Skip to Main Content

++

  • During the 1990s the increased use of angioplasty and the development of stents for the treatment of coronary artery disease started surgeons on a quest to identify new, less invasive methods of treating heart disease. Surgeons attempted to perform coronary artery bypass through keyhole-sized incisions assisted by thoracoscopic techniques.1,2 Other surgeons attempted to use robotic surgery to reduce surgical incision size. Many more surgeons simply attributed most of the difficulties associated with cardiac surgery to the use of cardiopulmonary bypass (CPB). As such, they continued to operate on patients using a full sternotomy but completed their bypass grafts without the use of CPB—in essence operating on the beating heart.
  • All of these surgical innovations presented challenges for anesthesiologists at one time or another. During surgery with CPB the surgical manipulations of the heart do not generally affect the patient's hemodynamics—after all the patient is on bypass. In the course of off-pump procedures, the heart must continue to beat and to supply blood to the tissues even when lifted out of the chest and potentially rendered ischemic during the sewing of vascular anastomoses. Consequently, the off-pump patient can deteriorate acutely requiring resuscitative measures and institution of emergency CPB. Never should off-pump cases be considered easy.

++

There are numerous surgical approaches that are designated as being "minimally invasive." Many so called minimally invasive off-pump procedures are done through a fully invasive median sternotomy. So, minimally invasive and off pump are not necessarily the same thing. A surgeon can perform a minimally invasive procedure on bypass or a procedure can be performed without using bypass but through a full sternotomy.

++

For this discussion, minimally invasive implies that the surgeon is using something other than a full sternotomy to access the heart. The heart can be approached using various ministernotomies, thoracotomies, robotic ports, and/or thoracoscopic assistance. Many of these minimally access approaches will present different challenges to the anesthesiologist compared with the "routine" cardiac anesthesia described in Chapter 4.

++

Off-pump revascularization of the coronary arteries can be done through minimally invasive approaches or through a full sternotomy. When a full sternotomy is used as in off-pump coronary artery bypass surgery (OPCAB), the heart is lifted and manipulated using various support devices to permit the completion of multiple coronary bypass grafts. For the minimally invasive approach, a small thoracotomy is used and only the left internal mammary artery is generally grafted to the left anterior descending artery as in the minimally invasive direct coronary artery bypass (MIDCAB) technique. In either approach during "off-pump" bypass surgery the surgeon will occlude blood flow to the vessel being bypassed both proximally and distally using silastic snares and other occlusive devices. The surgical field is occasionally flooded with carbon dioxide to minimize entrainment of air into the coronary artery during surgical manipulation. Since the beating heart, when operated upon, presents the surgeon with a moving target there are various stabilization devices (Figure 13–1...

Want remote access to your institution's subscription?

Sign in to your MyAccess profile while you are actively authenticated on this site via your institution (you will be able to verify this by looking at the top right corner of the screen - if you see your institution's name, you are authenticated). Once logged in to your MyAccess profile, you will be able to access your institution's subscription for 90 days from any location. You must be logged in while authenticated at least once every 90 days to maintain this remote access.

Ok

About MyAccess

If your institution subscribes to this resource, and you don't have a MyAccess profile, please contact your library's reference desk for information on how to gain access to this resource from off-campus.

Subscription Options

AccessAnesthesiology Full Site: One-Year Subscription

Connect to the full suite of AccessAnesthesiology content and resources including procedural videos, interactive self-assessment, real-life cases, 20+ textbooks, and more

$995 USD
Buy Now

Pay Per View: Timed Access to all of AccessAnesthesiology

24 Hour Subscription $34.95

Buy Now

48 Hour Subscription $54.95

Buy Now

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.