**4. Summary**

In conclusion, this review of currently published randomized controlled trials comparing outcomes after OPCAB and CCABG resulted in the following findings:


Current Evidence of On-Pump Versus Off-Pump Coronary Artery By-Pass Surgery 175

[9] Légaré J-F, Buth KJ, King S, Wood J, MD; Sullivan JA, Friesen HC, Lee J, Stewart K,

[10] Lingaas PS, Hol PK, Lundblad R, Rein KA, Tønnesen TI, Svennevig JL, Hauge SN,

[11] Sajja LR, Mannam G, Chakravarthi RM, Sompalli S, Naidu SK, Somaraju B, Penumatsa

[12] Puskas JD, Williams WH, Mahoney EM, Huber PR, Block PC, Duke PG, Stables JR, Glas

[13] Straka Z, Widimsky P, Jirasek K, Stros P, Votava J, Vanek T, Brucek P, Kolesar M,

[15] Karolak W, Hirsch G, Buth K, MSc, and J-F Legare. Medium-term outcomes of coronary

[16] Ascione R, Williams S, Lloyd CT, Sundaramoorthi T, Pitsis AA, Angelini GD. Reduced

[18] Parolari A, Mussoni L, Frigerio M, Naliato M, Alamanni F, Galanti A, Fiore G, MD,

[19] Parolari A, Mussoni L, Frigerio M, Naliato M, Alamanni F, Polvani GL, Agrifoglio M,

randomized study. J Thorac Cardiovasc Surg2007;133:378-88

Pump. Circulation. 2004;109:887-892

Heart Surgery Forum 2003:302621

2004;291:1841-1849

J Med 2009;361:1827-37.

Cardiovasc Surg 2005;130:303-8

bypass surgery. J Anesth 2007;21:297–303

controlled trial. Am Heart J 2007;153:689-95

techniques. J Thorac Cardiovasc Surg 2006;131:290-7

Hirsch GM. Coronary Bypass Surgery Performed off Pump Does NotResult in Lower In-Hospital Morbidity Than Coronary Artery Bypass Grafting Performed on

Vatne K,Fosse E. Clinical and Angiographic Outcome of Coronary Surgery with and without Cardiopulmonary Bypass: A Prospective Randomized Trial. The

RR. Coronary artery bypass grafting with or without cardiopulmonary bypass in patients with preoperative non–dialysis dependent renal insufficiency: A

KE, Marshall JJ, Leimbach ME, McCall SA, Petersen RJ; Bailey DE, Weintraub WS, Guyton RA. Off-pump vs conventional coronary artery bypass grafting: early and 1 year graft patency, cost, and quality-of-life outcomes. A randomized trial. JAMA

Spacek R. Off-Pump Versus On-Pump Coronary Surgery: Final Results From a Prospective Randomized Study PRAGUE-4. Ann Thorac Surg 2004;77:789 –93 [14] Shroyer AL, Grover FL, Hattler B, Collins JF, McDonald GO, Kozora E, Lucke JC, Baltz

JH, Novitzky D, for the Veterans Affairs Randomized On/Off Bypass (ROOBY) Study Group. On-Pump versus Off-Pump Coronary-Artery Bypass Surgery N Engl

artery bypass graft surgery on pump versus off pump: Results from a randomized

postoperative blood loss and transfusion requirement after beating-heart coronary operations: A prospective randomized study. Ann Thorac Surg 1999;68:493– 8 [17] Paparella D, Galeone A, Venneri MT, Coviello M, Scrascia G, Marraudino N, Quaranta

M, de Luca L, Schinosa T, Brister SJ, Activation of the coagulation system during coronary artery bypass grafting: Comparison between on-pump and off-pump

Veglia F, Tremoli E, Biglioli P, Camera M. Increased prothrombotic state lasting as long as one month after on-pump and off-pump coronary surgery. J Thorac

Veglia F, Tremoli E, Biglioli P, Camera M. The role of tissue factor and P-selectin in the procoagulant response that occurs in the first month after on-pump and offpump coronary artery bypass grafting J Thorac Cardiovasc Surg 2005;130:1561-6 [20] Tanaka KA, Thourani VH, Williams WH, Duke PG, Levy JH, Guyton RA, Puskas JD

Heparin anticoagulation in patients undergoing off-pump and on-pump coronary

myocardial injury and of increased incidence of atrial fibrillation after CCABG but no difference in the incidence of clinically important myocardial infarctions.

