Off-pump coronary artery bypass: the Sudbury experience

To examine factors relating to outcomes with off-pump coronary artery bypass (OPCAB) and to assess methods to improve the effectiveness of this approach

A small northern Ontario community hospital where surgical assistance, nursing familiarity with OPCAB and even anesthesiologist comfort varied

Prospective collection of data with incremental audit of results and retrospective analysis of events

One hundred twenty-four consecutive patients, operated on by the same surgeon between April 1996 and June 2002, were selected on the basis of coronary anatomy. Progressively more complex multivessel revascularization, including that to the posterior wall, was undertaken over the course of the study period. Every attempt was made not to compromise use of arterial conduits, quality of anastomoses or completeness of revascularization. This represents the 'learning curve' of this study.

Approximately 6% of patients developed a hemodynamic crisis requiring acute on-pump conversion. This tended to occur in patients undergoing complex multivessel OPCAB surgery and was associated with subsequent increased blood transfusion rate, operative time and mortality (2.8%), and poorer angiographic graft patency. This has led to a more cautious strategy including making the decision to proceed with OPCAB only after intraoperative assessment.

'Simple' OPCAB on easily accessible coronary arteries resulted in excellent early outcomes. Complex multivessel OPCAB for triple vessel disease involving difficult to access arteries was more demanding with higher perioperative complications and less effectiveness. Early enthusiasm for complex multivessel surgery has been gradually replaced with a more conservative use of OPCAB with improved intraoperative procedures, both of which have led to more favourable outcomes.