Opcab Technique-how I Do It
Himansu K. Dasmahapatra, FRCS.
Belle Vue Clinic and BR Singh Hospital, Kolkata, India.
OBJECTIVE: The techniques of Off-Pump Coronary Artery Bypass (OPCAB) varies from surgeons to surgeons across the world.The purpose of this presentation is to describe my technique of performing OPCAB
METHODS: The commercial conditions in India is different from the rest of the developed world. In India, the cardiac stabilizers are more expensive than oxygenators. For that reason, we re-use the stabilizers and other accessories to minimize the cost of operation.
Since the year 2000, I have been performing OPCAB as default option, with exceptions like-catheterization laboratory emergencies, acute stent thrombosis with unstable hemodynamics, severe HOCM with MVCAD.
My techniques of OPCAB - after standard general anesthesia, operative approaches - median sternotomy in the majority,(L) lateral thoracotomy in some redo CABG with patent LIMA, very rarely, (R) thoracotomy for RCA stenosis; use of LIMA in 99% of of OPCAB, skeletonized LIMA harvest, LIMA-RIMA harvest for total arterial OPCAB, either pedicled LIMA-RIMA grafts plus minus radial artery graft or LIMA-RIMA (Y) configuration. The pericardium is opened longitudinally veering to (R) and (L) of the cardiophrenic angles- opening of (R) pleura not usually done, 2-3 deep pericardial sutures (LIMA) in the (L) pericardial cavity inferiorly, Octopus used Guidant/Mackey- apical cardiac positioner never, intra-coronary shunts always, inotropes rarely, temporary pacing as required, IABP use rarely, and if emergency CPB conversion needed done early.
Grafting sequence for LIMA-SVG OPCAB: nearly always LIMA - LAD anastomosis first especially in critical LAD or critical left main stenosis followed by PDA/PLB territory prior to lateral circumflex branches- distal coronary anastomosis first prior to proximal aortic anastomosis using side biting clamp. The other intra operative measures are ACT check after second distal anastomosis (ideal level 250-350),serial blood gas analysis after induction, after second distal grafts or in the event of hemodynamic instability, optimal correction of acid-base and serum K+. with regard to post-opeartive ventilation, nearly all patients either extubated on-table or early within 6 hours of operation.
RESULTS: Personal experience > 2500 cases; emergency CPB conversion rate-1.2%
CONCLUSIONS: I consider that the way I perform OPCAB is simple, reproducible, and safe in the majority of patients undergoing OPCAB
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