Anaesthesia for off-pump coronary
artery surgery
Key points
Recent surgical advances have
made it possible for multiple
grafts in all coronary
territories.
The major anaesthetic
challenge is the maintenance
of haemodynamic stability
during enucleation of the
heart.
Proven benefits of off-pump
coronary artery bypass
(OPCAB) include a reduction
in requirement for blood and
blood products.
OPCAB may be of more
benefit to high risk rather than
low risk patient.
Good communication
between surgeon and
anaesthetist is vital for a
successful outcome.
David A Hett FRCA
Consultant Cardiac Anaesthetist
Anaesthetic Department
Southampton General Hospital
Tremona Road
Southampton SO16 6YD
UK
Tel: 02380 777222
Fax: 1489 557158
E-mail: hetts@msn.com
(for correspondence)
60
David A Hett FRCA
Off-pump coronary artery surgery was first
developed in the 1960s. The subsequent intro-
duction of cardiopulmonary bypass (CPB)
with bubble oxygenators and cardioplegia
resulted in CPB becoming the preferred tech-
nique for coronary artery bypass grafting.
Renewed interest in off-pump surgery occurred
in the 1980s, especially in centres with limited
resources. More recently, the rationale for
avoiding CPB in favour of off-pump coronary
artery bypass (OPCAB), has been the avoid-
ance of the complications of CPB including
systemic inflammatory response, coagulopa-
thies associated with platelet dysfunction,
accelerated fibrinolysis and consumption of
clotting factors, neurological injury and renal
impairment. With the improvement of surgical
techniques and the development of cardiac
stabilizing retractors, OPCAB has become an
established procedure.
Two surgical techniques have been
developed. Minimally invasive direct access
coronary artery bypass involves a left internal
mammary artery anastomosis to the left ante-
rior descending branch of the left coronary
artery through a small anterior left thoracot-
omy. The obvious disadvantage of this tech-
nique is that it only allows a single graft;
therefore, it is rarely used. This paper focuses
on the second technique via a conventional
mid sternotomy approach through which
multiple grafts can be carried out on a beating
heart i.e. OPCAB.
Operative technique
The key to successful OPCAB surgery is
effective local cardiac wall stabilization to
allow anastomotic suturing. Stabilizers placed
on the epicardium over the planned site
of arteriotomy reduce cardiac motion. The
Octopus stabilization system (Medtronic Inc.,
Minneapolis, USA), which consists of two
paddles with suction domes, has the advantage
over other devices of lifting the anastomotic
site, as opposed to depressing the site, thereby
impairing ventricular filling (Fig. 1). Cardiac
displacement allows the exposure of posterior,
Continuing Education in Anaesthesia, Critical Care & Pain | Volume 6 Number 2 2006
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lateral and inferior targets and can be achieved
either by the placement of deep pericardial
retraction sutures or the use of a stockinet
sutured into the oblique sinus. Traction on
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the sutures or stockinet rotates and vertically
displaces the heart out of the pericardial sac,
allowing surgical access to distal coronary
arteries.
Bleeding from the arteriotomy site during
anastomotic suturing is prevented by the use of
intra-coronary shunts that maintain coronary
perfusion, prevent ischaemia and reduce back
bleeding during suturing. A double limb shunt,
which fits into the proximal and distal ends of
the open coronary artery, is most commonly
used (Fig. 2). The use of shunts has superseded
an earlier technique of occluding the coronary
artery proximal to the arteriotomy site during
suturing. The ischaemia that results from this
occlusion is better tolerated if the technique
of ischaemic preconditioning is used. This
involves occlusion of the target vessel for
5 min, with subsequent reperfusion for 3 min
before occlusion for suturing. Preconditioning
significantly preserves muscle adenosine tri-
phosphate concentrations and this may confer
greater myocardial protection during occlu-
sion for suturing.1 The use of shunts is a
more elegant technique.
