**12. Conclusion**

The advance that has been made in the surgical management of coronary artery disease has placed us in a vantage position of judging the outcome of our management techniques not only by morbidity and mortality incurred, but also by the potential of our treatment modality to cause harm. This is why OPCAB has generated renewed, widespread and sustained interest. The resurgence of OPCAB has also ignited a keen enthusiasm in the refinement of CPB techniques and the management of on-pump CABG patients. In most practices, OPCAB is paradoxically dependent on, and guaranteed by the presence of the CPB machine. We would like to stress here that OPCAB is not for everyone. It is definitely not for the faint hearted surgeon, It needs a Team with a MINDSET. And the team has to gear itself from being able to perform CABG on full Cardiopulmonary bypass, with cross clamp and cardoplegia, to performing CABG on pump with a beating heart, and then going on to just cannulating the aorta, and then stabilizing the heart and performing OPCAB, to doing a full OPCAB. This should be a slow transition, than a sudden change. Then the results would be good. There has been numerous article comparing OPCAB with ONCAB, but in our opinion, a surgeon performing OPCAB would not have to perform ONCAB, what ever the coronary anatomy is, if he sets his mind to it.

In our last 12 years of OPCAB experience and over 2500 OPCABs, we have been able to perform the last 1600 OPCABs with only one conversion to the heart lung machine. That was when patient developed intractable arrhythmia. Hence in our opinion, intractable arrhythmia is the only reason for conversion. The mortality in the first one thousand patients have been 0.8% and in the second thousand is 0.4%.This proves to say that OPCAB has definitely reduced the mortality in coronary surgery. And if trained well we would be able to perform the same in patients with any ejection fraction.

### **13. References**

198 Special Topics in Cardiac Surgery

for the balloon pump only for distal anastomosis did come as a surprise to us. In the last 1600 odd patients, we had to convert only one patient on to the heart lung patient (That too when the patient developed intractable Ventricular arrhythmia). The mortality of the second thousand patients had come down by half and we have been able to maintain that result. Our results of the different parameters like the use of ionotropes, number of grafts, Renal failure, perioperative Myocardial infarction etc, in comparison with our two groups of

The advance that has been made in the surgical management of coronary artery disease has placed us in a vantage position of judging the outcome of our management techniques not only by morbidity and mortality incurred, but also by the potential of our treatment modality to cause harm. This is why OPCAB has generated renewed, widespread and sustained interest. The resurgence of OPCAB has also ignited a keen enthusiasm in the refinement of CPB techniques and the management of on-pump CABG patients. In most practices, OPCAB is paradoxically dependent on, and guaranteed by the presence of the CPB machine. We would like to stress here that OPCAB is not for everyone. It is definitely not for the faint hearted surgeon, It needs a Team with a MINDSET. And the team has to gear itself from being able to perform CABG on full Cardiopulmonary bypass, with cross clamp and cardoplegia, to performing CABG on pump with a beating heart, and then going on to just cannulating the aorta, and then stabilizing the heart and performing OPCAB, to doing a full OPCAB. This should be a slow transition, than a sudden change. Then the results would be good. There has been numerous article comparing OPCAB with ONCAB, but in our opinion, a surgeon performing OPCAB would not have to perform ONCAB, what

patients have been elucidated in the Table below.

ever the coronary anatomy is, if he sets his mind to it.

**12. Conclusion** 


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**9** 

*USA* 

**Strategies for the Prevention of Postoperative** 

Atrial fibrillation (AF) occurs in 15% to 50% of patients after cardiac surgery (Bradley et al., 2005; Dunning et al., 2006). Postoperative atrial fibrillation (POAF) most often develops between the second and fifth postoperative day, with a peak incidence in the first two to three days. While POAF can be self-limiting, it may also be associated with hemodynamic compromise, postoperative stroke, perioperative myocardial infarction (MI), ventricular arrhythmias, and heart failure (Echahidi et al., 2008; Kaireviciute et al., 2009). The development of POAF is associated with, on average, an additional hospital length of stay (LOS) of 1 to 1.5 days (Kim et al., 2001; Zimmer et al., 2003). Some studies, however, report that POAF increases hospital LOS by almost 5 days (Aranski et al., 1996; Gillespie et al., 2006). POAF is also associated with higher hospital costs with an average increase of

Practice guidelines for the prevention of POAF in patients undergoing cardiac surgery exist which include the American College of Chest Physicians (ACCP) 2005 POAF Guidelines, the ACCP 2005 Recommendations for the Role of Cardiac Pacing for POAF, the American College of Cardiology (ACC)/American Heart Association (AHA)/European Society of Cardiology (ESC) 2006 Atrial Fibrillation Guidelines, the ACC/AHA 2004 Coronary Artery Bypass Graft Surgery (CABG) Guidelines, the Canadian Cardiovascular Society (CCS) Consensus Conference Statements on AF, and the European Association for Cardio-Thoracic Surgery (EACTS) 2006 POAF Guidelines and updated ESC/EACTS 2010 AF Guidelines (Bradley et al., 2005; Maisel & Epstein 2005; Dunning et al., 2006; Fuster et al., 2006; Eagle et al., 2004; Mitchell

\$10,000-\$12,600 per hospitalization (Gillespie et al., 2006; Aranski et al., 1996).

et al., 2005; Kerr & Roy, 2004; European Society of Cardiology ([ESC], 2010) (Table 1).

The guidelines are consistent in that they all strongly recommend using beta-blockers to reduce POAF incidence (ACCP 2005 POAF Guidelines Strength A, ACC/AHA/ESC 2006 AF Guidelines and ACC/AHA 2004 CABG Guidelines Class I, Canadian Cardiovascular Society AF/POAF Consensus Class I, and ESC 2010 AF Guidelines Class I). The Surgical Care Improvement Project (SCIP) National Quality Measures also state that all patients undergoing cardiac surgery should receive a beta-blocker during the perioperative period if they were on a beta-blocker prior to arrival (Surgical Care Improvement Project [SCIP] Version 3.0a, 2009). Most institutions have incorporated this requirement into their prospective preoperative order sets for all patients without contraindications to beta-blockers.

**1. Introduction** 

**Atrial Fibrillation in Cardiac Surgery** 

*1Creighton University School of Pharmacy and Health Professions* 

Thomas M. Baker2 and Thomas J. Langdon2

*2Alegent Health, Cardiovascular and Thoracic Surgery* 

Estella M. Davis1, Kathleen A. Packard1, Jon T. Knezevich1,

