Application :  Off Pump Coronary Artery Bypass Surgery (OPCAB)

CABG is done on epicai-dial vessels. Cardio pulmonary by pass is used only to get a still heart for accurate anastomosis. If there is a method of stabilizing a small area of the heart over the coronary artery with the rest or heart beating and maintaining reasonable haemodynamics, it is possible to do the operation off pump (OPCAB) or beating heart surgery. A few ingenious mechanical stabilizers achieve the local stabilization. The most commonly used one currently is "OCTOPUS", which has two blades with suckers. The two blades are placed on either side of the target artery and mild suction applied on the suckers. Another equipment "STARFISH" which resembles its name sake in the ocean, when applied to the apex of the heart helps in exposing any surface of the heart as required without much haemodynamic compromise.

When a partially occluded coronary or a 100 per cent blocked artery with good collaterals is opened, there will be considerable bleeding. To control that, suitably sized intra luminal shunt devices are available. They help to control bleeding, permit distal perfusion and do not interfere with the anastomosis. While the last few sutures are being applied, the shunt is removed arid anastomosis is completed. When a shunt is not used, a carbon dioxide blower will help in keeping the field free of blood.

To perform successful OPCAB good cooperation between the surgeon and the anesthesiologist is needed. Controlled hand ventilation is needed at crucial stages. Arterial pressure and ECC changes like ST-T changes are monitored when heart is rotated or Trans located into light pleura. Trans oesophagenl ECHO helps in rnonitoring region wall motion of left ventricle. Usually the operation is done through median sternotomy. Minimally invasive techniques or a left thoracotomy may be used in selected cases. Befo1.e grafting, hepasin is administered in doses of 1-3 mg/kg. Hypothernlin is be avoided. A pump is kept standby which could be assembled, primed and go1 ready in a matter of few minutes. It is important to make the anastomosis accurate. The advantage of OPCAB is that recovery is faster Patient can be extubated same day, transferred from ICU next day and discharged in 6-7 days time. This brings down the cost of hospitalization significantly.