Coronary artery bypass graft surgery.

You have performed tens of thousands of procedures. Dr. Anton Titov, MD. You have a particular interest in off-pump coronary artery bypass graft surgery. This is a surgery on a beating heart. It's more demanding from the surgeon technically. But off-pump coronary artery bypass graft surgery has advantages for patients. Dr. Anton Titov, MD. Please compare risks and benefits of off-pump coronary artery bypass graft surgery and on-pump coronary artery bypass graft surgery. It is the classical technique of surgical operation. Tell us about your experience with this advanced technique of coronary artery bypass grafting.

The off-pump heart surgery

Dr. Jürgen Ennker, MD. The off-pump heart surgery was introduced in the 1990s in South America. It came to developed countries in North America and Europe with the so-called MIDCAB operation. This is a small incision on the lateral chest to do a revascularization of the left anterior descending artery. From this so-called OPCAB procedure, an off-pump coronary artery beating heart procedure was developed. You can graft all three vessels on the beating heart. The advantage is that you don't need the heart-lung machine. This i what "off-pump" name says. Because you have to cannulate the aorta to use the heart-lung machine. This may lead to a dislodgement of debris of aortic plaque. This may lead to embolism. In turn, this may lead to a cerebral infraction. Coronary artery patients were analyzed in the SYNTAX clinical trial. Brain stroke rate was 2.2%. Dr. Jürgen Ennker, MD. But you can use the off-pump heart surgery technique. You can do that with the so-called T-graft. You implant it the LIMA to the LAD. Then a second graft is implanted into the LIMA. This is done with the so-called aortic no-touch technique. You don't perform an aortic anastomosis. You have zero strokes. You have absolutely no cerebral infraction. This is generated by the heart surgery. It's a huge deal! We can decrease the risk of stroke with off-pump coronary artery bypass graft surgery. We will talk about that in a second. It is a very big deal! Yes! I'm doing off-pump coronary artery bypass graft surgery. I'm always resecting the left atrium of the heart. Because 90% of embolism from the left heart comes from the left atrium. Dr. Jürgen Ennker, MD. Because in atrial fibrillation, we have a thrombus formation. Sometimes the patient gets back into the sinus rhythm. Then the thrombus is ejected. You have brain embolism (stroke). When you resect the left heart atrium, you are eliminating the risk of brain stroke as well. So, this is another point. No aortic touch, resection of the left atrium, and then you have two major risk factors eliminated. This may lead to cerebral strokes and other neurological complications. The off-pump procedure has many advantages. They are related not only to a neurologic outcome. It can be done in patients with major deficiencies. You can do off-pump coronary artery bypass graft surgery on patients with renal disease, with pulmonary disease. The avoidance of the heart-lung machine leads to a substantial advantage. This has been proven by literature. Dr. Anton Titov, MD. Of course, you need an experienced cardiac surgeon. The surgical technique has to be adequate. But we have several tools nowadays. We are measuring the blood flow in the artery graft. We are measuring the patency of the arterial graft and the flow in it. You can exactly say that this arterial graft is patent. The literature says that 10 to 15% of the coronary artery anastomosis have technical defects. You can detect problems in arterial anastomosis immediately. It does not happen later in the intensive care via ECG or cardiac enzymes. Dr. Jürgen Ennker, MD. This is a big step towards patient safety. OPCAB surgery always maintains the blood pressure. You have the running ECG. You have the contracting heart. These are also parameters to tell you that you're on the safe side. You can be confident that your anastomosis is technically adequate. You can have confidence that the patient is going to do well in the long run. So, you have a feedback from the patient's body, from the heart, during that duration. This is also a significant advantage. That's exactly the point. The patients wake up in the same condition as after appendectomy. Dr. Jürgen Ennker, MD. After heart-lung machine use in coronary bypass graft surgery, patients are sent into a CT scan. Doctors see a cerebral edema that lasts for some period of time. You have mental deficiencies caused by the heart-lung machine. All these are detrimental factors for the patient. You don't have these brain swelling problems with OPCAB surgery. Dr. Anton Titov, MD. So it's a big step ahead. Off-pump CABG has major advantages for severely ill patients. Off-pump coronary artery bypass graft surgery is better for patients with neurological deficits. Those are the advantages. Patients profit very much from OPCAB surgery. But the key factor is a surgeon. Dr. Anton Titov, MD. Surgeon is the most important prognostic factor for the patient. There are also patient-related surgery risk factors, of course.