[HSF] "Patients don't want cardiopulmonary bypass" - the great con

[Mehta Sukumar]

Vipin,
  Sorry, I read your communication dated December, 2007, only just now while randomly picking up the HSF mails. I found it very apt. I agree with all the points except probably the 3rd point. ( I am neither for or against on pump or off pump and do CABGs by either technique as per my comfort level, keeping in mind the job I have to do in any given case ).
  My view is, heart lung bypass technology has sufficiently advanced to take care of pump times involved in carrying out 5 or 6 distals. As far as proximals are concerned, (if at all they are aorto coronary grafts), they can be done off pump, if one is concerned about pump time. Secondly, I found it difficult to understand, why "small vessels can sometimes be difficult to graft on-pump". In your communication, in para 1) you have mentioned excellent tricks and tips to a small vessel distal anastomosis off pump. The same tips and tricks can be used (if required), on pump to facilitate small vessel distal anastomosis.
  If at all these points have been discussed in the forum subsequently and I have missed them, I apologise.
  Sukumar.

Vipin Zamvar <zamvarv at hotmail.com> wrote:
  
Michael,

Let me correct a few misconceptions that many surgeons have about off-pump surgery. The following comments (which are randomly arranged) are based entirely on my own personal experience (248 of the last 250 CABG operations performed off-pump; of the 248 off-pump operations, one needed a conversion intraoperatively.)

1) The first one is that small vessels cannot be safely grafted: To perform a safe and secure anastomosis, the diameter is a critical issue only during the learning curve. I do not feel performing an anastomosis on a 1.25 mm vessel is any more difficult than on a 2 mm vessel. There are a few tricks that can be used while grafting a small vessel. (It is absolutely essential that the stabilization is secure, so there is no or minimal motion). A shunt is an absolute must. This prevents the inadvertent taking of the posterior wall of the coronary artery. In a small vessel the shunt also helps while turning corners at the heel or toe. You can gently puncture the shunt at the heel when the needle passes through the coronary wall, and then pull the shunt away. The needle is pulled along with the shunt; then the needle can be disengaged from the shunt, and pulled away. 

2) The second is that you cannot completely revascularise the patient: I routinely do 4 or 5 grafts for patients with 3 vessel disease, and occasionally also 6 grafts. The position of the coronary artery is absolutely not a problem. Again this is due to the use of many techniques, which combine to ensure that access for any part of the heart is no problem at all. These techniques include the single deep posterior pericardial stitch, opening of the right pleura, use of the trendelenburg position, and judicious use of intraoperative fluids. 

3) I have often felt that if I were doing on-pump surgery, then doing 5 or 6 grafts would be fraught with the dangers of a long pump time. I also find that small vessels can sometimes be difficult to graft on-pump (For example, when I am doing AVR + CABG). 

4) I often find myself comfortable in being able to offer coronary surgery to patients with diffusely diseased arteries and extensive comorbidities only because I am confident to be able to complete the operation off-pump. I often take on patients when others are more conservative or reluctant. 

5) I feel that surgeons who wish to start/increase performing off-pump surgery should not select their patients on the basis of size of the coronary artery. Sometimes a 2.5 mm artery which can bleed a lot when an arteriotomy is made, can be more difficult to deal than a 1.5 mm artery which does not bleed as much. 
In fact if anybody is serious about persuing off-pump surgery, he must not select patients at all. He must start off-pump in all patients. 

6) The one drawback I feel about off-pump surgery is that I find it difficult to give away cases to my trainees; unless they are relatively senior. I would have been able to give away a higher proportion of cases if I had been doing on-pump surgery. 

7) Off-pump surgery is associated with a significant decrease in perioperative morbidity; and because of this it is of great benefit especially in high risk patients. But to be able to get excellent results in high risk patients, the surgeon has to be doing this procedure all the time. 

Can I add that the pump is always available to me. I will use the pump without hesitation anytime I feel that the pump would be safer. 
Visiting cenres or surgeons that routinely perform a high proportion of cases off-pump can be a big advantage. 


Vipin Zamvar 
       
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