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  2. 2. DEFINITION • Off-pump coronary artery bypass or "beating heart" surgery is a form of CABG surgery performed without CPB (heart-lung machine) as a treatment for coronary heart disease. • During most bypass surgeries, the heart is stopped and a heart-lung machine takes over the work of the heart and lungs. • When a cardiac surgeon chooses to perform the CABG procedure off-pump, also known as OPCAB (Off-pump Coronary Artery Bypass), the heart is still beating while the graft attachments are made to bypass a blockage. DR GEETANJALI S VERMA
  3. 3. THE BEGINNING • First open heart surgery - performed by John Gibbon in 1952 using cardiopulmonary bypass • First successful OPCAB was performed in 1961 and Kolesov in 1964 performed the first successful anastomosis of left internal mammary artery (LIMA) to left anterior descending artery (LAD) • In 1967, Favalaro and Effler performed reversed saphenous vein grafting. • In 1968, Green performed anastomosis of the internal mammary artery to the coronary artery . DR GEETANJALI S VERMA
  4. 4. Development of modern epicardial stabilizers • In early reports, compressive devices (e.g., metal extensions rigidly attached to the sternal retractor) were used to reduce the motion of the coronary vessel during the cardiac and respiratory cycles. These devices often interfered with cardiac function and were impossible to use for left circumflex coronary artery lesions. • Modern devices typically apply gentle pressure or epicardial suction, reducing the effect on myocardial function while providing better fixation of the area immediately surrounding the coronary artery anastomotic site. These devices also allow greater access to arteries on the inferior and posterior surfaces of the heart DR GEETANJALI S VERMA
  5. 5. OPCAB tissue stabilization and heart positioning devices. Verma S et al. Circulation. 2004;109:1206-1211 Copyright © American Heart Association, Inc. All rights reserved. Genzyme Immobilizer utilizes a stabilization platform and silastic vessel loops the Medtronic Octopus4 tissue stabilizer and Starfish2 heart positioner utilize vacuum suction to stabilize and position the heart. Coro-Vasc System (CoroNeo Inc) illustrates silastic snares that are looped around the target coronary vessel and then fixed to a small immobile plate, thus directly immobilizing the target vessel.
  6. 6. PATIENT SELECTION • a. Early reports of OPCAB often described single-vessel or double-vessel bypass performed on low-risk patients - promoted for early recovery and discharge. • b. OPCAB is now promoted for multivessel bypass in patients with risk factors for adverse outcomes. Elderly patients at risk for stroke, patients with severe lung disease, or patients with severe vascular disease and/or renal dysfunction are often selected. • Zenati et al. and others have described combining MIDCAB (i.e. IMA to LAD) with angioplasty/stent to other vessels in high-risk patients. DR GEETANJALI S VERMA
  7. 7. OPCAB Demands Exposure of post, Lat wall of the heart. Stabilization of target area. Visualization Occlusion of the Coronary Ar. or Shunt. Stable Hemodynamics. DR GEETANJALI S VERMA
  8. 8. CONTRAINDICATIONS - Very small arteries ( <1mm) - Calcified arteries. - Poor conduits. - Huge hearts. - Hemodynamic Instability/Ischemia. - Cardiogenic shock. DR GEETANJALI S VERMA
  9. 9. GOALS OF ANESTHETIC MGMT • Provision of safe anaesthesia using a technique that offers maximum cardiac protection and stability • Maintaining haemodynamics in the intraoperative period by physical and pharmacological methods • Allowing early emergence, ambulation • Providing adequate pain relief in the postoperative period. DR GEETANJALI S VERMA
  10. 10. PRE OP ASSESSMENT • For optimization of diabetes, hypertension, reactive airway and other coexisting morbidities • To alley anxiety related to the procedure • Preoperative assessment of the carotid arteries • Essential investigations done: CBC, coagulation profile, lipid profile, electrolytes, Blood grouping and serology, renal and liver function tests, CXR, ECG, Echo, USG abdomen (elderly males), PFT DR GEETANJALI S VERMA
  11. 11. PRE MEDICATION - Anti aspiration prophylaxis: Ranitidine (150mg) / Pantoprazole (40mg) + prokinetic (Metochlopramide 10 mg) - Anti anxiety: tab Alprazolam 0.5-1mg oral - 0.05mg.kg -1 of midazolam + 1µg.kg -1 of fentanyl IV 30minutes prior to surgery with supplemental oxygen. - Regular medn: - Beta blockers should be continued in same dosage - Anti platelet medications - stopped atleast 1 week prior to surgery - ACE inhibitors may be stopped 24 to 36 hours prior to surgery (substituted with calcium channel blockers) - For DM patients – conversion to short acting Insulin DR GEETANJALI S VERMA
