**10. Role of IABP in OPCAB**

The use of intra-aortic balloon pump (IABP) either preoperatively or intraoperatively, to reduce operative risk and to facilitate posterior vessel OPCAB has been well documented. IABP has been useful in high-risk patients with left main coronary artery disease (> 75% stenosis), intractable resting angina, post infarction angina, left ventricular dysfunction (ejection fraction < 35%), or unstable angina.

Preoperative IABP counterpulsation has been shown to have better outcomes compared with perioperative or postoperative insertion in critical patients, and off-pump surgical procedures have been advocated to reduce mortality in high-risk patients.

In patients with high risk factors, higher mortality and morbidity rates have been demonstrated in spite of massive pharmacologic support combined with postoperative IABP support. IABP therapy results in a more favorable myocardial blood supply, increased stroke volume and cardiac output through augmentation of the diastolic pressure, and afterload reduction (Christenson, 1997, 1999).Intraoperative or postoperative IABP insertion has been reported to be associated with higher operative mortality rate and device-related complication rate, as compared with preoperative use of IABP.

Re-Engineering in OPCAB Surgery 197

Any patient who has a hemodynamic compromise or has an inclination to crash, gets an IABP inserted sheath less.(8 or &7 Fr). We had the IABP inserted in the early days when we had the patient included in one of the high risk group like- left main coronary artery disease (> 75% stenosis), intractable resting angina, ST depression more than 2.5mm,Post-infarction

We had noticed that the use of IABP was not high in the left main disease group and low ejection fraction group, but was high in patients with ongoing ischemia. Hence we reengineered our use of IABP such that every patient undergoing OPCAB gets a femoral arterial line and this is used for monitoring along with the radial arterial line. When a patient becomes ischemic during lifting the heart and while positioning for lateral wall grafting, then the heart is repositioned, and a sheathless IABP inserted. This is then used till the distal anastomosis is over. Once the anastomosis is complete and the heart repositioned for top end anastomosis, then the IABP is kept on standby mode. Then after the top end anastomosis is over, the heparin is reversed. Once the reversal is over and when the patient remains hemodynamically stable, we remove the IABP on the table, after inserting another femoral arterial line in the other groin. This technique has been very useful and we have been following this for the past four years, with excellent results. In fact this technique is being sent for publication. We have not had to reintroduce any IABP in any of these patients

We had analyzed the results of our last 2000 OPCAB patients. It was noticed that we had a higher rate of conversion onto the heart lung machine in our first thousand, when compared the second thousand. Probably, that was our initial learning curve which was seen in our technique, which we have developed and standardized. The use of IABP had been low in the early years, and probably the reason for the increased conversion on to the Heart lung machine. But as we understood the use of IABP, we found it more user friendly. Also the need

angina, Left ventricular dysfunction (ejection fraction < 35%), or unstable angina.

over the last four years.

**11. Results** 

Fig. 11. Shows the Coronary angiograms of patients, showing diffusely diseased coronary arteries.

Fig. 12. Showing the Double stabilizer technique while performing the long mammary patch anastomosis of LIMA on the LAD without enadarterectomy.

Fig. 11. Shows the Coronary angiograms of patients, showing diffusely diseased coronary

Fig. 12. Showing the Double stabilizer technique while performing the long mammary patch

anastomosis of LIMA on the LAD without enadarterectomy.

arteries.

Any patient who has a hemodynamic compromise or has an inclination to crash, gets an IABP inserted sheath less.(8 or &7 Fr). We had the IABP inserted in the early days when we had the patient included in one of the high risk group like- left main coronary artery disease (> 75% stenosis), intractable resting angina, ST depression more than 2.5mm,Post-infarction angina, Left ventricular dysfunction (ejection fraction < 35%), or unstable angina.

We had noticed that the use of IABP was not high in the left main disease group and low ejection fraction group, but was high in patients with ongoing ischemia. Hence we reengineered our use of IABP such that every patient undergoing OPCAB gets a femoral arterial line and this is used for monitoring along with the radial arterial line. When a patient becomes ischemic during lifting the heart and while positioning for lateral wall grafting, then the heart is repositioned, and a sheathless IABP inserted. This is then used till the distal anastomosis is over. Once the anastomosis is complete and the heart repositioned for top end anastomosis, then the IABP is kept on standby mode. Then after the top end anastomosis is over, the heparin is reversed. Once the reversal is over and when the patient remains hemodynamically stable, we remove the IABP on the table, after inserting another femoral arterial line in the other groin. This technique has been very useful and we have been following this for the past four years, with excellent results. In fact this technique is being sent for publication. We have not had to reintroduce any IABP in any of these patients over the last four years.

