**9. References**


Coronary artery bypass grafting remains one of the most frequently performed major operations worldwide. Even in the burgeoning era of percutaneous approaches to coronary heart disease, the indications for CABG continue to be based on relief of angina, prevention of myocardial damage from ischemic complications, and prolonged expected survival in select patients. In order to provide the best results for CABG patients, the surgeon's chief focus should be on improved long-term outcomes. Based on the information available, the best long-term outcomes of CABG are achieved when incorporating a strategy of grafting

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**8. Summary** 

with arterial conduits.

29-34.

294: 448-54.

2009; 360: 961-72.

2005; 294: 2446-54.

Surg 2006; 131: 956-62.

**9. References** 


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**7** 

Kim Houlind

*Denmark* 

*Dept. of Vascular Surgery,* 

*Kolding Sygehus - Little Belt Hospital* 

**Current Evidence of On-Pump Versus** 

**Off-Pump Coronary Artery By-Pass Surgery** 

Conventional coronary artery by-pass grafting (CCABG) performed using cardioplegic arrest and cardiopulmonary by-pass is a very well documented treatment for ischemic heart disease. The operation often relieves chest pain and it improves survival for patients with

Since it was introduced in the late 1960´es, CCABG has become one of the most commonly performed operations. In 2007, an estimated 408.000 surgical coronary revascularizations

Given the ageing populations in large parts of the world, CCABG is also increasingly being offered to elderly patients and to patients with co-morbidities. As a consequence, a significant number of operated patients suffer major or minor complications. Concerns have been raised that the use of cardiopulmonary by-pass (CPB) could cause neuro-cognitive dysfunction. Also, CPB has been linked to myocardial, renal and pulmonary damage. Several mechanisms have been suggested: Manipulation of the aorta during cannulation and clamping may cause dislodgment and embolization of atherosclerotic deposits, cardiac arrest may induce myocardial damage, and the long-lasting and repeated contact of blood with the non-biological surfaces of filters and tubing of the heart- lung- machine induce mechanical wearing of the formed elements and biochemical over-activation of the immune-

Development of the Off-pump Coronary Artery By-pass (OPCAB) technique has been driven by concerns of these possible side-effects from CPB. On the other hand, concerns have been raised about whether the quality of anastomoses constructed "on the beating heart" - i.e. without cardiopulmonary by-pass and cardioplegic arrest – would be as good as that of the anastomoses performed during CCABG. The question remains controversial. Best estimates of the proportion of surgical coronary revascularizations performed as OPCAB in the United States is around 25%. Some surgical centres perform almost all coronary by-pass operations off-pump, while others hardly or never use this technique. Tradition and economy dictate that OPCAB is the preferred method in some parts of the developing world. In the beginning of the OPCAB-experience, evidence was limited to small, published series by individual surgeons (2-3). Although seemingly providing good results, these observations were hampered by the lack of a control group. Later studies from databases were difficult to interpret because the original intention-to-treat was not

triple- vessel disease and left main coronary artery disease.

were performed in the United States alone (1)

**1. Introduction** 

and coagulation systems