There is conflicting evidence of increased need of inotropic or pressor drugs and of intra-aortic balloon pump after CCABG. There is strong evidence of increased release of biochemical markers of renal insufficiency after CCABG but not of postoperative need of dialysis.

There is conflicting evidence of differences in incidence of perioperative stroke. Limited evidence suggests that neuro-cognitive dysfunction is larger early after CCABG than after OPCAB. However, no difference is detected later than three months after the operation.

There is strong evidence of fewer chest infections and shorter ventilation times after OPCAB. Risk of peri-operative bleeding and need for transfusions is higher after CCABG than after OPCAB. There is conflicting evidence regarding increased risk of gastro-intestinal complications after CCABG.

There is strong evidence from a number of randomized, controlled trials that the inflammatory response and the oxidative stress is higher after CCABG than after OPCAB. However, the clinical significance of these findings remain unclear.

Finally, there is strong evidence that OPCAB is more cost-effective than CCABG at up to twelve months follow-up. Long term data on cost-effectiveness are not available.

### **5. References**


difference in the incidence of clinically important myocardial infarctions.

of dialysis.

operation.

**5. References** 

e209

2001;72(4):1282-8

2002; 359: 1194–99

Thorac Surg. 2002;73:1196-202

Surgery. JAMA 2007;297(7):701-708

gastro-intestinal complications after CCABG.

myocardial injury and of increased incidence of atrial fibrillation after CCABG but no

There is conflicting evidence of increased need of inotropic or pressor drugs and of intra-aortic balloon pump after CCABG. There is strong evidence of increased release of biochemical markers of renal insufficiency after CCABG but not of postoperative need

There is conflicting evidence of differences in incidence of perioperative stroke. Limited evidence suggests that neuro-cognitive dysfunction is larger early after CCABG than after OPCAB. However, no difference is detected later than three months after the

There is strong evidence of fewer chest infections and shorter ventilation times after OPCAB. Risk of peri-operative bleeding and need for transfusions is higher after CCABG than after OPCAB. There is conflicting evidence regarding increased risk of

There is strong evidence from a number of randomized, controlled trials that the inflammatory response and the oxidative stress is higher after CCABG than after

Finally, there is strong evidence that OPCAB is more cost-effective than CCABG at up to twelve months follow-up. Long term data on cost-effectiveness are not available.

[1] Roger VL, Go AS, Lloyd-Jones DM et al. Heart Disease and Stroke Statistics\_2011

[2] Benetti FJ. Direct coronary surgery with sphenoid vein bypass without either cardiopulmonary bypass or circulatory arrest. J Cardiovasc Surg 1985;26:217-22 [3] Buffolo E, Andrade JC, Succi J et al. Direct myocardial revascularization without

[4] Cleveland JC Jr, Shroyer AL, Chen AY, Peterson E, Grover FL. Off-pump coronary artery

[5] Magee MJ, Jablonski KA, Stamou SC, Pfister AJ, Dewey TM, Dullum MK, Edgerton JR,

[6] van Dijk D, Spoor M, Hijman R, Nathoe HM, Borst C, Jansen EWL, Grobbee DE, de

[7] Angelini GD, Taylor FC, Reeves BC, Ascione R.Early and midterm outcome after off-

[8] Czerny M, Baumer H, Kilo J, Zuckermann A, Grubhofer G, Chevtchik D, Wolner E,

and Without Cardiopulmonary Bypass. Ann Thorac Surg 2001;71:165–9

cardiopulmonary bypass. Thorac Cardiovasc Surg 1985:33;26-9

Update: A report from the American Heart Association. Circulation 2011;123:e18-

bypass grafting decreases risk-adjusted mortality and morbidity. Ann Thorac Surg.

