Innovative Surgical Strategies: Minimally Invasive CABG and Off-pump CABG.

Minimally invasive coronary artery bypass grafting (CABG) and off-pump coronary artery bypass grafting (OPCAB) have made up a significant facet of the recent attempts of surgical myocardial revascularization to evolve. Driven by an effort to limit the deleterious effects of cardiopulmonary bypass (CPB), along with a response to both the growing interests in performing procedures through smaller incisions and the successes of catheter-based therapies, these therapeutic options have found themselves moving into the future by resurrecting their past. Minimally invasive CABG is the procedure by which coronary grafting is performed through a small anterior thoracotomy, without the use of CPB. Although feasible, the inability to offer a more thorough degree of revascularization has limited the applicability of this procedure and, therefore, accounts for its overall minor contribution to the number of coronary revascularizations performed annually. Conversely, as the technical feasibility of performing complete revascularization without CPB has been achieved with OPCAB, its place as a mode of therapy remains uncertain. Several clinical trials have been performed to date with only a few being done in a prospective, randomized fashion. From this data has come a mix of information regarding either improvements or, at a minimum, no change in the rate of complications between CABG with, and without, CPB, while at the same time maintaining equivalent short-term graft patencies. The question remains, however, to which patient population is this approach to CABG optimal? Our practice has largely reserved OPCAB for those patients in whom manipulation of the aorta is considered not feasible due to severe calcification or in "high-risk" patients who are felt to be unable to tolerate the adverse physiologic effects of CPB. This makes up approximately 15% of our CABG population, roughly equal to the national average, with the remaining patients being revascularized with the assistance of CPB.