Off-Pump Coronary Artery Bypass Surgery

What is off-pump CABG?

Coronary artery bypass surgery, commonly known as CABG, is a type of heart surgery. Surgeons perform this type of surgery to bypass blockages in the coronary arteries. An “off-pump CABG” is a CABG performed without the use of a heart-lung machine (cardiopulmonary bypass). This means the heart continues to provide blood to the rest of the body during the surgery. It is sometimes referred to as “beating heart surgery.” In another method used during surgery, a machine takes over the functions of the heart and the lungs and the heart is still.

The coronary arteries deliver nutrients and oxygenated blood to the heart. Atherosclerosis is a disease that can cause hardened plaque to build up in the coronary arteries. This plaque narrows the arteries over time. This can limit the flow of blood to the heart and cause chest pain (angina). The plaque can also make blood clots more likely to form. These clots may completely block the blood flow through one of the arteries and cause a heart attack.

Off-pump CABG is one of the procedures that surgeons use to restore blood flow to the coronary arteries. The surgeon takes an artery or a vein from another place in the body. The surgeon then uses the vessel to “bypass” the blocked part of the vessel and restore normal blood flow to the heart. Your healthcare provider may plan the surgery in advance, or you might need it in an emergency if a vessel suddenly becomes blocked.

Sometimes surgeons perform off-pump CABG with the traditional, standard surgical approach. In this type of CABG, the surgeon makes a large cut down the front of the chest through the breastbone (sternotomy). Recently, some surgeons have started using smaller incisions to perform off-pump CABG. In this case, the surgeon makes a much smaller incision through the ribs to perform the surgery. This is a type of minimally invasive surgery. It is performed to reduce pain and recovery time.

Why might I need off-pump CABG?

If you have coronary artery disease, you may be able to manage your condition with lifestyle changes and medicines. Sometimes, a nonsurgical procedure called coronary angioplasty (also called coronary stenting) is a choice for some people.

If you have severe coronary artery disease, you are more likely to need coronary angioplasty or some type of CABG surgery. These treatments can help reduce chest pain and the risk of a heart attack as well as improve survival. It is possible that your type of blockages will not respond as well to treatment with angioplasty. In this case, you may need CABG surgery. Certain types of blockages may respond better to CABG than to angioplasty. For certain people one procedure or the other is clearly the best choice. Talk with your healthcare provider about the risks and benefits of both. Also ask if you have any choice in which surgery to have.

Once you and your healthcare provider have decided on CABG, you will need to decide what type of surgery is right for you. Certain types of people at high risk may be more likely to benefit from off-pump CABG. These include people with advanced atherosclerosis of the aorta, kidney problems, or chronic lung disease. Off-pump CABG may reduce the risks of postoperative inflammation, infection and irregular heart rhythms. It is important to have off-pump CABG performed by a surgeon with experience in the approach. Different surgical centers and different surgeons may prefer one technique over the other. Ask your healthcare provider about your risks and benefits of CABG with or without a heart-lung machine.

What are the risks of off-pump CABG?

Off-pump CABG may provide a slightly lower risk of complications than CABG performed with a heart-lung machine. Your particular risks will vary according to your particular medical conditions, your age, and other factors. In the off-pump technique, there may be a higher risk of needing another procedure to improve the hearts blood supply in the future. Be sure to talk with your healthcare provider about any concerns that you have.

Most people who have off-pump CABG will have a successful outcome. However, there are some possible risks. These include:

• Infection
• Bleeding
• Irregular heart rhythms
• Blood clots leading to stroke or heart attack
• Complications from anesthesia
• Kidney failure

Certain factors increase the risk of complications. These include increased age and other medical conditions.

How do I get ready for an off-pump CABG?

Talk with your healthcare provider about how to get ready for your upcoming surgery. Remember the following:

• Avoid eating or drinking anything after midnight before your surgery.
• If you smoke, try to stop smoking before your operation.
• You may need to stop taking certain medicines, such as warfarin, before your surgery.
• Follow your healthcare provider’s instructions regarding medicine use before surgery.

