Dual Inflow, Total-Arterial, Anaortic, Off-Pump Coronary Artery Bypass Grafting: How to Do It
This illustrated, instructional article details a reproducible, total-arterial surgical revascularization technique which does not require cardiopulmonary bypass or any manipulation of the ascending aorta. This guide aims to improve outcomes for surgeons new to off-pump coronary artery bypass grafting (OPCABG) and goes some way to addressing concerns raised by critics of OPCABG.
I am excited to read that yet another department has implemented the technique of TAR, NAT (No Aortic Touch) OPCAB I have been using for the last 13 years. I have a few suggestions for modifications you may consider:
1. Performing the LIMA to LAD (+/- Diagonal) anasatomoses first, wil usually make the heart more tolerant to enucleation for OM and PLA/PDA anastomoses.
2. Running the RIMA (+/- Radial composite extention through the transverse sinus, has previously been shown to be associated with decreased graft patency. I prefer running it counter-clockwise around the heart (PDA/PLA anastonoses first, OM anastomoses last) letting both the RIMA-RA I- graft and the LIMA enter the pericardium through separate holes in the pleura/pericardium.
3. Avoiding inotropes (milrenone) and vasoconstrictors (noradrenalin) as long as the heart has not been revascularized, follows the rule of “not whipping a tired horse”. If you exhaust the heart, you will more often need ECC support (I manage to avoid this in 98% of cases…so you have to be thick-skinned to comments from bored perfusionists :-D)
4. Creating a “cradle” over the heart to perform the RIMA-RA anastomosis is not necessary, if you place a wet pack on the right chest wall next to the sternotomy, and perform the anastomosis on that.