education and teaching proses all over the world after trained surgeons in a lot of countries that are active in coronary surgery I learn basically that the teams that have the desire to learn this operation, respect the teaching proses and try to applied in 100% Has in general excellent immediately and long term results .Remember in the different centers are a lot of variables that can influence the results with the off pump coronary surgery that was already reflected in many Studies and trials without any doubt the expertise of the team in this technique is the most important The economic situation and the costs of the operations are different all over the world Always the idea is to benefit the more number of people that need coronary surgery as possible For example in my Foundation in Rosario Argentina in the last 12 months we have 0% mortality 100% off pump no conversion Two days and a half of hospitalization in high risk population and the costs of the entire operation was less than 5000 thousand dollars , for us this and for probably most of the centers of the world this is almost impossible in on pump coronary surgery ;the history shows that in general the things can be reproduce We always need to remember for example that the left internal mammary connected to the Lad and patent is the most powerful predict of survival ` for a lot of patients with coronary disease The MIDCAB or the MINI OPCABG techniques off pump are two very low costs operations that can eventually drive the Hybrid Revascularization option So basically for this and others different reasons and scenarios is important for the surgeons in formation to learn off pump and the variables of the technique and having in the armamentarium
By definition complete revascularization can be achieved with off pump technique and not as difficult as it seems in BLGM surgeons are doing it routinely with zero conversion rates and complete revascularization with one of them having done 5000 OPCABS the only aspect that has to be addressed is the technique plus the surgeons temperament A matter of preference approach training understanding between surgeon and anesthetic quality of graft has always been questioned and answered yet debatable the presentation is good but biased in many aspects which is beyond the discussion here but can be considered as an opinion
I fully agree with Dr Himanshu. Off Pump Coronary revascularisation requires special skills and outcomes are mainly dependent on the expertise of not only the surgeon but the complete team including assistants and anesthetists. On pump CABG is a reproducible procedure with limited experience and skill levels, where as OPCAB has a long learning curve and outcomes of two different teams are not comparable. I feel OPCAB can't be written off based on few studies where the skill / expertise of surgeons is not taken care of. OPCAB is here to stay.......An experienced team of OPCAB surgeons can provide quality and completeness of revasularisation similar to on pump CABG along with advantages of OPCAB surgery like (Reduced Stroke/ Renal Dysfunction / Transfusion / Resp Infections / AF) My Advice for patients would be "IF YOU CAN CHOOSE THE SURGEON CHOOSE HIM IF NOT CHOOSE THE SURGERY"
Opcab vs Oncab, after all these years we are still debating what should be done. These days when does a surgeon see a case for bypass, when the cardiologist does not see much in a angiogram, instent restenosis, osteal disease, diffuse disease, and worse. Opcab as a tool should be utilised only in certain situations. Oncab is safe , lot more grafts, arterial or venous , sequential arterial , bilateral IMA and Y grafts can be performed safely and effectively without any morbidity and mortality . If you are in a private sector where you are accountable better not to Opcab. Every patient wants the best operation, relief of symptoms and better quality of life. What are we trying to prove. Nobody got a noble prize in cardiac surgery - Remember.
Congratulations to Dr. Sabik. We are witnessing by this presentation the very clear pitfalls of meta analysis. The Cochrane one with more than 10 thousand patients: do we have any sort of data, what VARIATION of myocardial support were used during off -pump CABG (like IABP). Or during on pump procedure were there any examples of doing the procedure on the beating heart). What proportion of the patients were given cardioplegia? I am convinced that there must be a profound heterogenity with regard the revascularized patients. What is more CONVERSION is a true FAILURE of PREOPERATIVE EVALUATION! (Pts, with complex lesions, bad LVF, rhytm disturbances should go on bypass.) Complete revascularization very well can be achieved by offpump surgery -if one is familiar with the construction of complex arterial grafts (LIMA-RIMA-Radial.rGEA) - therefore in experienced hands, there is no chance for incomplete revasc. -Occasionally stenosis on secondary branches can be dilated by intraoperative balloon angioplasty... Success rate is very much depends upon the surgeons' skill and experience. Therefore, it should not be declared, which modality is to be be the default option.
Once again, the eternal argument between On- and Off-Pump CABG. There is a very well known concept in physics: light has a dual nature, it behaves either as a wave or a particle. Therefore, On-Pump CABG should remain the default for all the known reasons. Off-Pump may well be an option in selected groups of patients offered by those who perform the procedure on a regular basis. It is only a matter of personal choice in our practice. Let's try to be more innovative and less argumentative.