Prince SL, Acuff TE, Corso PJ, Mack MJ. Elimination of cardiopulmonary bypass improves early survival for multivessel coronary artery bypass patients. Ann

Jaegere PTP, Kalkman CJ for the Octopus Study Group. Cognitive and Cardiac Outcomes 5 Years After Off-Pump vs On-Pump Coronary Artery Bypass Graft

pump and on-pump surgery inBeating Heart Against Cardioplegic Arrest Studies (BHACAS 1 and 2): a pooled analysis of two randomised controlled trials. Lancet

Grimm M. Complete Revascularization in Coronary Artery Bypass Grafting With

OPCAB. However, the clinical significance of these findings remain unclear.


Current Evidence of On-Pump Versus Off-Pump Coronary Artery By-Pass Surgery 177

[34] Krejca M, Skiba J, Szmagala P, Gburek T, Bochenek A. Cardiac troponin T release

[35] Chowdhury UK, Malik V, Rakesh Y Seth S, Ramakrishnan L, Kalaivani M, Reddy SM,

[36] Malik V, Kale SC, Chowdhury UK, Ramakrishnan L, Chauhan S, Kiran U.Myocardial

[37] Medved I, Anic D, Zrnic B, Ostric M Saftic I. Off-Pump versus On-Pump – Intermittent

[38] Sahlman A, Ahonen J, Nemlander A, Salmenperä M, Eriksson H, Rämö J, Vento A.

[39] Selvanayagam JB, Petersen SE, Francis JM, Robson MD, Kardos A, Neubauer S, Taggart

[40] Serrano CV Jr, Souza JA, Lopes NH, Fernandes JL Nicolau JC, Blotta MHSL, Ramires

[41] van Dijk D, Nierich AP, Jansen EWL, Nathoe HM, Suyker WJL, Diephuis JC, van Boven

[42] Vedin J, Jensen U, Ericsson A, Samuelsson S Vaage J. Pulmonary hemodynamics and

[43] Hendrik M, Nathoe HM, Moons KGM, van Dijk D, Jansen EWL, Borst C, de Jaegere

[44] Mantovani V Charles Kennergren C Bugge M, Sala A , Lönnroth P, Berglin E

of Cardio-thoracic Surgery 2000;18:594-601

337-341

350.

2008;135:1110-9

Heart Inst J 2006;33:321-7

Coll. Antropol. 2008;32:381–384

Thorac Surg 2005;4:493-497

Cardiol 2006;97:1482–1486

Cardiology 2010;143: 302–308

Scand Cardiovasc J 2003;37: 211–215,

conventional and three minimally invasive surgical techniques. European Journal

during coronary surgery using intermittent cross-clamp with fibrillation, on-pump and off-pump beating heart. European Journal of Cardio-thoracic Surgery 1999;16:

Subramaniam GK, Govindappa R, Kakani M. Myocardial injury in coronary artery bypass grafting: On-pump versus off-pump comparison by measuring highsensitivity C-reactive protein, cardiac troponin I, heart-type fatty acid–binding protein, creatine kinase-MB, and myoglobin release. J Thorac Cardiovasc Surg

Injury in Coronary Artery Bypass Grafting On-Pump versus Off-Pump Comparison by Measuring Heart-Type Fatty-Acid–Binding Protein Release Tex

Aortic Cross Clamping – Myocardial Revascularisation:Single Center Expirience.

Myocardial metabolism on off-pump surgery; a randomized study of 50 cases.