Anaesthetic technique
The anaesthetic goals of management of
OPCAB surgery include:
(i) The provision of safe induction and
maintenance of anaesthesia using a
technique that offers maximum cardiac
protection.
(ii) The maintenance of haemodynamic sta-
bility throughout surgery with the help
of adequate monitoring and pharmaco-
logical support.
(iii) Early emergence and ambulation in
association with excellent postoperative
analgesia. Avoiding CPB does not
shorten the surgical procedure but it
can accelerate immediate postoperative
recovery and shorten ICU length of stay.
doi:10.1093/bjaceaccp/mkl005

Fig. 1 The Octopus stabilization system (Medtronic Inc.,
Minneapolis, USA)
Fig. 2 Double limb intra-coronary shunt
Conventional techniques, with high dose opioids used in
association with a combination of volatile agents and propofol,
are often used when OPCAB is utilized.2 In some institutions,
general anaesthesia combined with intrathecal or thoracic
epidural anaesthesia is favoured. Whilst thoracic epidural anaes-
thesia has been shown to dilate epicardial arteries and decrease
myocardial oxygen demand at the same time as providing good
postoperative analgesia, studies have failed to demonstrate any
benefit from a combined technique over general anaesthesia
alone, except for earlier extubation.3 Techniques resulting in
extubation in the operating room have not demonstrated any
additional benefit or to be cost effective.4
Continuing Education in Anaesthesia, Critical Care & Pain | Volume 6 Number 2 2006
Anaesthesia for off-pump coronary artery surgery
In contrast to CPB surgery, beating heart surgery requires
the anaesthetist to maintain stable haemodynamics and
rhythm in an environment that changes rapidly because of regio-
nal ischaemia and cardiac manipulation. Good communication
between the surgeon and anaesthetist is essential. Adequate
premedication is required and tachycardia should be avoided
during induction of anaesthesia.
There is some experimental evidence indicating that isoflurane
and sevoflurane induce significant preconditioning giving some
protection against ischaemia; therefore, they may be particularly
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appropriate for OPCAB.5 Before the use of stabilization systems,
a bradycardia was relied upon to provide the surgeon with a
stable field. This is less important surgically, although it has
the added advantage of a reduction in myocardial oxygen con-
sumption, especially at a time when supply may be compromised.
The goal remains to avoid a tachycardia; this is often achieved
with esmolol, but verapamil and diltiazem have been used.
Esmolol has the advantage of being cardioselective, with a rapid
elimination half-life, allowing for rapid control of rate and quick
return to normal haemodynamics on stopping the drug.
Cardiac displacement increases the risk of intra-operative
arrhythmias, especially reperfusion arrhythmias. Therefore,
serum potassium is maintained at >4.5 mmol litre 1. Magnesium
5 g may also be given after induction of anaesthesia to decrease
the risk of arrhythmia. Anticoagulation is required during
OPCAB; the activated clotting time (ACT) is maintained at
250–300 s. Heparin 1–2 mg kg 1 is usually sufficient before divi-
sion of the internal mammary artery. It can be reversed with
protamine. Hypothermia should be avoided by the use of
warm i.v. fluids, warming blankets and a heat exchange device
on the fresh gas flow.
Management of haemodynamic changes
There are three causes of haemodynamic changes during OPCAB
surgery. Firstly, in order to work on posterior and lateral sur-
faces, the heart has to be lifted out of the pericardial sac. This
displacement of the heart has significant haemodynamic conse-
quences, including a reduction in cardiac output associated with
alterations in the right heart pressures. These changes result from
the heart being tilted into a vertical position requiring blood to
flow upwards into the ventricular cavities. Greater than normal
filling pressures are required to maintain ventricular filling.
A second cause of haemodynamic changes is pressure exerted
by the retractor on the ventricular wall which restricts wall
motion locally and reduces ventricular dimensions. Finally, the
vertical position of the heart distorts the mitral and tricuspid
annuli and may result in significant regurgitation.