  12. 12. INTRA OP MONITORING - ECG – lead II and V5 - well visualized 'P' wave and QRS complex prior to commencing the surgery - SpO2, ETCO2 - Temperature monitoring - Urinary output monitoring - Invasive blood pressure (IBP) monitoring - By radial or femoral artery - The cannulation of the femoral artery not only permits access to the central arterial tree but provides access to quick insertion of an intra aortic balloon pump. - If radial artery cannulation is planned the Allen's test must be performed prior to performing cannulation. DR GEETANJALI S VERMA
  13. 13. Pulmonary artery catheter (PAC) Usually placed via the right internal jugular vein. Indications:  Ejection fraction <0.4  Significant abnormality of the left ventricular wall motion.  LVEDP > 18 mm Hg at rest.  Recent MI and unstable angina. DR GEETANJALI S VERMA
  14. 14. Transesophageal echocardiography (TEE) Advantages: - Identify myocardial ischaemia early by detecting regional wall motion abnormalities. - Assess left ventricular dysfunction intra operatively. - Assessing the improvement in myocardial function after the completion of revascularization. Disadvantage Inability to image the required part of the heart during grafting . DR GEETANJALI S VERMA
  15. 15. INDUCTION • Induction should be slow • By intravenous (Propofol/ Etomidate/ Thiopentone + Opioids (fentanyl / morphine) +BZD) or inhalational method (Sevo/Iso in 1- 2 MAC) • Neuromuscular blockade - 0.7 mg/kg Rocuronium IV or Vecuronium 0.08-0.1 mg/kg IV (Pan/atrac – tachy) MAINTENANCE • Infusion of fentanyl, atracurium +/- Midazolam • Isoflurane / O2/ air DR GEETANJALI S VERMA
  16. 16. INTRAOP PROBLEMS 1. HYPOTENSION – treated with volume loading – Maintain adequate heart rate in sinus rhythm. – increasing afterload to maintain systemic perfusion pressures. – Inotrope therapy - dopamine, epinephrine, dobutamine infusion. – Phenylephrine – Inform surgeon - cotton packs can be placed under the heart and the epicardial stabilizers should be repositioned. – resting the heart in the pericardial cavity. – If there is no improvement, an intra aortic balloon pump support can be instituted.DR GEETANJALI S VERMA
  17. 17. 2. ARRYTHYMIAS - Rule out causes: MI, electrolyte imbalance, hypothermia - Use lidocaine (without preservative) infusion if patient has arrhythmia caused by myocardial ischaemia. - Electrolyte imbalance - potassium chloride, magnesium sulfate, calcium, bicarbonate – as suggested by ABG - Temperature correction DR GEETANJALI S VERMA
  18. 18. 3. HEPARINIZATION - Dose of heparin is 2mg.kg -1 (200 units.kg -1 ) intravenously. - ACT performed 3 minutes after administration. - The goal is to keep the ACT between 250 - 300 seconds. - ACT repeated hourly and repeat bolus of 5000 units Heparin is essential if ACT <250 seconds. - Heparin is reversed with protamine sulfate (1 mg/1mg of heparin. ) - Acceptable ACT – upto 140 seconds after protamine administration. - A high ACT will require additional protamine in a dose of 25 to 50 mg. DR GEETANJALI S VERMA
  19. 19. 4. HYPOTHERMIA - Warm blanket covers - OT room temp - The time taken for sterile preparation by painting and draping by sterile sheets should be kept to the minimum. - Warm IV fluids - Low fresh gas flows DR GEETANJALI S VERMA
  20. 20. 5. MYOCARDIAL ISCHEMIA - PREVENTION - Maintaining systemic blood pressure (+/- 10%), keeping MAP of at least 70 mm Hg at all times - Reduction in myocardial oxygen consumption by avoiding tachycardia using intra operative beta-blockers or calcium channel blockers. - Ischaemia during distal anastomosis can be prevented by using intraluminal coronary shunts . DR GEETANJALI S VERMA
  21. 21. Intracoronary shunts These are double limb shunts that fit into the proximal and distal ends of the open coronary artery DR GEETANJALI S VERMA
  22. 22. Intracoronary shunts Benefits:-  Native coronary arterial blood flow is maintained preventing intraoperative ischaemia.  Blood loss during coronary anastomosis is avoided or decreased.  Prevents embolization of CO2 into the coronary arteries.  Prevents the surgeon from taking a suture on the posterior wall of the coronary artery.  Assures proper coronary anastomosis.  Can reverse changes caused by ischaemia (like myocardial oedema, endothelial and contractile dysfunction) DR GEETANJALI S VERMA
  23. 23. OPCAB technology in use. Verma S et al. Circulation. 2004;109:1206-1211 Copyright © American Heart Association, Inc. All rights reserved.