You may need some routine tests before the procedure to assess your health before surgery. These may include:

• Chest X-ray
• Electrocardiogram (EKG), to assess the heart rhythm
• Blood tests
• Echocardiogram (to assess the structure and pump function of the heart)
• Cardiac stress testing (to evaluate the blood perfusion to the heart)

If needed, someone will shave your skin above the area of operation. About an hour before the operation, someone will give you medicines to help you relax.

What happens during an off-pump CABG?

Check with your healthcare provider about the details of your procedure. In general, during your off-pump CABG:

• A healthcare provider will give you anesthesia before the surgery starts. This will cause you to sleep deeply and painlessly during the operation. Afterwards you won’t remember the operation.
• The operation will take several hours.
• Your surgeon will make an incision to remove a vessel. Often this is a vessel taken from your chest wall or your leg.
• If you are having traditional off-pump CABG, your healthcare provider will make an incision down the middle of your chest to separate your breastbone.
• If you are having a minimally invasive off-pump CABG, your surgeon may make a small incision down the middle of your chest and separate part of your breastbone. Sometimes surgeons use special instruments and a camera to do the surgery. In this approach, your healthcare provider will make several small holes in your chest, between the ribs. Some surgeons use robot-controlled arms to perform the surgery.
• Your heart will keep beating during the surgery.
• Your surgeon will surgically attach the removed vessel to the aorta, the main blood vessel going out to the body. Your surgeon will attach the other end of the vessel to the blocked coronary artery, to bypass the blockage. An artery inside the chest wall is typically used as the first bypass vessel of choice because it has been shown to stay open the longest.
• Once the bypass grafts are complete, a surgery team will wire your breastbone back together (if necessary).
• The surgery team will then sew or staple the incisions on your skin.

What happens after an off-pump CABG?

After your off-pump CABG:

• You might wake up a bit confused at first. You might wake up a couple of hours after the surgery, or a little later.
• The surgery team will carefully monitor your vital signs, such as your heart rate. They may hook you up to several machines to assist in monitoring these continuously.
• You may have a tube in your throat to help you breathe. This may be uncomfortable, and you won’t be able to talk. This will usually be removed within 24 hours.
• You may have a chest tube to drain excess fluid from your chest.
• You will feel some soreness, but you shouldn’t feel severe pain. If you need it, you can ask for pain medicine.
• You should be able to sit in a chair and walk with help within a day or two.
• You may perform therapy to help remove fluids that collect in your lungs during surgery.
• You will probably be able to drink the day after surgery. You can have regular foods as soon as you can tolerate them.
• You will probably need to stay in the hospital around 5 days.

After you leave the hospital:

• Make sure you have someone to drive you home from the hospital. For a while, you will also need some help at home.
• You will probably have your stitches or staples removed in a follow-up appointment in 7 to 10 days. Be sure to keep all follow-up appointments.
• You may still tire easily, but you will gradually start to recover your strength. It may be several weeks before you fully recover.
• Do not drive until your healthcare provider says it is safe for you to do so.
• Avoid lifting anything heavy for several weeks.
• Follow all the instructions your healthcare provider gives you for medicines, exercise, diet, and wound care.
• Your healthcare provider may refer you to a cardiac rehab program to help in rebuilding your strength after surgery.

Next steps

Before you agree to the test or the procedure make sure you know:

• The name of the test or procedure
• The reason you are having the test or procedure
• What results to expect and what they mean
• The risks and benefits of the test or procedure
• What the possible side effects or complications are
• When and where you are to have the test or procedure
• Who will do the test or procedure and what that person’s qualifications are
• What would happen if you did not have the test or procedure
• Any alternative tests or procedures to think about
• When and how will you get the results
• Who to call after the test or procedure if you have questions or problems
• How much will you have to pay for the test or procedure