Dr Kaushalendra Rathore MCh FRACS
Cardiothoracic Surgeon
JJ group of Cardiothoracic Surgery
Coronary Artery Bypass Grafting: Different ways to achieve best outcomes, but which is “the best” ?

Coronary Artery Bypass (CABG) surgery has been around since last 3-4 decades and surgeons have seen improved results with the time1. But simultaneous improvement in the Per-Cutaneous Interventions (PCI), cases with lesser disease are referred for the stenting (DES) and surgeons are getting difficult cases with multiple co-morbidities2.

• Two established methods to perform CABG surgery are OFF PUMP (OPCABG) or beating heart surgery and ON Pump or surgery by stopping the heart and various surgeons choose these techniques depending on their experience and technical dexterity. OPCABG surgery is associated with early recovery and better mid-term outcomes but requires experience to achieve good results as it is highly operator dependent3.

• OPCABG surgery is performed with the help of pneumatic suctions stabilisers ( Octopus, Starfish, or other commercially available devices) and coronary arteries lumen is kept open with the help of intra-coronary shunts (Figure 1).

There are basically six key areas to higher achievement. Some people will tell you there are four while others may tell you there are eight. One thing for certain though, is that irrespective of the number of steps the experts talk about, they all originate from the same roots.

• OPCABG surgery for single or double vessel blocks can be performed with a small incision from the left chest and it is known as Minimally Invasive CABG surgery or MIDCABG (Figure 2). Cardiac surgery is not performed solely for the cosmetic reasons as heart surgery is done with one big goal of saving patients life and achieving good long-term outcomes, but if it can be done with smaller cut then should be encouraged.

• Various conduits can be used to perform the OPCABG surgery and arterial grafts give better long-term patency (Figure 3) but require other factors to be considered before using them. Most common arterial grafts are internal mammary arteries and radial arteries.

• During OPCABG surgery heart is mobilized with the stabilisers in the different positions to graft various territories (Figure 4). OPCABG is better in high-risk cases, calcified aorta, elderly patients with multiple co-morbidities4.


• Why OPCABG surgery: CABG surgery done with the use of LIMA grafts gives survival benefits and very long-term follow-up is far better than medical management or multiple stenting2.
• Does this surgery have any risk? Any intervention be it CABG of stenting has its own risk and benefits. With increasing experience mortality and morbidity is coming down and in routine cases it is 1% in the experienced hands.
• What to expect after discharge from the hospital: OPCABG surgery is a major surgery and takes 6-8 weeks to recover, but this recovery is faster compared to the On-pump CABG. 2-5% patients might require readmission after the surgery and main reasons of readmission are: lung infection, lung collapse and fluid collection, sternal bone instability, atrial arrythmias, wound infection and failure of proper rehabilitation.

Reference: 1. Mostad et al. Long-term survival after coronary bypass surgery and percutaneous coronary interventions. BMJ.DOI: http://dx.doi.org/10.1136/openhrt-2016-000489.
2. Serruys et al. Clinical outcomes of state-of-the-art percutaneous coronary revascularisation in patients with three-vessel disease: two-year follow-up of the SYNTAX II study. EuroIntervention 2019;15 e244-e252.
3. Davierwala et al. Current outcomes of off-pump coronary artery bypass grafting: evidence from real world practice. J Thoracic Diseases. DOI: 10.21037/jtd.2016.10.102.
4. Guida et al. Off-pump coronary artery bypass grafting in high-risk patients: a review.. J Thorac Dis. 2016 Nov; 8(Suppl 10): S795–S798.