**5. Incomplete myocardial revascularisation**

Early reports of OPCAB in the literature were uniformly consistent in the low number of grafts per patient [6,10]. The selection of patients with mainly single-vessel disease may, in part, explain this finding. But the persistence of lower average number of grafts in later comparative studies [Gundry S.R et al,1998 &Arom K.V.et al,2000] places OPCAB in a contentious position which detracts from its potential benefits. In their retrospective study, Gundry and colleagues reported a significantly lower mean number of grafts, and a twofold increase in cardiac re-intervention rate during a 7-year period with off-pump performed without cardiac stabilization, compared to on-pump CABG. This finding has been corroborated by other reports , and exemplifies incomplete revascularization with OPCAB. Effective cardiac retraction, stabilization and visualization systems with patient positioning enables grafting of all graftable targets, making complete myocardial revascularization (CMR) attainable in OPCAB [Calafiore A.M et al 1995 & Cartier R et al, 2000], and this has been demonstrated in a recent prospective randomized study [Puskas J.D et al,2003]. However, incomplete myocardial revascularization with OPCAB is still reported in retrospective studies . Technical difficulties due to small caliber of target vessels or their intramyocardial course, poor exposure of target sites, precarious intraoperative hemodynamic state, electrophysiological instability and inexperience of the surgeon are some of the reasons for incomplete myocardial revascularization.

Today we have no contraindications for OPCAB , the intramyocardial coronary arteries, small coronary arteries and diffuse coronary arteries [Anil D Prabhu et al, 2007&2008], have

Re-Engineering in OPCAB Surgery 191

Fig. 7. Showing the vein graft after anastomosis on the coronary artery.

patients with chronic renal for a better early clinical outcome.

Y.et al,2003]

mortality are decreased.

within 48 hr of acute myocardial infarction and some were in cardiogenic shock. OPCAB decreases the operative risk in the presence of impaired left ventricular function [Nakayama

Preoperative renal impairment is an independent predictor of poor prognosis after on-pump CABG [Ascione R et al 1999]]. OPCAB preserves renal function better than on-pump CABG [Ascione R.et al,2001], and available evidence favors the preferential use of OPCAB for

Patients with coexisting chronic obstructive airway disease derive better early clinical benefit from CABG performed without CPB compared with on-pump surgery [Güler M et al,2001], although in low-risk patients, OPCAB induces impairment of the mechanics of the respiratory system, lung and chest wall similar to on-pump CABG [Roosens C et al,2002]. Elderly patients are considered high risk surgical patients because of their reduced functional capacity and the presence of co-morbidities. Correspondingly, the outcome of onpump CABG in this group is characterized by increased morbidity and mortality [Montague N.T et al,,1985,,Mullany C.J et al,1980 & Hirose H,2000]. Interestingly, OPCAB has been shown to improve the clinical outcome in this growing population of surgical patients [Boyd W.D et al, 1999, Stamou S.C et al, 2000, Al-Ruzzeh S et al, 2001 & Hoff S.J.et al, 2002]. Specifically, the incidence of stroke, perioperative myocardial infarction, duration of mechanical ventilation, blood transfusion, length of intensive care and hospital stay, and

Fig. 6. Showing the dissection on the buried intramuscular coronary artery on the lateral wall of the heart.

been a thing of the past. Any patient who needs to undergo CABG would be able to have his coronary artery bypass surgery using the OPCAB technique.
