Beating heart surgery: does it make a difference?

Beating heart techniques were introduced into coronary artery bypass graft (CABG) surgery in the mid 1990s in an attempt to decrease the complications associated with the use of cardiopulmonary bypass. Significant advances in technique and technology, including suction stabilizers and exposure devices, have now allowed all coronary vessels to be routinely approached without the support of cardiopulmonary bypass, while maintaining hemodynamic stability. Currently, approximately 25% of all CABG is performed without cardiopulmonary bypass in the United States. An extensive body of literature attests to the strong interest in the technique and the outcomes available for analysis. Although randomized trials do not yet show a mortality benefit, they are all underpowered to do so. A review of large retrospective databases does appear to demonstrate a mortality benefit, but patient selection contributes bias. Strong evidence of benefit exists for blood loss/transfusion, postoperative renal failure, sternal infection, myocardial injury, extubation time, length of stay, and cost savings. Particular benefit is apparent in high-risk patient subgroups, including the elderly, reoperative patients, and those with significant comorbidities. Off-pump CABG does appear to make a difference in improved outcomes by maintaining the excellent results of traditional on-pump CABG, but with less perioperative complications.