OPCAB technique (without using a heart-lung machine)

The advantages of and indications for the off-pump coronary artery bypass (OPCAB) technique are that this operation technique is less invasive. A single-vessel bypass operation is today performed in most centres as an off-pump procedure without a heart-lung machine. The heart or the coronary artery is kept still locally with a suction cup or special holders (Octopus stabiliser) and the IMA and vein bypass grafts are then anastomosed (see illustration).

During revascularisation of the posterior wall of the beating heart, a device to expose the posterior wall of the heart is required in addition to stabilisation of the operating field with the Octopus. In our clinic, we use the Starfish Heart Positioner (Medtronic GmbH, Düsseldorf). The Starfish is positioned at the apex of the heart and attached by suction. The heart can then be lifted out of its pericardial bed without greatly interfering with haemodynamics so that the posterior wall of the heart and especially the region of the circumflex artery can be managed with bypasses.

Complete multiple coronary revascularisation of the heart is performed with these systems in both of our clinics (especially in the Augustinum Cardiac Clinic). Minimally invasive surgery offers considerable advantages in certain high-risk groups such as patients who are having coronary bypass re-operation. By forgoing ECC, the usually highly adherent heart does not have to be completely exposed and the aforementioned risk factors of ECC are thus minimised. A study at our clinic that compared coronary re-operation with and without the use of ECC showed a significantly shorter stay in the intensive care unit and less myocardial damage in the "off-pump" group.

Another area of use is the combination of an interventional catheter procedure (PTCA and/or stent insertion) and a minimally invasive heart operation, known as a hybrid procedure. This can be indicated for elderly patients with pronounced multimorbidity. The high risk for this group of patients of a long operation for multivessel disease using ECC is reduced considerably. The anterior coronary arteries are first operated minimally invasively and then in a second session the cardiologist dilates the remaining stenoses or inserts a stent. In future, this will also be done simultaneously by the cardiac surgeon and cardiologist in a hybrid procedure.