Leading expert in cardiac surgery, Dr. Jürgen Ennker, MD, explains the benefits and risks of off-pump coronary artery bypass graft (CABG) surgery compared to the traditional on-pump method. Off-pump CABG, performed on a beating heart, eliminates the need for a heart-lung machine, reducing the risk of stroke and neurological complications. Dr. Ennker discusses the advantages of this technique, particularly for patients with renal or pulmonary diseases, and emphasizes the importance of surgical expertise in achieving optimal outcomes.
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Off-Pump Coronary Artery Bypass Grafting: Benefits and Risks
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- Off-Pump Heart Surgery: An Overview
- Advantages of Off-Pump CABG
- Reducing Stroke Risk in CABG
- Importance of Surgical Expertise
- Patient Outcomes and Safety
- Full Transcript
Off-Pump Heart Surgery: An Overview
Dr. Jürgen Ennker, MD, describes the evolution of off-pump heart surgery, which began in the 1990s in South America and later spread to North America and Europe. This technique, known as OPCAB, allows surgeons to perform coronary artery bypass grafting on a beating heart without using a heart-lung machine. The procedure involves grafting all three coronary vessels while the heart continues to beat, avoiding the complications associated with the heart-lung machine.
Advantages of Off-Pump CABG
Off-pump CABG offers significant advantages, particularly for patients with renal or pulmonary diseases. Dr. Ennker highlights that avoiding the heart-lung machine reduces the risk of cerebral edema and mental deficiencies. Patients undergoing off-pump CABG often experience a quicker recovery, similar to that of an appendectomy, without the neurological side effects associated with traditional on-pump surgery.
Reducing Stroke Risk in CABG
Dr. Ennker emphasizes the reduced risk of stroke with off-pump CABG due to the "aortic no-touch" technique. By avoiding aortic manipulation, the risk of embolism and subsequent cerebral infarction is minimized. This approach, combined with the resection of the left atrium to prevent embolism from atrial fibrillation, significantly lowers the incidence of stroke in patients undergoing this procedure.
Importance of Surgical Expertise
Dr. Jürgen Ennker, MD, stresses the critical role of surgical expertise in the success of off-pump CABG. The procedure requires precise technique and experience to ensure the patency and functionality of arterial grafts. Advanced tools and techniques, such as measuring blood flow and graft patency, help surgeons achieve optimal outcomes and enhance patient safety.
Patient Outcomes and Safety
Off-pump CABG is associated with improved patient outcomes, particularly for those with severe comorbidities. Dr. Ennker notes that maintaining blood pressure and heart function during surgery provides real-time feedback, ensuring the safety and effectiveness of the procedure. Patients benefit from reduced neurological complications and a faster recovery, making off-pump CABG a valuable option for high-risk individuals.
Full Transcript
Dr. Anton Titov, MD: You have performed tens of thousands of procedures. You have a particular interest in off-pump coronary artery bypass graft surgery. This is a surgery on a beating heart. It's more demanding from the surgeon technically, but off-pump coronary artery bypass graft surgery has advantages for patients. Please compare the risks and benefits of off-pump coronary artery bypass graft surgery and on-pump coronary artery bypass graft surgery. It is the classical technique of surgical operation. Tell us about your experience with this advanced technique of coronary artery bypass grafting.
Dr. Jürgen Ennker, MD: The off-pump heart surgery was introduced in the 1990s in South America. It came to developed countries in North America and Europe with the so-called MIDCAB operation. This is a small incision on the lateral chest to do a revascularization of the left anterior descending artery. From this so-called OPCAB procedure, an off-pump coronary artery beating heart procedure was developed. You can graft all three vessels on the beating heart.
The advantage is that you don't need the heart-lung machine. This is what the "off-pump" name says. Because you have to cannulate the aorta to use the heart-lung machine, this may lead to a dislodgement of debris of aortic plaque. This may lead to embolism, which in turn may lead to a cerebral infarction. Coronary artery patients were analyzed in the SYNTAX clinical trial. The brain stroke rate was 2.2%.
Dr. Jürgen Ennker, MD: But you can use the off-pump heart surgery technique. You can do that with the so-called T-graft. You implant the LIMA to the LAD. Then a second graft is implanted into the LIMA. This is done with the so-called aortic no-touch technique. You don't perform an aortic anastomosis. You have zero strokes. You have absolutely no cerebral infarction generated by the heart surgery. It's a huge deal!
We can decrease the risk of stroke with off-pump coronary artery bypass graft surgery. We will talk about that in a second. It is a very big deal! Yes! I'm doing off-pump coronary artery bypass graft surgery. I'm always resecting the left atrium of the heart. Because 90% of embolism from the left heart comes from the left atrium.
Because in atrial fibrillation, we have a thrombus formation. Sometimes the patient gets back into the sinus rhythm. Then the thrombus is ejected. You have brain embolism (stroke). When you resect the left heart atrium, you are eliminating the risk of brain stroke as well. So, this is another point. No aortic touch, resection of the left atrium, and then you have two major risk factors eliminated. This may lead to cerebral strokes and other neurological complications.
The off-pump procedure has many advantages. They are related not only to a neurologic outcome. It can be done in patients with major deficiencies. You can do off-pump coronary artery bypass graft surgery on patients with renal disease, with pulmonary disease. The avoidance of the heart-lung machine leads to a substantial advantage. This has been proven by literature.
Dr. Anton Titov, MD: Of course, you need an experienced cardiac surgeon. The surgical technique has to be adequate. But we have several tools nowadays. We are measuring the blood flow in the artery graft. We are measuring the patency of the arterial graft and the flow in it. You can exactly say that this arterial graft is patent.
The literature says that 10 to 15% of the coronary artery anastomosis have technical defects. You can detect problems in arterial anastomosis immediately. It does not happen later in the intensive care via ECG or cardiac enzymes. This is a big step towards patient safety.
Dr. Jürgen Ennker, MD: OPCAB surgery always maintains the blood pressure. You have the running ECG. You have the contracting heart. These are also parameters to tell you that you're on the safe side. You can be confident that your anastomosis is technically adequate. You can have confidence that the patient is going to do well in the long run.
So, you have feedback from the patient's body, from the heart, during that duration. This is also a significant advantage. That's exactly the point. The patients wake up in the same condition as after appendectomy. After heart-lung machine use in coronary bypass graft surgery, patients are sent into a CT scan. Doctors see a cerebral edema that lasts for some period of time. You have mental deficiencies caused by the heart-lung machine. All these are detrimental factors for the patient.
You don't have these brain swelling problems with OPCAB surgery. So it's a big step ahead. Off-pump CABG has major advantages for severely ill patients. Off-pump coronary artery bypass graft surgery is better for patients with neurological deficits. Those are the advantages. Patients profit very much from OPCAB surgery. But the key factor is a surgeon.
Dr. Anton Titov, MD: The surgeon is the most important prognostic factor for the patient. There are also patient-related surgery risk factors, of course.