An 8-12% conversion rate to ONCAB! Ridiculous! The surgeons in these trials are simply terrible at off-pump in all-comers, no matter how many they have done. There is something wrong with their technique. The conversion rate by an expert should be less than 1%. Obviously this will have a huge impact on their outcomes regarding death, stroke and MI. Undoubtedly the quality of their anastamoses also suffer because these surgeons are not as good at off-pump as they need to be. I've done over a 1000 OPCABS on all comers in a row, including all emergencies that were alive coming to the OR, with a 0.2% conversion rate. None were for the so-called hemodynamic instability - this is prevented with patience and good teamwork. Overall, what these studies show is non-inferiority by surgeons who are inadequate at this technique, except with regard to the number and quality of grafts that they do. Obviously with such a high conversion rate, they are not going to do a good job on the number or quality of grafts either. My patients routinely get more grafts than my ONCAB colleagues, so this is also a problem with the surgeons in these studies. Long term benefit is well documented by Dr. Sabik and his colleagues to be enhanced by well performed arterial bypass grafts. The clinic does not have the same expertise with regards to off-pump. Dr. Sabik is incorrect to suggest that there is a problem with OPCAB in its entirety. He should suggest instead that surgeons exercise good judgement about their own skill level before deciding to utilizing OPCAB as their default technique. Patients benefit in many ways from a well performed OPCAB over an ONCAB. An intention-to-treat analysis of trial data will not show this when the conversion rate is so high at 10%. Surgeons with this high a conversion rate need to recognize that there is something wrong with their technique that must be corrected. Until then, they need to be selective with their patients for OPCAB and they must be able recognize when to convert earlier before they do harm to a patient or the heart. The bugaboos with OPCAB are emergent conversion and grafting proficiency, just as ONCAB has the bugaboos of aortic dissection and myocardial protection. With education, we as a profession have learned over time how to mostly overcome these problems of ONCAB. For the benefit of our patients, we ought to be doing the same with OPCAB.
More Than 10 % of convertion means the surgeon and there team dont know how to do OPCABG There are Surgeons and Teams that can teach OPCABG all over the world Remenber the Institutions can be very good and for differents reasons are not interested in do OPCABG or sometimes the heart team dont fell confortable because they dont know how to use this thecnique correctly
I absolutely agree with Dr Sabik's opinion which was supported by extensive data. I started OPCAB in year 2000 only in patients with EuroScore>5. But with all the evidence now, I would consider OPCAB only in selected cases ie: all arterial grafts (zero aortic manipulation).
I am watching And doing CABG surgery since long trends set by seniors and personal observations plus large reports bring changes. CABG done by any technique quality anastomoses, complete revascularisation is the key. I have seen different institutions where all cases done with fibrillating arrest, other with cold cardioplegia, warm blood cardioplegia , Antigrade/retrograde cardioplegia etc and tons of literature to advocate and lastly empty beating heart using all tools of beating heart surgery. Seen days of liberal extensive endarterectomies and their bed results. Personal experience with on pump and than transition to off pump initially required more than 10 % conversions but now we do almost 100%off pump and less than 1% conversion and 1% IABP almost complete revascularisation and after 1000 cases feel more comfortable with off pump. It is not possible to get angiography frequently but time will tell which is better. Reusable stabiliser may cut cost but if it is disposable than on pump is cheaper. Use of cell saver also increase cost. We are able to do CABG in average less than $2500.
OPCABG cant be performed with shaking hearts!!!! Ive been doing all CABGs SYSTEMATICALLY Off PUMP as of 2012... Learning curve is a must AND should not brake our R...evolution... It s a style of how-to-do with better outcomes... I agree that OFFPUMP is here to stay...
I have gone through all the comments made by renowned surgeons . Definitely opcab is a technically demanding surgery, needs skills and experience. It has many advantage and superiority over oncabg, actually it is the best way to solve the difficulties and disadvantage with oncabg. I am doing opcab in nearly 100% cases with <1% conversion. I am doing difficult and risky cases safely on opcab-like calcified aorta by no touch aorta technique(lima-rima y), or no clamp proximal anastomoses, CKD with cr.4-5, esrd on dialysis, poor lv . It is justified that less experienced surgeon will do simple cases by oncabg and experienced surgeon will do opcab difficult and complicated cases. Lastly I should say from my experience that opcab is better and safe than oncabg in experienced hands.
Only because of the OPCAB, we are able to perform CABG to the hapless poor patients in Medical College, Kolkata. We use LIMA for LAD, and veins (SVG) for the rest. Conversion rates are small. If we had to use Pumps for all these patients, hardly they could have afforded CABG. Most of our patients are Bidi (small dried leaf bound tobacco) smokers, mostly farmers and porters by occupation ( comparable to the middle class Indian cigarette smokers with larger coronary arteries in our private practice). Though the vessels are small (LADs most often 1.25 to 1.5 mm, OMs and PDs 1-1.25mm, similar to the narrowed arteries found in Buergers disease or TAO probalbly due to bidi smoking and diabetes prevalent in Indian subcontinent), they can soon resume their occupation within a month of their discharge. Our MCh students have hardly seen a full on pump CABG, except a few after crashes. Patients are doing well after OPCAB. How can some argue that the grafts are incomplete! Of course we are sterilizing the shunts. Stabilizer is an Eschtec metal reusable stabilizer. My patients are for follow up for more than 10 years. I don't feel the grafts are incomplete. I agree that some vein grafts can close. But that does not mean that OPCAB is responsible for the grafts failure. We use side to side anastomosis of veins (after tying the distal ends with two silk ties) to native coronary arteries with 8-0 prolenes for last 8 to 9 years, after abandoning the much practiced end to side techniques, because it is easy and luminal size mismatch can be avoided.
Off-pump CABG should be abandoned by surgeons who can't achieve the same rate of revascularization and similar if not better outcomes than with the on-pump CABG. A conversion rate higher than 1-2% should prompt a first on-pump approach in low risk CABG patients.

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