**Abstract**

OPCAB was performed before the advent of heart lung machine. But with the development of stabilizers, coronary artery bypass grafting has been performed over the last two decades successfully in many centres around the world. But still 80% of bypass surgeries are done on the heart lung machine. We were one of the few teams who have been performing this OPCAB for the past 18 years. All along, we have been innovating, fabricating and developing and patenting instruments, techniques and technology to help us perform OPCAB in 100% of all our coronary patients. That too being able to reduce the mortality of bypass surgery to less than 0.5%. In this chapter, we have attempted to write down our strategy, in order to successfully perform OPCAB in all our patients, so that the coming generation can benefit from it.

**Keywords:** OPCAB, CABG, arterial graft, venous graft, bilateral mammary grafting, IABP, mammary patch, VAO, SIMS, stabilizer

#### **1. Introduction**

OPCAB has been the procedure of choice in quite a few centres around the world. Though, the numbers of surgeons performing 100% of their CABGs off pump are still miniscule. The main issue is that performing OPCAB in all patients becomes quite strenuous for some surgeons because in OPCAB, the margin of error is very low. And that when a patient is converted to the heart lung machine then the morbidity and the mortality is high. The learning curve is very steep in order to master this technique. Our team had to perform over 500 OPCABs till the team became comfortable to perform this procedure in all patients who needed coronary revascularisation. There are two important issues that have to be tackled before a team gets to be able to perform 100% OPCABs over a decade [1]. One is the mind set and another is team work. If one achieves these two goals, then the rest is only a question of time, when the team could achieve it. Every team player has to become confident that we would be able re-vascularise every patient without going on pump. That confidence and strategy is the key to the success of the surgery. Apart from preparing for surgery, and planning for difficult cases, the execution,

intraoperative and post-operative management till he returns to his room and to his further follow up, all are to be planned and executed with precision. Every patient needs to get a tailor made surgical approach. As, no two coronaries are same. Likewise no two grafting are same. Accordingly no two patients would have same postoperative course. Hence there should be no slackness on the part of the team thinking that it is just a straight forward case and we can relax. We have always found that we make mistakes when we are not agile or when we take things for granted. As every patient is important. Hence, we should care for him like we care for our parents or our colleague. Once we are able to achieve this, then success can be assured.

#### **2. Surgical strategy**

In this chapter, we would like to present our view on how we plan our surgical strategy. Starting from the type of surgery, which the patient is going to undergo, to the revascularisation techniques which we plan are going to be discussed here. As we said, every patient needs to have his surgery tailor made according to his specific needs. Our main aim is to perform complete revascularisation on all patients, then, the next priority is to perform the coronary bypass without using the heart lung machine. Then our priority is to use arterial grafts where ever possible. The use of left internal mammary artery (LIMA) to the left anterior descending artery (LAD) is a rule or standard for all patients. We have noticed that as the LAD is the most important artery in the heart, if the LIMA remains patent over 10 years then it usually remains open for life [2]. The presence of nitric oxide in LIMA in fact does not allow any clot formation inside it and that even a small LIMA remains patent as long as the run off of the LAD is good. And that once we anastomose a LIMA to the LAD, then it is unlikely that the LAD distal to the anastomosis would develop atherosclerosis. This is because of the nitric oxide that is secreted from the LIMA which prevents the development of atherosclerosis being formed in that region. This is unlike in case of drug eluting stent where we see narrowing of the vessel distal to the stent.

#### **3. Preoperative preparation in OPCAB**

Preparation of patients in OPCAB is rather less cumbersome than in patients with on-pump CABG. That is, we do not have to stop the antiplatelet medication in patients who are going to undergo OPCAB. Hence in patients with acute coronary syndrome we have the advantage of continuing the antiplatelet and the injection heparin till the day of surgery. Thereby avoiding ischemia in these patients. The only medicine we stop is beta blockers on the day of surgery. As we do not wish to reduce the heart rates unlike in other centres, we in fact like to increase the heart rate so as to increase the cardiac output in turn. This is how we are able to avoid the use of inotropes in all our patients during the positioning of the heart before grafting [1]. Apart from this there are no changes in the management of patients in either groups.

#### **4. Anaesthesia management**

Anaesthetic management of patient being induced for OPCAB is similar in line, as for all cardiac surgical patients, except that they are not totally ironed out.

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**Figure 1.**

*Patient on the table with left arm on the side for radial artery harvesting.*

*Revascularisation Strategies in OPCAB (Off Pump Coronary Artery Bypass)*

all through the procedure, though this warrants a separate chapter.

This is to make sure that the mean blood pressure is maintained above 75 mm of Hg,

Once the patient is positioned, painted and draped (**Figures 1** and **2**).

The idea is to harvest the arterial grafts first and then the vein graft if necessary. The skin incision extends from 2 cm below the sternal notch to 1 cm above the xiphoid process. We usually dissect the xiphoid process out from both sides and its attachment below from the diaphragm using diathermy (which is at 70 coagulation and zero on the cutting—that is our setting on the diathermy). Hence the sternotomy starts by cutting the xiphoid out first and then starting the sternotomy as usual. The chest is opened as usual and the pericardium is slit longitudinally to expose the heart. The pericardium near the diaphragm is cut along the diaphragm up to the inferior vena cava (IVC). This is done after the right pleura is opened and the thymus is tied up near the superior vena cava (SVC). This helps in allowing the heart to lie freely when the heart is being positioned during grafting

It is very important to maintain strict haemostasis all through the opening of the sternum till grafting at least—as all these patients are on antiplatelet medications and/or on heparin, so any bleeding site left unattended at this stage would cause unnecessary blood loss (photo of chest opened before harvesting the mammary). Hence, if we spend time for haemostasis during opening of the chest, then the clos-

*DOI: http://dx.doi.org/10.5772/intechopen.88102*

**5. Surgical techniques in OPCAB**

**5.1 Harvesting of the conduit**

of the lateral wall vessels.

ing becomes easy and tidy.

This is to make sure that the mean blood pressure is maintained above 75 mm of Hg, all through the procedure, though this warrants a separate chapter.
