Off-Pump CABG (OPCAB)
Patient phenotype
Selected CAD patients — calcified aorta (avoid manipulation), elderly, renal dysfunction, recent stroke. Increasingly used. Surgeon-dependent.
Procedure
Sternotomy (or MIDCAB lateral thoracotomy). Heart manipulated on beating field with stabilizers (Octopus). Vessels grafted while heart beats. No CPB → no cardioplegia, no full anticoagulation.
Anesthetic plan
Cardiac GETA. A-line, CVC (PA optional), TEE. Be ready for emergent CPB conversion. Heparin lower dose (200-300 U/kg) than full bypass. Vasopressors for cardiac displacement effects.
Setup
- ·A-line
- ·CVC + PA catheter (controversial — TEE often substitutes)
- ·TEE
- ·Cell saver
- ·External defib pads
- ·CPB primed + ready (conversion in 5-10% of cases)
- ·Inotrope/pressor infusions
Biggest concerns by phase
Hemodynamic effects of cardiac manipulation
Lifting heart for posterior/lateral grafts → kinks great vessels, drops CO. Trendelenburg + fluid + pressors. Communicate with surgeon — pause manipulation if BP unrecoverable.
Coronary occlusion during anastomosis
Target vessel temporarily occluded → ischemia. ECG (lead II + V5) for ST changes. TEE for new wall motion. May need lidocaine, NTG, or CPB conversion.
Heparinization — lower than CPB
200-300 U/kg target ACT > 250-300. Less anticoagulation than full CPB → risk of cerebral microthrombi. Some surgeons full-dose anyway.
Bridge to CPB if needed
5-10% conversion rate. Triggers: instability, ischemia, technical difficulty. Have CPB primed throughout. Cannulation site already prepped.
Renal preservation + early extubation
OPCAB advantage: less AKI than CPB. Maintain MAP, avoid contrast. Fast-track extubation common (in OR or early ICU).
Mock-defense scenarios
Practice answering these out loud. The probes show what an examiner is listening for.
75-yo M with severe LM + 3VD CAD, EF 50%, eGFR 35, calcified ascending aorta on echo. Cardiac surgery elects OPCAB. Anesthesia plan?
What an examiner probes for
- ▹Full invasive monitoring
- ▹Lower-dose heparin
- ▹Hemodynamic management during heart positioning
- ▹CPB conversion preparedness
- ▹Renal protection + fast-track extubation
Sources
- Kaplan's Cardiac 7e
- Anesth Analg OPCAB review
Anatomy reference
Sourced reference images. 4 matches for "heart coronary cardiac".
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