Off-pump coronary artery bypass grafting - Excellent results in a group ofselected high-risk patients

Background. Off-pump coronary artery bypass grafting (OPCABG) has assumed a n increasing role in many surgical practices. The ideal candidate has not b een defined, but high-risk patients seem to benefit most when cardiopulmona ry bypass (CPB), aortic cross clamping and cardioplegic arrest are avoided. Methods. Fourteen high-risk patients (age 52 to 81 years, 1 female, EF 44% +/- 8, Parsonnet score 23 +/- 4) were studied. They presented with acute co ronary syndroms on platelet glycoprotein IIb/IIIa antagonists, acute myocar dial infarction, worsening renal failure, decompensating ischemic cardiomyo pathy, religious beliefs and denial of blood transfusion, and severe periph eral/cerebrovascular disease (total bilateral internal carotid artery occlu sion and/or > 90% stenosis). These patients underwent OPCABG via sternotomy with the intention of complete coronary revascularization. Results. An average of 2.3 grafts/patient were performed and the posterior descending artery (PDA) and marginal branches of the circumflex artery (1,C X) were grafted in 79% of the patients. There were 3 events of intraoperati ve cardiac arrest precipitated by occlusion of right coronary artery (RCA) or positioning a cardiomegaly heart leading to immediate intravascular shun ting (2) and/or conversion to CPB (1). One patient was converted to CPB and graft revision (intraoperative ultrasound and probing). The mortality rate was 0% and one stroke was observed on postoperative day 1. Coronary angiog raphy (n=6) showed no significant stenosis. Conclusions. OPCABG complete revascularization is feasible in high-risk pat ients with low morbidity and mortality and excellent early results. OPCABG may be indicated in patients on platelet receptor antagonists preventing bl eeding complications. Cardiomegaly can cause difficult off-pump LCX and PDA exposure and stabilization. RCA grafting off-pump is less tolerated and PD A grafting is preferred. High-risk patients for CPB are the ones who may be nefit the most from OPCABG.