OPCABG for Full Myocardial Revascularisation How we do it 28 th SHA Conferance Dr.Farouk Oueida Head of Cardiac Surgery Dept. SBCC-Dammam KSA
The Less Invasive CABG Full Revascularisation Full Sternotomy Minimyse the CPB Adverse Effects (Minibypass) Avoid the CPB Adverse Effects (OPCAB) Endoscopic Vein Harvesting
Colessov 1964 OPCABG 37% world wide
Studies All patients Better outcome Lower Morbidity ComparableGraft Patency? Health Care Cost
J Thorac Cardiovasc Surg. Author manuscript; available in PMC 2010 March 11. J Thorac Cardiovasc Surg. 2009 February; Effects of on- and off-pump coronary artery surgery on graft patency, survival, and health-related quality of life: Long-term follow-up of 2 randomized controlled trials Gianni D. Angelini, MCh, MD, FRCS, FETCS,a Lucy Culliford, BSc, MSc, PhD,a David K. Smith, BSc, MRCP,a Mark C. K. Hamilton, MRCP, FRCR,b Gavin J. Murphy, BSc, ChB, MD, FRCS(CTh),a Raimondo Ascione, MD, MCh, FRCS, FETCS,a Andreas Baumbach, MD, FRCP, FESC,b and Barnaby C. Reeves, BA, MSc, DPhila a Bristol Heart Institute, University of Bristol, Bristol Royal Infirmary, Bristol, United Kingdom Methods: Participants in 2 randomized trials comparing off-pump coronary artery bypass and coronary artery bypass grafting with cardiopulmonary bypass were followed up for 6 to 8 years after surgical intervention to assess graft patency, major adverse cardiac-related events, and health-related quality of life. Patency was assessed by using multidetector computed tomographic coronary angiographic analysis Major adverse cardiac-related events and health-related quality of life were obtained from questionnaires given to participants and family practitioners. Results: Patency was studied in 199 and health-related quality of life was studied in 299 of 349 survivors. There was no evidence of attrition bias. The likelihood of graft occlusion was no different between off-pump coronary artery bypass (10.6%) and coronary artery bypass grafting with cardiopulmonary bypass (11.0%) groups (odds ratio, 1.00; 95% confidence interval, 0.55 1.81; P>.99). Conclusions: Long-term Graft Patency and health outcomes with off-pump coronary artery bypass are similar to those with coronary artery bypass grafting with cardiopulmonary bypass when both operations are performed by experienced surgeons
Cross-Clamp Cardioplegia CPB Adverse No Conversion No Surgeon Stress No Cross-Clamp No Cardioplegia No CPB Adverse Risk of Conversion Surgeon stress Adverse
Adverse Effects of CPB Cause Effect Hemodilution Neutrophil activation, decrease in surfactant Platelet destruction by CPB platelet aggregation Destruction by cardiopulmonary bypass Embolus formation, bypass >2 hours Cannulation, bubble oxygenator Cannulation of femoral artery Release of catecholamines (epinephrine, norepinephrine) due to hypothermia Release of tumor necrosis factor-@ Diuresis Hypothermia Glucagon release Systemic heparinization Leukocyte release Leukocyte release, microemboli activation, vasopressin release, hypothermia Fluid retention, interstitial fluid accumulati Pulmonary dysfunction Thrombocytopenia Hemoglobinemia Stroke, neurological dysfunction Air emboli Aortic dissection Hypertension Hypotension, tachycardia Hypokalemia Myocardial depression Hyperglycemia bleeding Capillary leakage Organ failure Renin- angiotensin Oliguria
Recently, there have been attempts to decrease these adverse effects (inflammatory reaction) caused by the use of CPB by developing better, more effective systems
Resting Heart or Mini By-Pass
Benefits of Resting 1- Closed System (no blood activation). 2- No Cardiotomy Suction. 3- Low Prime Circuit (reduce hemodilution). 4- Venous Air Removal Device (VARD)
New Studies should be done to find the real position of Resting Heart Technique
My personal opinion: Resting Heart should be located very close to the OPCAB
SBCC Experience First OPCABG SBCC 25/07/2003 OPCABG Today 3000 Resting Heart 350
How we do it?
Our Technique
Atrial Pacing
Mid CAB For single graft to LAD Not for multi vessel disease
The Less Invasive CABG Full Revascularisation Full Sternotomy Minimyse the CPB Adverse Effects (Minibypass) Avoid the CPB Adverse Effects (OPCAB) Endoscopic Vein Harvesting
Introduction - BITA less than 10% of CABG have multiple arterial grafts. Increase the trend of total arterial revascularization. In 10 yrs : 95% LITA / LAD patent 50% SV occlusion / stenosis 20% SV early occlusion in 1 year Tatoulis, Ann Cardiothorac Surg, 2013;2(4):499-506
BITA 2 ITAs better than 1 at 10 yrs Survival is superior - 90% Fewer recurrent cardiac event Rate of reoperation - 50% Long term patency Lytle et al, Circulation, 2001 Taggart et al, Euro Heart Journal, 2010 Pevni et al, Ann Thorac Surg, 2016
SBCC Experience 2013-2016 653 CABG with ITAs 325 SITA ± SV (49.8%) 328 BITA ± SV (50.2%)
SBCC BITA 80% 70% 60% 50% 40% SITA BITA 30% 20% 10% 0% 2013 2014 2015 2016
BITA Configurations in SBCC 1- (LL/RL) LITA-LAD with In situ RITA to Left Coronary Tree 2- (RL/LL) RITA-LAD with In situ LITA to Left Coronary Tree 3- (Y-graft) LITA-LAD with Free RITA based on LITA 4- (LL/RR) LITA-LAD with In situ RITA to Right Coronary Tree
Our Technique
OPCAB Ygraft
Pre Op Angio Bilateral Mammary
LIMA to LAD
RIMA to RCA
Improve Mammary lenghth
Improve RIMA lenghth
Improve RIMA lenghth
Resting Heart
RIMA to LAD (post op angio)
RIMA to Diag( post op Angio)
RIMA to OM (post op angio)
Y Graft (post op angio)
LAD Endartrectomy
Resting Heart for Impaired LV Function 32 cases of resting heart for severely impaired left ventricle
Table (1): Preoperative demographic and laboratory results.
Table (2): Operative data of the patients. CABG: Coronary arteries bypass grafting CPB: Cardio-pulmonary bypass. Min: minute.
Table (3): Clinical outcome and Postoperative laboratory results. SD: standard deviation; ICU: intensive care Unit; FFP: fresh frozen Plasma; PRBCS: packed red blood cells.
My personal opinion: Resting Heart should be located very close to the OPCAB
Leg Wound The main patient Complain
Endoscopic Vein Harvesting
Vasoview System
EVH Flow Sheet
EVH INDICATOR FROM 16/3/2013 TO 6/2/2014 %6 %15 %79 EVH EVH + Open Open
EVH 1
EVH 2
EVH 3
Never compromise Myocardial Full Revascularization for Esthetics. The main patient complain post CABG is from the leg wound. Mid-CAB only for LIMA to LAD+ More BITA for better long term The real Minimal invasive CABG? 1 - Minimize or avoid the Adverse effects of CPB by Resting Heart or OPCAB. 2 - Avoid the complications of the Conventional Saphenous Vein Harvesting By EVH Technique