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Beating heart 'off-pump' coronary artery bypass surgery

Professor Gianni Angelini, Professor Raimondo Ascione and colleagues in the Bristol Heart Institute, University of Bristol and UH Bristol

Coronary artery bypass grafting (CABG) is carried out to improve the blood supply to the heart in patients with severe coronary heart disease. Conventional CABG surgery involves stopping the heart (cardioplegic arrest) and the use of a cardiopulmonary bypass pump (CPB), and is being done in an increasingly high-risk population (caused by increasing age, smoking, diabetes, hypertension and high cholesterol). The use of cardioplegic arrest and CPB in these high-risk patients is associated with significant in-hospital mortality and morbidity - largely due to the fact that the heart has to be stopped during surgery. To overcome this problem, researchers have pioneered the novel technique of off-pump coronary artery bypass surgery, avoiding both stopping the heart and use of CPB.  This means that patients have bypass surgery whilst their hearts are still beating - just the small area which is being operated on at the time is kept still - and there is no need to circulate the blood using a machine.  Over ten clinical trials and several large cohort studies have now been completed to assess the impact of this technique on high-risk patients.

The results have shown that off pump surgery is as safe as the conventional coronary artery bypass grafting (CABG) technique. Most importantly, however, off-pump surgery significantly reduces the risk of post-operative complications, and reduces morbidity and mortality. It also reduces the time patients spend in intensive care, and overall in hospital. In 2011 (the last year for which data are available), 20% (one in five) of CABG operations in the UK were carried out with the OPCAB technique and it has had significant take-up overseas (e.g. 18% of CABG operations in the USA and 21% in EU). NICE (the National Institute for Health and Care Excellence) has recommended the use of OPCAB surgery.

Over the years, an effective programme of training in OPCAB surgery has been implemented at the Bristol Heart Institute (BHI). Once surgeons are trained and accustomed to doing it, they are reluctant to go back to CABG-CPB because they are more comfortable with the OPCAB technique and its reduction in early post-operative morbidity and use of resources. Consultants trained in beating heart coronary surgery at BHI and now performing this surgery elsewhere include six in the UK outside Bristol, and six internationally. The usage of the OPCAB technique is expected to more than double in the US and worldwide in the next few years.

The usage of the OPCAB technique has had a profound impact post-operative complications that patients experience, and on hospital resources and cost, with a 25% saving per patient.

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