General Thoracic and Cardiovascular Surgery

, Volume 61, Issue 8, pp 429–434 | Cite as

Off-pump coronary artery bypass: techniques, pitfalls, and results

  • Tadashi TashiroEmail author
  • Hideichi Wada
  • Masaru Nishimi
  • Noritoshi Minematsu
Current Topics Review Article


In coronary artery bypass grafting (CABG), coronary artery anastomosis is generally performed under cardiac arrest using cardiopulmonary bypass (CPB). To avoid the invasiveness of CPB, off-pump coronary artery bypass (OPCAB) is currently also used. In Japan, in particular, OPCAB now accounts for 60 % of all CABG operations and has become a standard surgical procedure. We herein provide a discussion of OPCAB. The goals of coronary artery bypass surgery are to achieve complete revascularization and maintain a high rate of graft patency for the long term. This requires stable exposure of the coronary arteries, including those located on the posterior surface of the heart and the formation of good-quality anastomoses. Achieving this depends not only on the competency of the individual surgeon, but also on smooth and effective teamwork among everyone involved, including the other surgeons, anesthetists, clinical technicians, and nurses. It is important for surgeons and surgical teams to examine their own outcomes and engage in self-scrutiny in an endeavor to improve these outcomes.


Off-pump coronary artery bypass OPCAB Techniques Pitfalls Results 


  1. 1.
    Kuwano H, Amano J, Yokomise H. Thoracic and cardiovascular surgery in Japan during 2010, Annual report by The Japanese Association for Thoracic Surgery. Gen Thorac Cardiovasc Surg. 2012;60:680–708.CrossRefGoogle Scholar
  2. 2.
    Goetz RG, Rohman M, Haller JD, et al. Internal mammary—coronary anastomosis. A nonsuture method employing rings. J Thorac Cardiovasc Surg. 1961;41:378–86.PubMedGoogle Scholar
  3. 3.
    Kolesov VI. Mammary artery—coronary artery anastomosis as a method of treatment of angina pectoris. J Thorac Cardiovasc Surg. 1967;54:535–44.Google Scholar
  4. 4.
    Favaloro RG. Saphenous vein autograft replacement of severe segmental coronary artery occlusion. Operative technique. Ann Thorac Surg. 1968;5:334–9.CrossRefGoogle Scholar
  5. 5.
    Sezai Y, Yamazaki A, Inoue H, Ogawa H, Sakai H, Hanaoka K, Sekeiguchi H. Direct coronary artery operation. Kyoubugeka. 1970;23(888–89):7.Google Scholar
  6. 6.
    Benetti FJ. Direct coronary surgery with saphenous vein bypass without either cardiopulmonary bypass or cardiac arrest. J Cardiovasc Surg (Torino). 1985;26:217–22.Google Scholar
  7. 7.
    Buffolo E, Andrade JC, Succi J, Leao LE, Gallucci C. Direct myocardial revascularization without cardiopulmonary bypass. Thorac Cardiovasc Surg. 1985;33:26–9.CrossRefGoogle Scholar
  8. 8.
    Benetti FJ, Naselli G, Wood M, Geffner L. Direct myocardial revascularization without extracorporeal circulation. Experience in 700 patients. Chest. 1991;100:312–6.CrossRefGoogle Scholar
  9. 9.
    Tashiro T, Todo K, Haruta Y, et al. Coronary artery bypass grafting surgery without cardiopulmonary bypass. J Jpn Assoc Thorac Surg. 1993;41:598–602.Google Scholar
  10. 10.
    Tashiro T, Todo T, Haruta Y, Tachikawa Y. Coronary artery bypass grafting without cardiopulmonary bypass for high-risk patients. Cardiovasc Surg. 1996;4:207–11.CrossRefGoogle Scholar
