Off-pump coronary artery bypass grafting: the myth, the reality

摘要

Coronary revascularization (percutaneous coronary intervention (PCI) and coronary artery bypassgrafting (CABG)) has become the principal treatment modality in patients with severe coronary artery disease.Worldwide CABG has been performed predominantly with the use of cardiopulmonary bypass (CPB) andcardioplegic arrest, which allows optimization of the surgical field and consistent placement of grafts. However,CPB initiates a systemic inflammatory response largely determined by blood contact with foreign surfaces andthe activation of complement. It is generally accepted that CPB-induced whole-body inflammatory reactioncontributes substantially to postoperative organ dysfunction and morbidity. A surgical technique avoidingcardiopulmonary bypass should, in theory, reduce the incidence of such complications and lead to improvedpatient outcomes. This assumption has rekindled interest in performing off-pump coronary artery bypass(OPCAB) surgery, which for the past decade or so has been the focus of intense scientific scrutiny. The existingworld medical literature contains a staggering amount of research related to this technique. Although theavailable evidence from a large number of randomized clinical trials (RCTs), nonrandomized clinical trials,propensity-matched analyses, and experimental data suggests that outcomes are better after off-pump than afteron-pump CABG, skepticism still exists about the safety and efficacy of the off-pump technique. This invitedlecture attempts to provide an overview of the current outcomes of OPCAB in comparison with on-pump CABGand addresses the concerns and controversies related to OPCAB which are in part responsible for the widevariation in the adoption rates of this technique universally.