**5. Coronary artery bypass grafting without cardiopulmonary bypass**

Cardiopulmonary bypass is still the most common technique used for coronary artery bypass grafting procedures. Offpump coronary artery bypass (OPCAB) grafting, being the major improvement in cardiac surgeries, is performed at a rate of 20-30%. Despite the lack of definitive literature, its safety and efficacy in providing improvement in several outcomes have been proven, especially in high-risk patients with co-morbidities associated with higher mortality and morbidity from CPB (e.g. cerebrovascular and renal disease), avoiding the adverse effects of cannulation and CPB including hypothermia, risk of rewarming, coagulation abnormalities, renal impairment, arrhtyhmias, manipulation and crossclamping of the ascending aorta (which increases the risk of aortic dissection/ neurologic sequelae) and prolonged postoperative ventilation. These procedures shorten the duration of the procedure, lenght of stay in ICU and hospital, and possibly decrease the cost (London et al,2008; Barnes, 2002b).

OP-CAB or minimally invasive direct CAB (MIDCAB) are the alternatives to be used in order to avoid CPB. In these settings the anesthetists encounters more surgeon-induced hemodynamic changes when it is compared to routine CABG; having a major role for anticipating and communicating with the surgeon about the adverse events that occur during surgical manipulation. The operation on the beating heart may be more prone to develop arrhtyhmias because of ischemia, manipulation and reperfusion. Antiarrhtyhmics, asking the surgeon to temporarily stop manipulation and treating severe bradycardia pharmacologically or with epicardial or transvenous pacing are the main strategies. During the exposure of the arteries, the heart is lifted and rotated, when the heart is repositioned venous return will be compromised leading to a decrease in preload reducing the cardiac output. Fluid resuscitation, inotropic medications and peripheral vasoconstrictors may be required. Maintenance of adequate coronary perfusion is provided by the maintenance of the mean blood pressure close to baseline. In OP-CAB for the proximal anastamoses a sidebiting C-clamp is placed on the aorta providing that the blood pressure is lowered. Nitroglycerin and nitroprusside can be used for this purpose (Barnes,2002b). With a skilled surgeon, the changes are modest and can be managed by using simply the Trandelenburg position, inotropes and vasoconstrictors, however severe changes associated with acute ischemia, mitral regurgitation or unrecognized right ventricular compression necessiate emergent conversion to CPB (London et al,2008).

A large bore cannulae should be in place, cross-matched blood should be readily available and CPB circuit should be set up with a perfusionist on standby. In MIDCAB method, since the access to the heart is limited, external defibrillator and pacing pads should be ready during the operation (Barnes,2002b). Although there is no definitive type of monitoring described, most observational studies have used extensive monitoring including PAC and TEE. However, as the practice improves, particularly for the low-risk patients the recommended type of monitoring will probably become less sofisticated (London et al,2008).

#### **6. References**

44 Perioperative Considerations in Cardiac Surgery

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The rules of myocardial protection during ischemia and reperfusion, indirectly protect the lungs from several proinflammatory factors produced during the process (Apostolakis et

Cardiopulmonary bypass is still the most common technique used for coronary artery bypass grafting procedures. Offpump coronary artery bypass (OPCAB) grafting, being the major improvement in cardiac surgeries, is performed at a rate of 20-30%. Despite the lack of definitive literature, its safety and efficacy in providing improvement in several outcomes have been proven, especially in high-risk patients with co-morbidities associated with higher mortality and morbidity from CPB (e.g. cerebrovascular and renal disease), avoiding the adverse effects of cannulation and CPB including hypothermia, risk of rewarming, coagulation abnormalities, renal impairment, arrhtyhmias, manipulation and crossclamping of the ascending aorta (which increases the risk of aortic dissection/ neurologic sequelae) and prolonged postoperative ventilation. These procedures shorten the duration of the procedure, lenght of stay in ICU and hospital, and possibly decrease the cost (London

OP-CAB or minimally invasive direct CAB (MIDCAB) are the alternatives to be used in order to avoid CPB. In these settings the anesthetists encounters more surgeon-induced hemodynamic changes when it is compared to routine CABG; having a major role for anticipating and communicating with the surgeon about the adverse events that occur during surgical manipulation. The operation on the beating heart may be more prone to develop arrhtyhmias because of ischemia, manipulation and reperfusion. Antiarrhtyhmics, asking the surgeon to temporarily stop manipulation and treating severe bradycardia pharmacologically or with epicardial or transvenous pacing are the main strategies. During the exposure of the arteries, the heart is lifted and rotated, when the heart is repositioned venous return will be compromised leading to a decrease in preload reducing the cardiac output. Fluid resuscitation, inotropic medications and peripheral vasoconstrictors may be required. Maintenance of adequate coronary perfusion is provided by the maintenance of the mean blood pressure close to baseline. In OP-CAB for the proximal anastamoses a sidebiting C-clamp is placed on the aorta providing that the blood pressure is lowered. Nitroglycerin and nitroprusside can be used for this purpose (Barnes,2002b). With a skilled surgeon, the changes are modest and can be managed by using simply the Trandelenburg position, inotropes and vasoconstrictors, however severe changes associated with acute ischemia, mitral regurgitation or unrecognized right ventricular compression necessiate

A large bore cannulae should be in place, cross-matched blood should be readily available and CPB circuit should be set up with a perfusionist on standby. In MIDCAB method, since the access to the heart is limited, external defibrillator and pacing pads should be ready during the operation (Barnes,2002b). Although there is no definitive type of monitoring described, most observational studies have used extensive monitoring including PAC and TEE. However, as the practice improves, particularly for the low-risk patients the recommended type of monitoring will probably become less sofisticated (London et al,2008).

**5. Coronary artery bypass grafting without cardiopulmonary bypass** 

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