Off Pump Coronary Artery Bypass Graft Surgery (OPCAB)

What is OPCAB?

If conservative treatment options for coronary artery disease are unsuccessful and you continue to have chest pain or are at risk of having a heart attack, your cardiologist may refer you to a Cardiothoracic surgeon for coronary artery bypass surgery. One type of bypass surgery that may be recommended is called Off-Pump Coronary Artery Bypass.

Off-Pump Coronary Artery Bypass (OPCAB), also called “Beating Heart” surgery, is an operation to treat narrowed or blocked coronary arteries. This is accomplished by going around or “bypassing” the blocked artery with a healthy vessel called a “graft” that is taken from the leg, arm or chest. The graft will now carry the blood around the blockage to improve the blood flow to the heart muscle.

Traditionally, coronary artery bypass surgery is performed with the heart stopped and the patient on a heart-lung bypass pump. The pump’s function is to oxygenate and circulate the blood while the heart is stopped. This is referred to as cardiopulmonary bypass or CPB. Because there are certain risks associated with CPB, specially trained Cardiothoracic surgeons are now performing bypass surgery “off-pump”, meaning without the bypass machine.

OPCAB surgery is open-heart surgery performed without the patient on cardiopulmonary bypass (CPB) and with the heart still beating.

“Open Heart Surgery” is a common term used when referring to Coronary Artery Bypass surgery. Many people believe the heart is “opened up” in “open heart surgery”. However, this is not the case. The name actually refers to the fact that the surgery is performed through a large, open, chest incision. Since the surgery is actually performed on the vessels on the outside of the heart there is no need to cut the heart open.

Some surgeons are performing minimally invasive coronary bypass surgery (MICABG) through tiny incisions called portals enabling a quicker recovery time with decreased trauma to the tissues and bones. This surgery is not yet widely available and research is ongoing to evaluate and improve minimally invasive techniques.

Risks of CPB

Cardiopulmonary bypass or CPB has been shown to have associated risks. Some risks that may be related to CPB include:

    • Neurocognitive Changes – Impaired mental capability including memory loss, decreased attention span, depression etc.
    • CVA or Stroke – The risk of CVA while on CPB is believed to be from micro-embolisms of air or debris that block blood flow to the brain
    • Systemic Inflammation Response Syndrome (SIRS) – A serious condition causing inflammation throughout the whole body that may lead to multiple organ failure and shock
    • Coagulopathy – A defect in the blood clotting ability of the body causing heavy and prolonged bleeding
    • Pulmonary Dysfunction – Respiratory problems including increased work of breathing, shallow breaths, hypoxemia (low blood oxygen), and ineffective coughing. Benefits of OPCAB surgery may include:
    • Lessens the risks associated with the use of cardiopulmonary bypass pump
    • Less blood loss and need for transfusions post operatively
    • Lower rate of wound infections
    • Lower incidence of kidney complications
    • Avoidance of systemic inflammatory response syndrome (SIRS)
    • Decreased risk of Atrial Fibrillation (irregular, fast, ineffective heart beat)
    • Faster recovery
    • Shorter operating time
    • Shorter hospital stay
    • Less costly than traditional coronary bypass surgery

OPCAB surgery is not for everyone and your surgeon will discuss with you whether this surgery is a good option for your particular situation.

Candidates for OPCAB may include the following:

    • Elderly patients (over 70) with multiple diseased vessels
    • Patients with lung disease such as COPD or emphysema
    • Patients with kidney disease or who are on dialysis
    • Patients with a high risk of stroke (CVA) or with a previous history of stroke or transient ischemic attacks (TIA or “mini-stoke)
    • Patients with a low EF (ejection fraction) indicating poor heart function
    • Patients with heavy atherosclerosis in the aorta
    • Immunosuppressed patients
    • Patients who refuse blood transfusions for religious or other reasons

OPCAB is not recommended in the following patients:

    • ┬áPatients with enlarged hearts
    • Patients with valve disease
    • Patients who require long grafts
    • Patients with blockages extending into the heart muscle

OPCAB Surgical Procedure

The goal of Off-Pump Coronary Artery Bypass surgery is:

    • To relieve symptoms of CAD
    • Improve blood flow to the heart
    • To lengthen the patient’s life

Off -Pump Coronary Bypass surgery is performed by Cardiothoracic surgeons in the operating room with the patient under general anesthesia. The operation usually takes about 3 hours but may be longer depending on the number of bypasses to be done. During OPCAB, the patient is placed lying on their back on the operating table. The chest and graft area are shaved and scrubbed with antiseptic. You will be given a general anesthetic so you will be asleep and not feel any pain.

