**6. High risk surgical patients**

OPCAB has been demonstrated to offer prognostic advantage over on-pump CABG in patients with exaggerated surgical risk from complicated coronary artery disease and/or debilitating co-morbidities [Tashiro T et al,1996,Akiyama K.et al,1999,Yokoyama T. et al,2000 & Prifti E et al,2000]. More importantly, the preoperative optimization of high risk patients plays a crucial role in determining the clinical outcome for both methods of myocardial revascularization.

Acute myocardial infarction and depressed left ventricular function constitute a high surgical risk with on-pump CABG, because the myocardial damaging effects of CPB and the often cumbersome and, inefficient intraoperative myocardial protection do not prevent immediate postoperative cardiac dysfunction [Buckberg Get al,1996,Christenson J.T..et al,1997 &.D'Ancona G,2001]. OPCAB achieves comparatively better outcomes in patients who have myocardial revascularization soon after recent AMI [Locker C,2001]. Mohr et al. [Mohr R et al 1999] reported a mortality of 1.7% with 1- and 5-year actuarial survival rates of 94.7 and 82.3%, respectively, in a series of 57 patients in which 56% had emergency surgery

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

coronary artery bypass surgery using the OPCAB technique.

been a thing of the past. Any patient who needs to undergo CABG would be able to have his

OPCAB has been demonstrated to offer prognostic advantage over on-pump CABG in patients with exaggerated surgical risk from complicated coronary artery disease and/or debilitating co-morbidities [Tashiro T et al,1996,Akiyama K.et al,1999,Yokoyama T. et al,2000 & Prifti E et al,2000]. More importantly, the preoperative optimization of high risk patients plays a crucial role in determining the clinical outcome for both methods of

Acute myocardial infarction and depressed left ventricular function constitute a high surgical risk with on-pump CABG, because the myocardial damaging effects of CPB and the often cumbersome and, inefficient intraoperative myocardial protection do not prevent immediate postoperative cardiac dysfunction [Buckberg Get al,1996,Christenson J.T..et al,1997 &.D'Ancona G,2001]. OPCAB achieves comparatively better outcomes in patients who have myocardial revascularization soon after recent AMI [Locker C,2001]. Mohr et al. [Mohr R et al 1999] reported a mortality of 1.7% with 1- and 5-year actuarial survival rates of 94.7 and 82.3%, respectively, in a series of 57 patients in which 56% had emergency surgery

wall of the heart.

**6. High risk surgical patients** 

myocardial revascularization.

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

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 Y.et al,2003]

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 chronic renal for a better early clinical outcome.

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 mortality are decreased.

Re-Engineering in OPCAB Surgery 193

Fig. 8. Shows the Vettath's anastomotic obturator , the whole length of the device and the

working end of the piece that goes into the aorta.
