This site is not optimized for Internet Explorer 8 (or older).

Please upgrade to a newer version of Internet Explorer or use an alternate browser such as Chrome or Firefox.

Dual Inflow, Total-Arterial, Anaortic, Off-Pump Coronary Artery Bypass Grafting: How to Do It

Thursday, September 13, 2018

Submitted by


Source Name: Annals of Cardiothoracic Surgery


Fabio Ramponi, Michael Seco, James B. Edelman, Andrew G. Sherrah, Paul G. Bannon, R. John L. Brereton, Michael K. Wilson, Michael P. Vallely

This illustrated, instructional article details a reproducible, total-arterial surgical revascularization technique which does not require cardiopulmonary bypass or any manipulation of the ascending aorta. This guide aims to improve outcomes for surgeons new to off-pump coronary artery bypass grafting (OPCABG) and goes some way to addressing concerns raised by critics of OPCABG.


I am excited to read that yet another department has implemented the technique of TAR, NAT (No Aortic Touch) OPCAB I have been using for the last 13 years. I have a few suggestions for modifications you may consider: 1. Performing the LIMA to LAD (+/- Diagonal) anasatomoses first, wil usually make the heart more tolerant to enucleation for OM and PLA/PDA anastomoses. 2. Running the RIMA (+/- Radial composite extention through the transverse sinus, has previously been shown to be associated with decreased graft patency. I prefer running it counter-clockwise around the heart (PDA/PLA anastonoses first, OM anastomoses last) letting both the RIMA-RA I- graft and the LIMA enter the pericardium through separate holes in the pleura/pericardium. 3. Avoiding inotropes (milrenone) and vasoconstrictors (noradrenalin) as long as the heart has not been revascularized, follows the rule of "not whipping a tired horse". If you exhaust the heart, you will more often need ECC support (I manage to avoid this in 98% of you have to be thick-skinned to comments from bored perfusionists :-D) 4. Creating a "cradle" over the heart to perform the RIMA-RA anastomosis is not necessary, if you place a wet pack on the right chest wall next to the sternotomy, and perform the anastomosis on that.

Add comment

Log in or register to post comments