DP. Effects of Off-Pump Versus On-Pump Coronary Surgery on Reversible and Irreversible Myocardial Injury. A Randomized Trial Using Cardiovascular Magnetic Resonance Imaging and Biochemical Markers. Circulation. 2004;109:345-

JAF MD, Hueb WA. Reduced expression of systemic proinflammatory and myocardial biomarkers after off-pump versus on-pump coronary artery bypass surgery: A prospective randomized study. Journal of Critical Care 2010;25: 305–312

W-J, Borst C, Buskens E, Grobbee DE, de Medina EOR, de Jaegere PTP, for the Octopus Study Group. Early Outcome After Off-Pump Versus On-Pump Coronary Bypass Surgery Results From a Randomized Study Circulation. 2001;104:1761-1766

gas exchange in off pump coronary artery bypass grafting Interact CardioVasc

PTP, Grobbee DE, for the Octopus Study Group Risk and Determinants of Myocardial Injury During Off-Pump Coronary Artery Bypass Grafting. Am J

Myocardial metabolism assessed by microdialysis: A prospective randomized study in on- and off-pump coronary bypass surgery. International Journal of


[21] Cheng DC, Bainbridge D, Martin JE, Novick RJ. The Evidence-based Perioperative

[22] Widimsky P, Straka Z, Stros P, Jirasek K, Dvorak J, Votava J, Lisa L, Budesinsky T,

Versus Mechanical Stabilization. Ann Thorac Surg 2000;69:1466 –70 [24] Nathoe HM, Dijk D, Jansen EWL, Suyker WJL, Diephuis JC, Boven WJ, Riviere AB,

Anesthesiology. 2005;102(1):188-203

England Journal of Medicine 2003;348:394-402.

Cardio-thoracic Surgery 2006;30:294—299

Surg 2009;137:650-7

Cardiothoracic and Vascular Anesthesia 2008;22:515-521

167

Clinical Outcomes Research Group. Does Off-pump Coronary Artery Bypass Reduce Mortality, Morbidity, and Resource Utilization When Compared with Conventional Coronary Artery Bypass? A Meta-analysis of Randomized Trials.

Kolesar M, Vanek T, Brucek P. One-Year Coronary Bypass Graft Patency A Randomized Comparison Between Off-Pump and On-Pump Surgery. Angiographic Results of the PRAGUE-4 Trial. Circulation. 2004;110:3418-3423 [23] Kochamba GS Yun KL, Pfeffer TA, Sintek CF, Khonsari S.Pulmonary Abnormalities

After Coronary Arterial Bypass Grafting Operation: Cardiopulmonary Bypass

Borst C, Kalkman CJ, Grobbe DE, Buskens E, Jaegere PPT. A comparison of onpump and off-pump coronary bypass surgery in low-risk patients. The New

Sigwart U, Pepper J. A Randomized Comparison of Off-Pump and On-Pump

Steinbrüchel DA. Graft patency after off-pump versus on-pump coronary artery surgery in high-risk patients. Scandinavian Cardiovascular Journal, 2010; 44: 161–

cardioplegic arrest studies (BHACAS 1 and 2): quality of life at mid-term follow-up in two randomised controlled trials. European Heart Journal 2004; 25: 765–770 [28] Bjorner JB, Kreiner S, Ware JE, Damsgaard MT, Bech P. Differential item functioning in the Danish translation of the SF-36. J Clin Epidemiol 1998;51:1189-202. [29] Al-Ruzzeh S, George S, Bustami M, Wray J, Ilsley C, Athanasiou T, Amrani M. Effect of

off-pump coronary artery bypass surgery on clinical, angiographic, neurocognitive, and quality of life outcomes: randomised controlled trial BMJ 2006;332:1365-72 [30] Jensen BO, Hughes P, Rasmussen LS, Pedersen PU, Steinbrüchel DA. Health-related

quality of life following off-pump versus on-pump coronary artery bypass grafting in elderly moderate to high-risk patients: a randomized trial. European Journal of

Outcomes After Coronary Artery Bypass Surgery With and Without Cardiopulmonary Bypass: A Prospective Randomized TrialJournal of

Off-pump versus on-pump myocardial revascularization in patients with STsegment elevation myocardial infarction: A randomized trial. J Thorac Cardiovasc

W, Schuelera S. Interleukin-1, interleukin-6 and myocardial enzyme response after coronary artery bypass grafting: a prospective randomized comparison of the

[31] Tully PJ, Baker RA, Kneebone AS, Knight JL. Neuropsychologic and Quality-of-Life

[32] Fattouch K, Guccione F, Dioguardi P, Sampognaro R, Corrado E, Caruso M, Ruvolo G.

