**4. Quality of distal anastamosis**

Performing vascular anastomoses on small arteries on a beating heart can be a daunting and frustrating adventure, and so far, no available method of target vessel stabilization can achieve a steady bloodless field comparable to an arrested heart. This was a major concern with OPCAB. The beating heart with a bloody operating field poses a major challenge to delicate tissue handling, and casts a shadow of uncertainty about the quality of the distal anastomosis. However, with the application of effective target vessel stabilization, and efficient visualization systems the early and mid-term patency of OPCAB has been encouraging

The stabilizers we use are the suction stabilizers. The position of the stabilizer is very. important to achieve a very stable anastomotic site to perform a good coronary anastomosis. We have tried all types of suction stabilizers, from the Medtronic -Octopus II, III and the Octopus IV. We are now using the Maquet, which was the previous Guidant – Acrobat

Re-Engineering in OPCAB Surgery 189

Fig. 5. Showing the clarity of the coronary anastamosis, while performing LIMA to LAD

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

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

**5. Incomplete myocardial revascularisation** 

some of the reasons for incomplete myocardial revascularization.

anastamosis.

Fig. 4. Photograph showing the positioner on the RV free wall to graft the distal RCA or the acute marginal.

stabilizer. The Re- engineering in this is the pressure used for suction of these stabilizers. We use 100-150 mm of Hg on these stabilizers. The stabilizer is positioned according to the convenience of the surgeon. The position of our stabilizer is shown in the photographs. We do not use any suction while stabilizing the lateral wall, as the heart is allowed to fall on the stabilizer pods.

In order to achieve a stable bloodless field while accessing the coronary artery, we use the following technique. After stabilizing the coronary artery by using the acrobat stabilizer, we use a 5.0 polypropelene suture to run around the proximal part of the coronary artery, proximal to where the arteriotomy is planned to be made. The two ends of the 5.0 polypropylene are suspended using rubber shod . They are tightened just before the coronary arteriotomy is made. This is made using the bevel of a 18 gauge needle on a 2 ml syringe. After the nick is made on the coronary artery, the forward or the backward cutting scissors is used to open the coronary artery. A Castroveijo scissors is used to open the arteriotomy. The arteriotomy is usually one centimeter long. Then the intra-coronary shunt is inserted according to the size of the coronary artery. The shunt is to be deaired after inserting the proximal end first, then the snare is released and the then the distal end is inserted. Then the anastomosis of the coronary is performed using the conduits as preferred. We use shunts in nearly all the distal anastomosis.

Fig. 4. Photograph showing the positioner on the RV free wall to graft the distal RCA or the

stabilizer. The Re- engineering in this is the pressure used for suction of these stabilizers. We use 100-150 mm of Hg on these stabilizers. The stabilizer is positioned according to the convenience of the surgeon. The position of our stabilizer is shown in the photographs. We do not use any suction while stabilizing the lateral wall, as the heart is allowed to fall on the

In order to achieve a stable bloodless field while accessing the coronary artery, we use the following technique. After stabilizing the coronary artery by using the acrobat stabilizer, we use a 5.0 polypropelene suture to run around the proximal part of the coronary artery, proximal to where the arteriotomy is planned to be made. The two ends of the 5.0 polypropylene are suspended using rubber shod . They are tightened just before the coronary arteriotomy is made. This is made using the bevel of a 18 gauge needle on a 2 ml syringe. After the nick is made on the coronary artery, the forward or the backward cutting scissors is used to open the coronary artery. A Castroveijo scissors is used to open the arteriotomy. The arteriotomy is usually one centimeter long. Then the intra-coronary shunt is inserted according to the size of the coronary artery. The shunt is to be deaired after inserting the proximal end first, then the snare is released and the then the distal end is inserted. Then the anastomosis of the coronary is performed using the conduits as preferred.

acute marginal.

stabilizer pods.

We use shunts in nearly all the distal anastomosis.

Fig. 5. Showing the clarity of the coronary anastamosis, while performing LIMA to LAD anastamosis.
