1. Clampless CABG Techniques: Anaortic CABG with ITA Inflows John D. Puskas, MD, MSc, FACS, FACC Professor of Cardiothoracic Surgery, Icahn School of Medicine at Mount Sinai Chairman, Department of Cardiovascular Surgery, Mount Sinai Beth Israel Director, Surgical Coronary Revascularization, Mount Sinai Health System 95th Annual Meeting of the American Association for Thoracic Surgery Seattle, WA April 25, 2015

2. Disclosures/Conflicts  Royalties from coronary surgical instruments invented by the author and marketed by Scanlan, Inc.  No other relevant financial COI’s.

3. Effect of Aortic Clamping Strategies on Neurologic Outcomes Daniel…Puskas…Halkos JTCVS 2014;147:652-7  10,054 consecutive isolated CABG cases  141 (1.4%) patients with stroke matched 1:4 to 565 patients without stroke

4. Meta-analysis of Stroke After Anaortic OPCAB vs Side-Clamp OPCAB and Anaortic OPCAB vs Conventional CABG Edelman, et al Heart Lung and Circulation, 2012

5. Clampless OPCAB: State of the Art CABG Borgermann et al, Circulation 2012; 126:S176-182  395 consecutive clampless OPCAB (310 PAS-Port; 85 all-arterial without proximals)  Propensity Score matching on 15 preop risk variables to compare outcomes among 394 pairs of clampless OPCAB vs cCABG: In-hospital death (OR 0.25; 95% CI 0.05-1.18 ; p=0.08) Stroke (OR 0.36; 95% CI 0.13-0.99 ; p=0.048) Death or Stroke (OR 0.27; 95% CI 0.11-0.67 ; p=0.005)  2 years F/U: Death (OR 0.39; 95% CI 0.19-0.80 ; p=0.01), Death or Stroke (OR 0.58; 95% CI 0.34-1.00 ; p=0.05)  MACCE (OR 0.62; 95% CI 0.37-1.02 ; p=0.06)  Repeat revasc (OR 0.74; 95% CI 0.40-1.38 ; p=0.35)

6. Aortic No-Touch Technique Makes the Difference in OPCAB Emmert et al JTCVS 2011; 142:1499-506.  2004-2009: 4314 patients, OPCAB 2203, cCABG 2111.  Propensity-adjusted regression, OPCAB vs cCABG: Death (1.6% vs 2.4%; OR 0.51; CI 95% 0.26-0.99 ; p=0.47) MACCE (7.9% vs 17.1%; OR 0.67; CI 95% 0.52-0.84 ;p=0.001) MI (1.1% vs 2.2%; OR 0.50; CI 95% 0.26-0.98 ; p=0.044) Stroke (1.1% vs 2.4%; OR 0.35; CI 95% 0.17-0.72 ; p=0.005) Composite respir/renal/bleed (OR 0.46; CI 95% 0.35-0.91 ; p<0.001)

7. Aortic No-Touch Technique Makes the Difference in OPCAB Emmert et al JTCCVS 2011; 142:1499-506.  Two OPCAB groups: PC n=567 vs HS n=1365  Propensity-adjusted regression, HS vs PC: Stroke (0.7% vs 2.3%; OR 0.39; CI 95% 0.16-0.90 ; p=0.04) MACCE (6.7% vs 10.8%; OR 0.55; CI 95% 0.38-0.79 ; p=0.001)  Stroke rate similar between cCABG and PC OPCAB

8. Strategies to Reduce Stroke No CPB No or miminal aortic clamp Anaortic OPCAB is the gold standard to reduce stroke after CABG Moss…Halkos…Puskas et al. J Thorac Cardiovasc Surg. 2015;149:175-80.

9. Common Strategies for Anaortic OPCAB BITA inflow, with multiple possible outflows: RITA I-graft with radial segment to RCA LITA-RITA “T”-graft; LITA-RA “T”-graft ITA and RA sequential grafts More complex configurations to revascularize the more targets with fewer grafts: “K”-graft

10. LIMA-RIMA T-Graft

11. Anaortic CABG: BITA plus RA

12. Kobayashi “K”-Graft: 2 Arterial Grafts, 3 or More Targets LIMA Radial A Radial-Diag LIMA-LAD Radial-OM

13. Anaortic BITA plus RA: “K” Graft

14. Less Common Strategies for Anaortic OPCAB Right Axillary or Left Subclavian inflow In-situ GEA inflow Descending thoracic aortic inflow (redo CABG via left thoracotomy)

15. Summary Anaortic OPCAB is associated with lowest risk of stroke during surgical revacsularization. Epiaortic U/S should be routinely used to identify patients who will benefit most from this complex grafting strategy.