    • Your surgeon will make a long incision down the middle of your chest bone (sternum). This is called a median sternotomy. Special instruments called retractors are used to spread the ribs apart so the surgeon can access the heart
    • At the same time, another surgeon will “harvest” (remove) a vessel from either your arm (radial artery) or leg (long saphenous vein) to be used as the graft. This may be done through a large “open” incision or endoscopically through a much smaller incision
    • Your surgeon may choose to use an artery in the chest called the internal thoracic artery. In this case you will not have a “graft site” incision on your arm or leg unless you are having multiple bypasses performed
    • With the heart beating, your surgeon will stabilize the heart muscle on either side of the blockage with a special device. This enables the surgeon to work on a small area with minimal movement but with the heart still beating and pumping blood throughout the body
    • If a leg or arm graft is used the surgeon then attaches one end of the graft with fine sutures to the Aorta
    • The other end of the graft is then attached to the coronary artery beyond the blockage. This enables the blood to “bypass” the blockage and flow freely to the heart muscle
    • If the internal thoracic artery is used, your surgeon will redirect the artery by detaching one end of it and reattaching it below the blockage on the coronary artery
    • Once your surgeon has completed the number of bypasses needed the surgeon will use wires to reattach the sternum and suture the incision closed, usually with dissolvable sutures

Post Operative Guidelines

After OPCAB surgery you will be taken to the intensive care unit (ICU) for monitoring for 24 hours.

You will probably have a tube in your throat connected to a respirator for the first day to help you breathe. You will not be able to speak while the tube is in place.

You will have drain tubes in your chest to help drain blood and fluids.

You will likely spend 4-5 days in the hospital.

Common post-operative guidelines following Off-Pump Coronary Artery Bypass surgery include the following:

    • You will need someone to drive you home after you are released from the hospital. You should not drive for 4-6 weeks after the surgery. If you drive commercially, you will usually have to wait 3 months
    • You will be given instructions on care of your incisions. Normally, you will be able to shower without restrictions
    • Expect significant fatigue for the first two weeks after your surgery. This is common and will improve gradually over the next month
    • Your surgeon will give you activity restrictions such as no heavy lifting or strenuous exercise for the first 4-6 weeks to allow the sternum to heal completely
    • You will usually be able to resume sexual activity after 3-4 weeks
    • You may be able to return to work in 6-8 weeks depending on the type of work you do
    • You will have soreness and bruising around the incision and graft sites for the first month or so. You may hear a clicking sound in the chest while the sternum is healing. You will probably have chest pain with sudden movement, coughing, or sneezing. Be assured this is usually musculoskeletal pain and not angina. Your doctor will prescribe pain medications for you to take at home
    • Your doctor will prescribe blood-thinning medicines to prevent blood clots. It is very important that you adhere to your prescribed medications to prevent blood clots from forming
    • It is common to feel depressed after heart surgery. Talk with your doctor, as treatment is available through medication or therapy
    • Sleep disturbances are commonly reported. Again, discuss your concerns with your doctor should you have problems sleeping
    • You will be referred to a cardiac rehabilitation program to educate and assist you with your recovery. This usually involves exercise, lifestyle modification, and monitoring
    • It is important to know abnormal symptoms to report: Contact your doctor immediately if you have a fever, chills, purulent drainage from incisions, redness, bleeding, irregular heart beat, chest pain, shortness of breath, weakness, or dizziness

Risks & Complications

  • As with any medical procedure there are potential risks involved. The decision to proceed with the procedure is made because the advantages outweigh the potential disadvantages
  • It is important that you are informed of these risks before the procedure takes place

Most patients do not have complications after Off-Pump Coronary Artery Bypass surgery; however complications can occur and depend on what type of surgery your doctor performs as well as the patient’s health status. (i.e. obese, diabetic, smoker, etc.)

Complications can be medical (general) or specific to OPCAB.

Medical complications include those of the anesthesia and your general well being. Almost any medical condition can occur so this list is not complete. Complications include:

    • Allergic reaction to medications or dye
    • Blood loss requiring transfusion with its low risk of disease transmission
    • Heart attack, strokes, kidney failure, pneumonia, bladder infections
    • Complications from nerve blocks such as infection or nerve damage
    • Serious medical problems can lead to ongoing health concerns, prolonged hospitalization, or rarely death

Specific complications for Off-Pump Coronary Artery Bypass surgery include:

    • Heart Attack
    • Stroke
    • Bleeding
    • Deep wound infection requiring IV antibiotics and possible surgical debridement
    • Arrhythmia (Irregular heart beat)
    • Nerve damage causing weakness, neuropathy, or paralysis
    • Blood vessel damage requiring an operation for repair
    • Conversion to traditional CABG on emergency basis with need for CPB and its associated risks
    • Vein graft occlusion or stenosis
    • Recurrent Angina
    • Blood clots
    • Death (less than 3%)

Risk factors that can increase the chance of complications following Off-Pump Coronary Artery Bypass surgery include:

    • Diabetes
    • History of kidney disease
    • Poor cardiac function
    • Extensive heart disease
    • Poor nutrition
    • Smoking
    • Obesity
    • Age (over 60)
    • Alcoholism
    • Chronic Illness
    • Steroid Use

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