Asian Cardiovasc Thorac Ann 2002;10:158-159
© 2002 Asia Publishing EXchange Pte Ltd
Invited Commentary
Erik WL Jansen, MD
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Department of Cardiothoracic Surgery Heart Lung Institute University Hospital Utrecht Room E 03.406 P.O. Box 85500 Utrecht 3508 6A The Netherlands
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Off-pump coronary artery bypass (OPCAB) has been accepted as an attractive modality in addition to the traditional on-pump technique. Since its popularization in 1995, many studies have supported the acceptance of OPCAB. Yet, the contribution of OPCAB is not growing rapidly. For 2001, the global penetration of OPCAB is estimated as approximately 20% (25% in the United States and 12% in Europe). Recently, randomized studies have been published.1–11 Surprisingly, the outcome of routine coronary surgery in selected patients by off-pump and on-pump techniques is comparable.10,11 Nevertheless, the off-pump technique is advocated for patients who are poor candidates for cardiopulmonary bypass, particularly for elderly patients with comorbid conditions and for those with a calcified or atheromatous ascending aorta, to reduce the risk of a thromboembolic event.
Heart failure, hemodynamic instability, severe left ventricular dysfunction, and cardiac enlargement are generally considered as contraindications to OPCAB. However, good results have been reported with off-pump techniques in patients with severe left ventricular dysfunction.12 For multivessel bypass grafting, good exposure of all coronary arteries optimizes the quality of the anastomoses. In these patients, the heart-lung machine may support and unload the heart (possibly in a beating heart procedure without aortic crossclamping). This gives good exposure of all target sites, using a tissue stabilizer. New techniques may be applied to more patients for coronary surgery without a heart-lung machine, such as heart exposure by apical suction in addition to the tissue stabilizer, or partial circulatory support.
With respect to the latter, a right ventricular assist system is well presented in this paper. It is a 3-case report of elegant, successful, beating heart procedures, showing stable hemodynamics and patency of the grafts. However, using only right ventricular support, it may not be easy to expose the lateral and posterior walls of an enlarged left ventricle. It is clear that the modalities for coronary surgery are increasing. Their role has to be defined. The authors are right in asserting that the new techniques should be evaluated, preferably by randomized studies.
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This article has been cited by other articles:
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S. G Raja and G. D Dreyfus
Current Status of Off-pump Coronary Artery Bypass Surgery
Asian Cardiovasc Thorac Ann,
April 1, 2008;
16(2):
164 - 178.
[Abstract]
[Full Text]
[PDF]
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