Off-pump coronary artery bypass grafting: Anno 2011.

Since 1998, a large body of literature regarding off-pump coronary bypass surgery has been published, although varying techniques and outcomes likely have led to its inconsistent application. One approach has been developed and standardized at the University Hospitals Leuven, Campus Gasthuisberg, Leuven, Belgium. This approach is straightforward and can be replicated without need for conversion toward cardiopulmonary bypass. The patient is 'conditioned' before and during the procedure. Both mammary arteries are harvested through a standard median sternotomy. The anterior surface of the heart is exposed with a horizontal line of left-sided pericardial stitches, just above the level of the heart. The anterior coronary vessels are anastomosed after routine shunting. The lateral and inferior aspects of the heart are exposed without deforming the atrio-ventricular axis. This is performed in a stepwise manner. The first step is anchoring a sling into the posterior pericardium under the roof of the left atrium. Second, this sling is gradually pulled upwards, supporting the heart as a cradle. Once the heart is exposed towards the zenith, an apical suction device stabilizes, reformats and exposes the ventricle. The lateral and inferior walls are then revascularized. As a strict no-touch aorta technique is used, free grafts are anastomosed to in-situ arterial grafts.