Off‐pump coronary surgery (OPCAB), advatages and disadvantages

 "Off-pump" coronary bypass bypass surgery (OPCAB) was developed in response to concerns regarding the potential side effects of CPB. The goal of this procedure is to achieve total revascularization while avoiding CPB. Positioning the heart for transplantation without compromising hemodynamics is achieved with the use of several retraction devices and deep pericardial sutures. A platform that provides stability reduces movement at the arteriotomy site. After performing an arteriotomy, ischemia can be reduced via intracoronary or aortocoronary shunting.

a Switch to on-pump surgery can be required in the following situations:
i. Very tiny, deeply damaged, or intramyocardial coronary arteries.
ii. Severe cardiomegaly or hypertrophy that prevents sufficient cardiac translocation without hemodynamic compromise or arrhythmias, or extremely low left ventricular performance.
iii. The heart is incredibly tiny and oriented vertically.
iv. Distal shunting does not resolve vascular occlusion, leading to uncontrollable ischemia or arrhythmias.
v. Bleeding becomes uncontrollable and cannot be stopped by intracoronary shunts or vascular loops.

b. OPCABs lower the need for transfusions and the incidence of AF, but it's still debatable if they lower the danger of stroke and renal failure. OPCABs typically lead to a reduction in the number of grafts inserted, which increases the amount of repeat and partial revascularization. Several long-term surveillance studies have demonstrated lower survival compared to on-pump surgery. There is not much enthusiasm for this approach, and less than 20% of CABGs are thought to be off-pump procedures. Though most surgeons save its use for patients with limited illness, one randomized research showed demonstrate improved outcomes with OPCABs when performed for a STEMI within six hours of the onset of symptoms or for patients in cardiogenic shock. Its main benefit might be for extremely high-risk patients with numerous comorbidities.

c. In certain individuals suffering from severe ventricular dysfunction, the heart may not be able to withstand the necessary manipulation during off-pump surgery. Right ventricular (RV) assist devices can be utilized in this situation to enhance hemodynamics.
Alternatively, to prevent the period of cardioplegic arrest, surgery might be performed on the pump when the heart is empty and beating. This method permits safe cannulation and the use of an aortic punch, such as the Heartstring proximal seal device (MAQUET Cardiovascular), to accomplish the proximal anastomoses, and may be helpful for patients with ascending aortic disease that precludes safe aortic cross-clamping.