[33] Gulielmos V, Menschikowski M, Dilla H-M, Ellera M, Thiele S, Tugtekina SM, Jarossb

[25] Khan NE, De Souza A, Mister R, Flather M, Clague J, Davies S, Collins P, Wang D,

Multivessel Coronary-Artery Bypass Surgery. N Engl J Med 2004;350: 21-8. [26] Møller CH, Perko MJ, Lund JT, Andersen LW, Kelbæk H, Madsen JK, Gluud, C,

[27] Ascione R, Reeves BC, Taylor FC, Seehraa HK, Angelini GD.Beating heart against

conventional and three minimally invasive surgical techniques. European Journal of Cardio-thoracic Surgery 2000;18:594-601


Current Evidence of On-Pump Versus Off-Pump Coronary Artery By-Pass Surgery 179

[58] Andersson LG, Ekroth R, Bratteby LE, Hallhagen S, Wesslen O. Acute renal failure in

[59] Abu-Omar Y, Ratatunga C. Cardiopulmonary by-pass and renal injury. Perfusion 2006;

[60] Ascione R, MD, Lloyd CT, Underwood MJ, Gomes WJ, Gianni D, Angelini GD. On-

[61] Tang ATM, Knotta J,. Nanson J, Hsua J, Hawa MP, Ohri SK. A prospective randomized

[63] Covino E, Santise G, Di Lello F, De Amicis V, Bonifazi R, Bellino I, Spampinato N:

[64] Cox CM, Ascione R, Cohen AM, Davies IM, Ryder IG, Angelini GD. Effect of

[65] Syed A, Fawzy H, Farag A, Nemlander A, Comparison of Pulmonary Gas Exchange in OPCAB Versus Conventional CABG. HeartLung and Circulation 2004;13:168–172 [66] Raja SG, Haider Z, Ahmad M. Predictors of gastrointestinal complications after conventional and beatingheart coronary surgery. Surg J R Coll Surg 2003:221-228 [67] Formica F, Broccolo F, Martino A, Sciucchetti J, Giordano V, Avalli L, Radaelli G, Ferro

[68] Nesher N, Frolkis I, Vardi M, Sheinberg N, Bakir I, Caselman F, Pevni D, Ben-Gal Y,

[70] Wildhirt SM, Schulze C, Conrad NE, Schütz A, Reichart B. Expression von TNF-alpha

ohne extrakorporaler Zirkulation. Z Herz- Thorax- Gefäßchir 2001;15:7–13 [71] Johannson-Synnergren M, Nilsson F, Bengtsson A, Jeppson A, Wiklund L. Off-pump

Pump Coronary Artery Bypass Surgery J Card Surg 2006;21:395-402 [69] Onorati F, Rubino AS, Nucera S, Foti D, Sica V, Santini F, Gulletta E, Renzulli A. Off-

European Journal of Cardio-thoracic Surgery 2010;37: 897—904

factors. J Thorac Cardiovasc Surg 1989;98:1107-12

Randomized Study. Ann Thorac Surg 2000;69:140 –5

Function. Ann Thorac Surg 1999;68:493– 8

Thorac Surg 2001;71:152–7

2001;42(1):23-6.

Surg 2009;137:1206-12

58, 2004

21:209-213

the patient undergoing cardiac operation. Prevalence, mortality rate, and main risk

Pump Versus Off-Pump Coronary Revascularization: Evaluation of Renal

study to evaluate the renoprotective action of beating heart coronary surgery in low risk patients. European Journal of Cardio-thoracic Surgery 2002;22:118–123 [62] Güler M, Krali K, Toker ME, Bozbug N Ömeroglu SN , Aknc E, Yakut C. Different

CABG Methods in Patients With Chronic Obstructive Pulmonary Disease. Ann

Surgical myocardial revascularization (CABG) in patients with pulmonary disease: Beating heart versus cardiopulmonary bypass. J Cardiovasc Surg (Torino).