  24. 24. 6. Haemodynamic changes related to heart position  Lifting and rotating the heart during OPCAB can alter the haemodynamics such as cardiac output, stroke work, left ventricular end diastolic pressure and right atrial pressure.  During grafting of right coronary artery, bradycardia can occure due to reduction in blood supply to the sinus and AV nodes, so if required use atropine and atrial pacing  During grafting of the right coronary artery and obtuse marginal branches "verticalization" of the heart is required, so posterior pericardial stitches and a gentle retracting socket will greatly facilitate haemodynamics  Reduction in the dose of intravenous vasodilators can increase the haemodynamic changes. During such times it may be essential to reduce the dose of the vasodilator and add a vasoconstrictor. DR GEETANJALI S VERMA
  25. 25. POST OP MGMT • MONITORING • 5 lead ECG monitoring - for any fresh changes like ischaemia or myocardial infarction - treated with LMWH, anti platelet medications, insertion of an intra aortic balloon pump or revision of grafting. • SpO2, ETCO2, IBP, Temp., ABG • Always carry prefilled syringes of diluted 1:200,000 adrenaline, 1.2mg of atropine and 100mg of lidocaine (preservative free) to treat a crisis during the transfer phase. DR GEETANJALI S VERMA
  26. 26. POST OP PAIN MGMT • Epidural analgesia: epidural fentanyl infusion with Fentanyl 3000 mcg (60 ml), 0.5% bupivacaine 55ml and saline 155ml are added to make a final total volume 265 ml & start at a rate of 2ml.hour -1 • Intravenous opioids: Fentanyl 3000mcg and saline 215ml are added to make a final concentration 11 mcg.ml -1 of fentanyl. DR GEETANJALI S VERMA
  27. 27. ICU MGMT VENTILATION FiO2 of 0.8 • Vt 6-10 ml/kg • RR: 12- 15/min • I:E ratio of 1:2 • controlled mode of ventilation. • ABG performed after thirty minutes. • FiO2 is reduced to 0.4 if oxygenation, carbon dioxide elimination and tissue perfusion maintained DR GEETANJALI S VERMA
  28. 28.  Thirty minutes later, assessment of foll done:  blood loss (not more than 10% of blood volume)  fluid balance (not more than 10-15 ml.kg- 1 body weight)  core temperature ( not less than 35 deg Celsius ),  arrhythmias  urine output (at least 1-2 ml.kg -1 .hr -1 ) If the residual neuromuscular blockade is present then reversed by injecting a combination of neostigmine and glycopyrrolate.  After confirming adequacy of reversal ventilatory mode is switched to the spontaneous modes of ventilation, such as pressure support, or continuous positive airway pressure.  Thirty minutes after supported ventilation, ABG analysis is repeated and if the analysis shows satisfactory values of oxygenation, carbon dioxide elimination and metabolism, the patients are extubated. DR GEETANJALI S VERMA
  29. 29. FAST TRACK ANESTHESIA • Defined as tracheal extubation within 8 hours after cardiac surgery, early mobilization of patient and early discharge from the hospital. • Use of short acting opioid medications • Long acting sedatives should be avoided • Early extubation resulted in regaining the cough reflex and thus a lower incidence of atelectasis and pneumonia. • Patients not suitable - bleeding, dysrryhtmias and haemodynamic instability DR GEETANJALI S VERMA
  30. 30. COMPARING ON AND OFF PUMP CABG 1. Systemic inflammatory response syndrome (SIRS) -A combination of non pulsatile flow, myocardial ischaemia, hypothermia and contact of the patient blood with the artificial surface of the extra corporeal circuit is responsible for the inflammatory process. 2. Coagulopathy-disruption of the coagulation system and haemodilution after cardiopulmonary bypass is avoided in OPCAB Less blood loss in OPCAB Ascine – Eur. J. Cardioth. Surg. 1999 Puskas – Ann. Thor. Surg. 1998 DR GEETANJALI S VERMA