  11. 11.
    Tashiro T, Nakamura K, Morishige N, Iwakuma A, Tachikawa Y, Shibano R, Iwahashi H, Zaitsu R, Hayashida Y, Koga S, Takeuchi K, Kimura M. Off-pump coronary artery bypass grafting in patients with end-stage renal disease on hemodialysis. J Card Surg. 2002;17(5):377–82.CrossRefGoogle Scholar
  12. 12.
    Bull DA, Neumayer LA, Stringham JC, Meldrum P, Affleck DG, Karwande SV. Coronary artery bypass grafting with cardiopulmonary bypass versus off pump cardiopulmonary bypass grafting: does eliminating the pump reduce morbidity and cost? Ann Thorac Surg. 2001;71:170–5.CrossRefGoogle Scholar
  13. 13.
    Ascione R, Williams S, Lloyd CT, Sundaramoorthi T, Pitsis AA, Angelini GD. Reduced postoperative blood loss and transfusion requirement after beating-heart coronary operations: a prospective randomized study. J Thorac Cardiovasc Surg. 2001;121:689–96.CrossRefGoogle Scholar
  14. 14.
    Bergsland J, Karamanoukian HL, Soltoski PR, Salerno TA. “Single suture” for circumflex exposure in off-pump coronary artery bypass grafting. Ann Thorac Surg. 1999;68(4):1428–30.CrossRefGoogle Scholar
  15. 15.
    Chang W, Kim K, Kim JH, Ham BM, Kim YL. Hemodynamic changes during posterior vessel off-pump coronary artery bypass: comparison between deep pericardial sutures and vacuum-assisted apical suction device. Ann Thorac Surg. 2004;78:2057–62.CrossRefGoogle Scholar
  16. 16.
    Edgerton JR, Dewey TM, Magee MJ, Herbert MA, Prince SL, Jones KK, et al. Conversion in off-pump coronary artery bypass grafting: an analysis of predictors and outcomes. Ann Thorac Surg. 2003;76:1138–43.CrossRefGoogle Scholar
  17. 17.
    Reeves BC, Ascione R, Caputo M, Angelini GD. Morbidity and mortality following acute conversion from off-pump to on-pump coronary surgery. Eur J Cardiothorac Surg. 2006;29:941–7.CrossRefGoogle Scholar
  18. 18.
    Mukherjee D, Ahmed K, Baig K, Patel VM, Darzi A, Athanasiou T. Conversion and safety in off-pump coronary artery bypass: a system failure that needs re-emphasis. Ann Thorac Surg. 2011;91:630–9.CrossRefGoogle Scholar
  19. 19.
    Chowdhury R, White D, Kilgo P, Puskas JD, Thourani VH, Chen EM, Lattouf OM, Cooper WA, Myung RJ, Guyton RA, Halkos ME. Risk factors for conversion to cardiopulmonary bypass during off-pump coronary artery bypass surgery. Ann Thorac Surg. 2012;93:1936–42.CrossRefGoogle Scholar
  20. 20.
    Mishra M, Malhotra R, Mishra A, Meharwal ZS, Trehan N. Hemodynamic changes during displacement of the beating heart using epicardial stabilization for off-pump coronary artery bypass graft surgery. J Cardiothorac Vasc Anesth. 2002;16:685–90.CrossRefGoogle Scholar
  21. 21.
    Mueller XM, Chassot PG, Zhou J, Eisa KM, Chappuis C, Tevaearai HT, Segesser LK. Hemodynamics optimization during off-pump coronary artery bypass: the “no compression” technique. Eur J Cardiothorac Surg. 2002;22:249–54.CrossRefGoogle Scholar
  22. 22.
    Novitzky D, Boswell BB. Total myocardial revascularization without cardiopulmonary bypass utilizing computer-processed monitoring to assess cerebral perfusion. Heart Surg Forum. 2003;3(3):198–202.Google Scholar
  23. 23.
    Guizilini S, Gomes WJ, Faresin SM, Bolzan DW, Buffolo E, Carvalho AC, De Paola AV. Influence of pleurotomy on pulmonary function after off-pump coronary artery bypass grafting. Ann Thorac Surg. 2007;84:817–22.CrossRefGoogle Scholar