Cardiopulmonary Bypass on Pulmonary Gas Exchange: A Prospective

O, Corti F, Cocuzza C, Paolini G. Myocardial revascularization with miniaturized extracorporeal circulation versus off pump: Evaluation of systemic and myocardial inflammatory response in a prospective randomized study. J Thorac Cardiovasc

Sharony R, Bolotin G, Loberman D, Uretzky G, Weinbroum AA,. Higher Levels of Serum Cytokines and Myocardial Tissue Markers During On-Pump Versus Off-

pump coronary artery bypass surgery versus standard linear or pulsatile cardiopulmonary bypass: endothelial activation and inflammatory response

und löslichen Adhäsionsmolekülen nach koronarchirurgischen Eingriffen mit und

CABG reduces complement activation but does not significantly affect peripheral endothelial function: a prospective, randomized study. Scand Cardiovasc J 38; 53–


[45] Ascione R, Caputo M, Calori G, Lloyd CT, Underwood MJ,Angelini GD. Predictors of

[46] Møller CH, Perko MJ, Lund JT, Andersen LW, MD, Kelbæk H, Madsen JK, Winkel P,

[47] Wijeysundera DN, Beattie WS, Djaiani G, Rao V, Borger MA, Karkouti K, Cusimano RJ.

[48] Diegeler A, Hirsch R, Schneider F, Schilling L-O, MD, Falk V, Rauch T, Mohr FW.

[49] van Dijk D, Jansen EWL, Hijman R, Nierich AP, Diephuis JC, Moons KGM, Lahpor JR,

[50] Lee JD, Lee SJ, Tsushima WT, Yamauchi H, Lau WT, Popper J, Stein, A, Johnson D, Lee

[52] Motallebzadeh R, Bland JM, Markus HS, Kaski JC, Jahangiri M. Neurocognitive

[54] Zamvar V, Williams D,Hall J, Payne N, Cann C, Young K, Karthikeyan S, Dunne J.

[55] Selnes OA, Grega MA, Borowicz LM Jr, Barry S, Zeger S, Baumgartner WA, McKhann

[56] Wandschneider W, Thalmann M, Trampitsch E, Ziervogel G, Kobinia G, Off-Pump

[57] Yin Y-q, Luo A-l, Guo X-y, Li L-h Huang Y-g. Postoperative neuropsychological change

Coronary Artery Bypass Surgery. Ann Thorac Surg 2007;83:475– 82 [53] Naseri MH, Pishgou B, Ameli J,Babaei E, Taghipour HR. Comparison of post-operative

pass surgery Pak J Med Sci 2009;25:137-141

controls. Ann Thorac Surg. 2005 Apr;79(4):1201-9.

grafting. Chin Med J 2007;120:1951-1957

Less Cerebral Damage? Ann Thorac Surg 2000;70:1577–9

Prospective, Randomized Study. Circulation. 2000;102:1530-1535

The Best Bypass Surgery Trial. Circulation. 2010;121:498-504

Coronary Bypass Operation. Ann Thorac Surg 2000;69:1162– 6

2005;46(5):872-82.

2002;287(11):1405-1412

2000;119:148-54

BMJ 2002;325:1268

Atrial Fibrillation After Conventional and Beating Heart Coronary Surgery. A

Gluud C, Steinbrüchel DA. No Major Differences in 30-Day Outcomes in High-Risk Patients Randomized to Off-Pump Versus On-Pump Coronary Bypass Surgery.

Off-pump coronary artery surgery for reducing mortality and morbidity: metaanalysis of randomized and observational studies. J Am Coll Cardiol.

Neuromonitoring and Neurocognitive Outcome in Off-Pump Versus Conventional

Borst C, Keizer AMA, Nathoe HM, Diederick E. Grobbee DE, De Jaegere PTP, Kalkman CJ, for the Octopus Study Group. Cognitive Outcome After Off-Pump and On-Pump Coronary Artery Bypass Graft Surgery. A Randomized Trial. JAMA.

