Anaesthesia for off-pump coronary artery bypass surgery

Despite the developments in cardiopulmonary bypass equipment and technique, coronary artery bypass graft (CABG) surgery performed on cardiopulmonary bypass may be associated with deleterious effects. This has renewed interest in off-pump CABG (OPCAB) surgery. The development of mechanical stabilizers, and a median sternotomy, allows grafting of multiple vessels. A balanced anaesthetic technique of moderate dose of opioids, propofol and volatile agents (sevoflurane or isoflurane) is usual. The use of transoesophageal echocardiography monitoring is common, and mixed venous oxygenation is useful. OPCAB grafting may be associated with ischaemia and major haemodynamic instability when the heart is displaced during grafting of the inferior, lateral, and especially, the posterior aspect of the heart. Specific advantages of the technique include a reduction in blood loss and transfusion requirements, shorter period of ventilation, ICU stay and potential cost-saving. Pulmonary function appears to be better and the incidence postoperative cognitive function is better at least in the short-term. Advantages in terms of renal function and the incidence of stroke are not, as yet, accepted by all clinicians. The technique may be unsuitable in patients with poor ventricular function requiring multiple grafts, and in patients with certain patterns of coronary disease. The procedure is technically demanding for the surgeon, and OPCAB performed in low volume centres is associated with a greater mortality. Early graft patency and outcome is at least equivalent, although the long-term outcomes remains uncertain. The main advantage of the technique is likely to be in the high-risk patient with significant co-morbidities. © 2006 Elsevier Ltd. All rights reserved.