  24. 24.
    Rivetti LA, Gandra SM. Initial experience using an intraluminal shunt during revascularization of the beating heart. Ann Thorac Surg. 1997;63:1742–7.CrossRefGoogle Scholar
  25. 25.
    Bergsland J, Lingaas PS, Skulstad H, Hol PK, Halvorsen PS, Andersen R, Småstuen M, Lundblad R, Svennevig J, Andersen K, Fosse E. Intracoronary shunt prevents ischemia in off-pump coronary artery bypass surgery. Ann Thorac Surg. 2009;87:54–61.CrossRefGoogle Scholar
  26. 26.
    Letsou GV, Grunkemeier GL, Salaskar AL, Bavare C, Wu Y, Rampurwala MM. Selective left anterior descending shunting provides effective off-pump myocardial protection. Ann Thorac Surg. 2010;89:24–9.CrossRefGoogle Scholar
  27. 27.
    Mathison M, Edgerton JR, Horswell JL, Akin JJ, Mack MJ. Analysis of hemodynamic changes during beating heart surgical procedures. Ann Thorac Surg. 2000;70:1355–61.CrossRefGoogle Scholar
  28. 28.
    Do Q, Goyer C, Chavanon O, Couture P, Denault A, Cartier R. Hemodynamic changes during off-pump CABG surgery. Eur J Cardiothorac Surg. 2002;21:385–90.CrossRefGoogle Scholar
  29. 29.
    Virmani S, Tempe DK. Anaesthesia for off-pump coronary artery surgery. Ann Card Anaesth. 2007;10:65–71.CrossRefGoogle Scholar
  30. 30.
    Chassot PG, Linden P, Zaugg M, Mueller XM, Spahn DR. Off-pump coronary artery bypass surgery: physiology and anaesthetic management. Br J Anaesth. 2004;92:400–13.CrossRefGoogle Scholar
  31. 31.
  32. 32.
    Etienne PY, Papadatos S, Glineur D, Mairy Y, Khoury EE, Noirhomme P, Khoury GE. Reduced mortality in high-risk coronary patients operated off pump with preoperative intraaortic balloon counterpulsation. Ann Thorac Surg. 2007;84:498–503.CrossRefGoogle Scholar
  33. 33.
    Mannacio V, Tommaso L, De Amicis V, Stassano V, Musumeci F, Vosa C. Preoperative intraaortic balloon pump for off-pump coronary arterial revascularization. Ann Thorac Surg. 2012;93:804–9.CrossRefGoogle Scholar
  34. 34.
    Parolari A, Alamanni F, Cannata A, Naliato M, Bonati L, Rubini P, Veglia F, Tremoli E, Biglioli P. Off-pump versus on-pump coronary artery bypass: meta-analysis of currently available randomized trials. Ann Thorac Surg. 2003;76:37–40.CrossRefGoogle Scholar
  35. 35.
    Parolari A, Alamanni F, Polvani G, Agrifoglio M, Chen YB, Kassem S, Veglia F, Tremoli E, Biglioli P. Meta-analysis of randomized trials comparing off-pump with on-pump coronary artery bypass graft patency. Ann Thorac Surg. 2005;80:2121–5.CrossRefGoogle Scholar
  36. 36.
    Puskas JD, Williams WH, Duke PG, Staples JR, Glas KE, Marshall JJ, Leimbach M, Huber P, Garas S, Sammons BH, McCall SA, Petersen RJ, Bailey DE, Chu H, Mahoney EM, Weintraub WS, Guyton RA. Off-pump coronary artery bypass grafting provides complete revascularization with reduced myocardial injury, transfusion requirements, and length of stay: a prospective randomized comparison of two hundred unselected patients undergoing off-pump versus conventional coronary artery bypass grafting. J Thorac Cardiovasc Surg. 2003;125:797–808.CrossRefGoogle Scholar
  37. 37.
