History In the late 1940s Dr.vineberg first reported on the implantation of the LIMA on the myocardiom In 1950s Muray and coworkers reported on successful case of coronary endarterectomy In 1961, Goetz, anastemosed RIMA to the RCA and demonstrated for the first time that direct myocardial revascularization without CPB. In 1967, Kolessove, grafted LIMA to the LAD through a left thoracotomy(MIDCAB) During the years following, as a consequence of technical difficulties related to the initial experience with off-pump myocardial revascularization and refinements of techniques of CPB, the off-pump approach was largely abandoned. In 1980 two independent groups continued their work on off-pump and reported favorable outcomes.

Surgical and Anesthetic Concerns Define basic anesthetic concerns Define Off-pump CABG Surgery

Anesthetic Management GETA with or without Thoracic Epidural Monitors – Arterial Line, CVC, PAC, TEE, Cerebral Oximetry, 5Lead EKG IVF – Fluid warmers, Colloid vs Crystalloid, RBCs Drugs – Low dose Heparin, Antifibrinolytics, Narcotics CPB on Backup

There are three anesthetic approach in OPCAB 1. GA with opioids and inhalation anesthesia or total intravenous anesthesia(TIVA) 2. Combined GA with controlled ventilation and neuraxial blockade using high thoracic epidural analgesia(TEA)or combined GA/intrathecal morphine(ITM) 3. Awake regional anesthesia with apontaneous ventilation using TEA alone.

High TEA combined with GA provides: better analgesia better pulmonary outcome reduction in perioperative morbidity &mortality reduction in extubation time shorter hospital stay

High TEA attenuates neuro-hormonal response, provides : thoracic sympatholysis (which improves coronary and mammary artery perfusion) ensures hemodynamic stability decreases myocardial oxygen demand improves myocardial blood flow reduces the risk of arrhythmia myocardial ischemia improves renal function significantly decreases heart rate.

A wake OPCAB : combined femoral block/TEA or spinal anesthesia/TEA or TEA alone Awake cardiac surgery might have some benefits, such as: Short ICU stay, maintenance of spontaneous respiration avoids the disadvantages of mechanical ventilation and GA in high-risk patients Awake cardiac surgery is feasible, but should be performed only in selected patients by highly specialized and experienced health care.

Hemodynamic changes during OPCAB Heart positioning can lead to reduced SV and BP and increases CVP and RVEDP During heart tilting compression free wall RV which is thin and easily deformable lead to abstraction of RV outflow The atria increase their size and become larger than ventricles, contributing to the reduction cardiac output Distortion of mitral and tricuspid annuli leads to MR and TR Terendelenburg position (20 head down) inotropes, adequate fluids, pleuropericardial position, IABP, is helpful

Management ischemia Good collaboration between anesthesiologist and surgeon Maintaining MAP>70 mmHg allows an adequate coronary perfusion Changes in SvO2 and PaCO2 are associated with changes in SjO2 Maintaining value of SvO2>70% maybe important to prevent reduction in cerebral blood flow during OPCAB Heart rate between 70 and 80 bpm, treat tachycardia and prophylactic administration of anti-arrhythmic agents To maintain to myocardial perfusion the surgeon can insert a small shunt into the coronary artery

Benefits of OPCAB Surgery Avoidance of CPB Coagulopathy Neurologic Deficit Air/Plaque Embolism Aortic Manipulation/Clamping Avoidance of Ventricular Arrest, Defibrilation, Pacing Difficulty of separation from CPB Transfusion PRBC, FFP, PLT, Cryo Cannulation site trauma/bleeding Risk of full dose Heparin and Protamine Risk of deep hypothermia <34 Risk of Hemodilution and Volume Shifts Potentially Faster Surgery

Benefits of OPCAB Surgery Decreased Cost to Patient Decreased ICU and Hospital stay Decreased duration of Intubation Decreased requirement for Inotropic, Chronotropic, or Vasoconstrictive support Potentially decreased risk of infection and improved wound healing Potentially Faster recovery

Technical aspects of Off-Pump Surgical approaches Exposure of the coronary targets - Hemodynamic consequences of cardiac elevation and displacement -Preserving hemodynamics during cardiac elevation Mechanical stabilizers The use of the coronary snare - Intracoronary shunts Improving visualization:the co2 blower/saline aeroslizer

CABG+ETCSequ SVG Sequ LIMA CABGYear TotalOFFON Total Mean Number Grafts: 3.76

Conclusion Historically,one of the main obstacles to complete revascularization without CPB has been represented by the inability to adequately: expose the coronary targets minimize their motion preserving cardiac function hemodynamic stability The introduction: the stabilizers of the new generation refinements in techniques of coronary revascularization on the beating heart have improved the feasibility and reliability with which distal anastomosis to all coronary arteries can now be constructed

Thank you for your attention