D, Petrovitch H, Dang CR. Benefits of Off-Pump Bypass on Neurologic and Clinical Morbidity: A Prospective Randomized Trial. Ann Thorac Surg 2003;76:18 –26 [51] Lloyd CT, Ascione R, Underwood MJ, Gardner F, Black A, Angelini GD. Serum S-100

protein release and neuropsycologic outcome during coronary revascularization on the beating heart: A prospective randomized study. J Thorac Cardiovasc Surg

Function and Cerebral Emboli: Randomized Study of On-Pump Versus Off-Pump

neurological complications between on-pump and off-pump coronary artery by-

Assessment of neurocognitive impairment after off-pump and on-pump techniques for coronary artery bypass graftsurgery: prospective randomised controlled trial.

GM. Cognitive outcomes three years after coronary artery bypass surgery: a comparison of on-pump coronary artery bypass graft surgery and nonsurgical

Coronary Bypass Operations Significantly Reduce S100 Release: An Indicator for

and its underlying mechanism in patients undergoing coronary artery bypass


**8** 

*Kozhikode Kerala* 

 *India* 

**Re-Engineering in OPCAB Surgery** 

Murali P. Vettath, Et Ismail, Av Kannan and Athmaja Murali

Coronary artery bypass surgery is a procedure that started off with the first implantation of the internal mammary artery to the cardiac muscle in 1946 by Vineberg [Vineberg AM, 1954]. Later, the coronary anastomosis distal to the occlusion using the saphenous vein graft (SVG) or the internal mammary artery (IMA) was experimentally conceived by Murray [Murray et al, 1954]. Bailey et al [Bailey et al, 1957] were the first group to approach the problem of coronary occlusion in 1957. Though the pioneers of OPCAB were Goetz and colleagues [Goetz et al, 1961] and Kolessov [Kolessov VL, 1967] who performed the procedure in isolated cases. The first clinical series of consecutive patients was by Trapp and

Then, with the development of direct coronary surgery, under the leadership of Favaloro [Favaloro RG,1968] and Green and coworkers [Green GE, Stertzer SH 1968], with procedures being performed in an arrested heart with the use of extracorporeal circulation, off-pump coronary surgery was abandoned. Thus the surgeons all over the world started performing CABG on the heart lung machine , and that became the standard of care for

 In 1981 Enio Buffolo [Buffolo E ,et.al,1985]from Brazil and Benneti [Benetti FJ,1985] from Argentina had started experimenting on this technique of Direct Myocardial revascularization. Both of them published their series around 1985 which rekindled the idea of OPCAB in the western world. It was probably the idea of minimally invasive direct coronary artery bypass graft (MIDCABG), introduced in the mid-1990s by Benneti [Benetti FJ ,1985,1995], that called attention to the possibility and advantages of not using CPB. Calafiore's [Calafiore AM,et al,1996,1998] publications re- enforced the advantages of the LAST(left anterior small thoracotomy) operation. The LIMA stitch was acclaimed as an extraordinary step in the development of off-pump coronary surgery, which allowed grafting of posterior branches of the coronary arteries. The introduction of stabilizers in the mid 1990s further facilitated the procedure[Borst C,1996]. Eric Jansen, was one of those surgeon in the mid nineties who was probably the man who had made the word -Octopusso very popular in the rest of the world. The article published in 1991 by Benetti [Benetti F.J et al,1991] in Chest, gave confidence to the Cardiac surgeons around the world to perform OPCAB in all anterior vessels. But even then the circumflex territory became a danger zone for most surgeons to perform a safe coronary anastomoses. Though LIMA stitch was used quite often, it was the availability of the Positioners that that made the process of

Bisarya [Trapp WG, Bisarya R,1975] and Ankeney [Ankeney JL,1975].

**1. Introduction** 

patients with coronary artery disease.

Verticalisation of the heart more comfortable.