    Puskas JD, Williams WH, Mahoney EM, Huber PR, Block PC, Duke PG, Staples JR, Glas KE, Marshall JJ, Leimbach ME, McCall SA, Petersen RJ, Bailey DE, Weintraub WS, Guyton RA. Off-pump vs conventional coronary artery bypass grafting: early and 1-year graft patency, cost, and quality-of-life outcomes: a randomized trial. JAMA. 2004;291:1841–9.CrossRefGoogle Scholar
  38. 38.
    Khan NE, De Souza A, Mister R, Flather M, Clague J, Davies S, Collins P, Wang D, Sigwart U, Pepper J. A randomized comparison of off-pump and on-pump multivessel coronary-artery bypass surgery. N Engl J Med. 2004;350:21–8.CrossRefGoogle Scholar
  39. 39.
    Gerola LR, Buffolo E, Jasbik W, Botelho B, Bosco J, Brasil LA, Branco JN. Off-pump versus on-pump myocardial revascularization in low-risk patients with one or two vessel disease: perioperative results in a multicenter randomized controlled trial. Ann Thorac Surg. 2004;77(2):569–73.CrossRefGoogle Scholar
  40. 40.
    Shroyer AL, Grover FL, Hattler B, Collins JF, McDonald GO, Kozora E, Lucke JC, Baltz JH, Novitzky D, for the Veterans Affairs Randomized On/Off Bypass (ROOBY) Study Group. On-pump versus off-pump coronary-artery bypass surgery. N Engl J Med. 2009;361:1827–37.CrossRefGoogle Scholar
  41. 41.
    Kobayashi J, Tashiro T, Ochi M, Yaku H, Watanabe G, Satoh T, Tagusari O, Nakajima H, Kitamura S, for the Japanese off-pump coronary revascularization investigation (JOCRI) study group. Early outcome of a randomized comparison of off-pump and on-pump multiple arterial coronary revascularization. Circulation. 2005;112(suppl-I):I-338–43.Google Scholar
  42. 42.
    Angelini GD, Culliford L, Smith DK, Hamilton MK, Murphy GJ, Ascione R, Baumbach A, Reeves BC. 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. J Thorac Cardiovasc Surg. 2009;137:295–303.CrossRefGoogle Scholar
  43. 43.
    Racz MJ, Hannan EL, Isom OW, Subramanian VA, Jones RH, Gold JP, Ryan TJ, Hartman A, Culliford AT, Bennett E, Lancey RA, Rose EA. A comparison of short- and long-term outcomes after off-pump and on-pump coronary artery bypass graft surgery with sternotomy. J Am Coll Cardiol. 2004;43:557–64.CrossRefGoogle Scholar
  44. 44.
    Mack MJ, Pfister A, Bachand D, Emery R, Magee MJ, Connolly M, Subramanian VA. Comparison of coronary bypass surgery with and without cardiopulmonary bypass in patients with multivessel disease. J Thorac Cardiovasc Surg. 2004;127:167–73.CrossRefGoogle Scholar
  45. 45.
    Sabik JF, Blackstone EH, Lytle BW, Houghtaling PL, Gillinov AM, Cosgrove DM. Equivalent midterm outcomes after off-pump and on-pump coronary surgery. J Thorac Cardiovasc Surg. 2004;127:142–8.CrossRefGoogle Scholar
  46. 46.
    Puskas JD, Thourani VH, Kilgo P, Cooper W, Vassiliades T, Vega JD, Morris J, Chen E, Schmotzer BJ, Guyton RA, Lattouf OM. Off-pump coronary artery bypass disproportionately benefits high-risk patients. Ann Thorac Surg. 2009;88:1142–7.CrossRefGoogle Scholar
  47. 47.
    Puskas JD, Mack MJ, Smith CR. On-pump versus off-pump CABG. N Engl J Med. 2010;362:851.CrossRefGoogle Scholar

Copyright information

© The Japanese Association for Thoracic Surgery 2013

Authors and Affiliations

  • Tadashi Tashiro
    • 1
    Email author
  • Hideichi Wada
    • 1
  • Masaru Nishimi
    • 1
  • Noritoshi Minematsu
    • 1
  1. 1.Department of Cardiovascular SurgeryFukuoka University School of MedicineFukuokaJapan

Personalised recommendations