The management of these changes involves maintaining a
high perfusion pressure (MAP >70 mm Hg) and low myocardial
oxygen consumption. Hypotension commonly occurs when the
heart is tilted; MAP is then maintained using the Trendelenburg
position, administration of fluids and infusion of a vasopressor.
Myocardial oxygen consumption will be increased with a
61
Anaesthesia for off-pump coronary artery surgery
significant tachycardia and this can be treated using a b-blocker
for example esmolol. If a bradycardia results from manipulation
of the heart, pacing wires can be connected to the right atrium.
Monitoring during OPCAB
Conventional 5-lead ECG monitoring is routine but heart
manipulations modify the positional relationship between the
heart and surface electrodes. Therefore, the shape of the tracing
is altered and the amplitude is reduced. The diagnostic accuracy
of the ECG is impaired during heart manipulations. The use of a
12 lead ECG, with simultaneous monitoring of lead II and the
lateral precordial (V4 and V5) leads increases the efficacy of
ischaemia detection. The addition of ST segment trending may
further aid the early detection of ischaemia.
Invasive arterial blood pressure monitoring is mandatory
and the use of flow directed pulmonary artery catheters is com-
monplace, although right atrial and pulmonary wedge pressures
may be distorted with the verticalization of the heart. SvO2 is
a useful tool to evaluate cardiac output and also demonstrate
adequacy of tissue oxygenation. SvO2 < 50% has been associated
with the development of bowel ischaemia.
Whilst transoesophageal echocardiography (TOE) rapidly
demonstrates regional wall motion abnormalities, which may
indicate regional ischaemia, its interpretation becomes very dif-
ficult with displacement of the heart, presence of air around the
heart and swabs near the oesophagus. The images are usually of
very poor quality, although they may still be interpretable. As
mortality and morbidity are low, the use of TOE is commonplace
in beating heart surgery.
Outcome of OPCAB
Analysis of the National Adult Cardiac Surgery Database of
3396 OPCAB procedures shows a reduction in risk adjusted
mortality from 2.9% in CABG to 2.3% for OPCAB. The com-
plication rate was also reduced from 12% (CABG) to 8%
(OPCAB).6 Other studies have not demonstrated a difference
in mortality or morbidity.7
Derangements in the coagulation system after coronary artery
surgery are well recognized. Both coagulation factors and plate-
lets are affected by extracorporeal circulation and hypothermia;
most studies have shown a reduction in the need for transfusion
of blood and blood products in OPCAB compared with CPB.8
Duration of ventilatory support and ICU stay are reduced in
OPCAB with a consequent reduction in costs.9 Early outcomes
and short-term patency rates are comparable between the two
techniques but information on long-term patency is still lacking.
The incidence of postoperative atrial fibrillation is similar.
62 Continuing Education in Anaesthesia, Critical Care & Pain | Volume 6 Number 2 2006
Neurological dysfunction after cardiac surgery has long been
recognized as a major contributor to morbidity. The causes are
probably macro or micro embolic events as a result of the manip-
ulation of the ascending aorta. The need for manipulation is
reduced in beating heart surgery but not eliminated completely.
Despite this, the incidence of stroke has only been found to be
reduced in isolated studies and effects on cognition remains
inconclusive. CPB results in the activation of a generalized
inflammatory response with a rise in the postoperative markers
such as C3a, C5a, TNF-a and the interleukins IL-6 and IL-8.
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This rise in inflammatory markers is reduced in OPCAB patients.
In a low risk population having coronary artery surgery, the
morbidity and mortality rates are low using CPB and it is
therefore difficult to demonstrate any advantage in outcome
with OPCAB. A possible advantage of OPCAB may be in the
high risk patient group with significant co-morbidities and an
expected risk of >5%. Indeed, some studies suggest an advantage
in these patients.10
References
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Please see multiple choice questions 10–12.