Off-pump coronary artery bypass grafting: the myth, the logic and the science

Coronary artery bypass grafting is a highly investigated surgical procedure and yet continues to attract rigorous research aimed at reducing observed and potential morbidity and mortality. Improvements in perioperative care, surgical technique and methods of attenuating the untoward effects of cardiopulmonary bypass have resulted in improved clinical outcome of on-pump myocardial revascularisation. The continuing drive to improve clinical outcome and compete with the ever-evolving non-surgical methods of myocardial revascularisation has provided the incentive for the rebirth of off-pump coronary artery bypass grafting (OPCAB). The appeal of avoiding cardiopulmonary pass with its direct and indirect physiological insult, the prospect of improved clinical outcomes, and the favourable economic impact gives OPCAB the potential of preference that may mark the dawn of a new era in our search for the optimal surgical strategy for the treatment of coronary artery disease. However, there are very genuine and serious concerns with this surgical technique. The logical appeal of OPCAB can only be validated by scientific scrutiny otherwise it would remain a myth. This comprehensive review examines the "physiological cost" of cardiopulmonary bypass, the theoretical and clinical benefits of OPCAB, the concerns with this technique and strategies for maximizing the benefits. And in so doing, explore the myth, the logic and the science of this surgical technique.