  31. 31. 3. Neurologic dysfunction- due to embolization, inflammation, hypoperfusion and hyperthermia. Type 1 - Death either due to stroke or hypoxic encephalopathy, stupor & coma. (Risk factors are DM, atherosclerosis in the proximal aorta and pre existing impairment of cerebral blood flow) Type 2 - Intellectual dysfunction - memory deficits, confusion or agitation - due to small micro emboli and inadequate perfusion The incidence of stroke after OPCAB is about 1% when compared to 9% after ON pump CABG DR GEETANJALI S VERMA
  32. 32. Neurological Outcome Only few prospective Randomized Trials showed superiority of OPCAB Vs CABG. 1. Sedrakan - Stroke 2006 41 randomized trials – 50% reduction of stoke in OPCAB 2. Glenville – Ann. Thor. Surg. 2004 Elderly P. Stroke CABG – 3% OPCAB 1% 3. Mohr – Ann. Thor. Surg. 2003 16,184 p. Stroke CABG - 3.8% OPCAB 1.9% Others 1. Alamanni – Eur. J. Cardioth. Surg. 2007 No difference stroke rate 2. Lund – Ann. Thorac. Surg. 2005 No difference in long term cognitive function or MRI evidence of brain injury On the Other Hand Puskas – Ann. Thor. Surg. 2000 In series of 10,800 p. found 3 independent variables for prediction of stroke – age, previous Tia, carotid bruit DR GEETANJALI S VERMA
  33. 33. 4. MYOCARDIAL INJURY as assessed by biochemical markers is much less after OPCAB when compared to CABG. Rastan – Eur. J Cardioth. Surg. 2005 5. PULMONARY DYSFUNCTION caused by atelectasis, inflammation, increased shunting and volume infusion. Reddy. Eur. J. Cardthor. Surg. 2006 6. RENAL DYSFUNCTION - lower in patients undergoing OPCAB. DR GEETANJALI S VERMA
  34. 34. An example of outcome between CABG Vs. OPCAB is presented in study of “Care Registry” CABG OPCAB No. of patients 654 597 Mean no. of grafts 3.4 +1 2.9+1.2 Op. Mortality 1.7% 1.7% Stroke 0.9% 0.7% Reop. for bleeding 2.6% 1.0% Prolonged Ventilation 10.0% 3.4% Atrial Fibrillation 23.0% 15.0% Transfusions needed 51.0% 35.0% Hospital stay 7.5 d 6.2 d Mortality 1 y 4.9% 4.6% Myocardial Infarction 1y 1.0% 0.7% Need for Re-vascularization 2.8% 4.1% Ann. Thor. Surg. 2007 DR GEETANJALI S VERMA
  35. 35. Innovations in OPCAB - Possible to operate in patients with neoplastic comorbidities. (Decrease in: inflammatory response, coagulopathy disorders, immunity response and spreading of malignancy). - Possiblity to perform in SEMI awake patient CABG (Br. J. Anaesth. (2008) 100 (2): 184-189.) - Hybrid Re-vascularization (defined by the performance of coronary bypass surgery and coronary stenting during the same operation.) DR GEETANJALI S VERMA
  36. 36. OPCAB in a patient with extensive aortic and carotid artery atherosclerotic calcification, analogous to our case presentation. Verma S et al. Circulation. 2004;109:1206-1211 Copyright © American Heart Association, Inc. All rights reserved. OPCAB in a patient with extensive aortic and carotid artery atherosclerotic calcification, In this patient, complete arterial revascularization was performed using the OPCAB technology without aortic manipulation, cannulation, or proximal anastomosis. The left internal thoracic artery (LITA) was anastomosed to the LAD, with a free radial T graft from the LITA anastomosed to both the second obtuse marginal and posterior descending branches. An angiogram showing a radial T graft appears to the right.
  37. 37. RELATED ARTICLES • Chakravarthy MR, Prabhakumar D. Anaesthesia for off pump coronary artery bypass grafting - the current concepts. Indian J Anaesth 2007 ;51:334. http://www.ijaweb.org/text.asp?2007/51/4/334/61162 • Frank W. Sellke, MD, Co-Chair; J. Michael DiMaio, MD. Comparing On- Pump and Off-Pump Coronary Artery Bypass Grafting. Circulation. 2005; 111: 2858-2864 • Does off-pump coronary artery bypass (OPCAB) surgery improve the outcome in high-risk patients?: a comparative study of 1398 high-risk patients. Eur J Cardiothorac Surg (2003) 23 (1): 50-55. doi: 10.1016/S1010- 7940(02)00654-1 • Diastolic dysfunction and off-pump coronary artery bypass. Br. J. Anaesth. (2009) 102 (6): 887-888. doi: 10.1093/bja/aep118 • Haemodynamic changes in OPCAB procedures regarding different coronary artery anastomoses. European Journal of Anaesthesiology: July 2001 - Volume 18 - Issue - p 25–26 DR GEETANJALI S VERMA
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