Graft patency after off-pump coronary artery bypass surgery is inferior even with identical heparinization protocols: Results from the Danish On-pump Versus Off-pump Randomization Study (DOORS)

There is a significant learning curve for OPCAB! through pt selection, there can be excellent clinical outcomes. In the largest RCTs in which graft patency was systematically studied, there were no differences in patency rate for pts undergoing OPCAB or conventional CABG.

This trial confirms that short term graft patency is significantly less in the off pump group compared to on pump group. This finding could be explained by the two technical points First is the fact that the quality of anastomosis is not as good as when it is done on pump because the grafting is usually more distal on arteries of smaller diameter and the heart is shaking all the time. Second is the fact that the vein grafts are usually longer and so more likely to get kinked and occluded. The other fact that was confirmed in all trials, although not statistically significant, that less number of vessels get grafted in the off pump patients. The findings of this trial and similar findings of other trials at midterm follow up, and the fact that all randomized trials so far failed to show any advantage of the off pump in any patient groups including old age, poor LV ,and those with renal impairment, then I would suggest that the on pump is still the gold standard of coronary surgery and the off pump to be used in very selected cases like calcified aorta.

I have to agree with colleagues talking about a real learning curve concerning the OffPump CABG. However i dont feel that graft patency is practically so inferior in the OPCABG vs ONCABG. Personnally i am doing all my CABGs as OFF PUMP from about 3 years ago. I can frankly say that the beguinning was somehow stressful but with time things were changing concretly. Some parameters must be considered,essentially technical anastomotic aspects,good target vessel exposure,optimal choice of the arteriotomy site,length of the SVG ,and controlled ACT,early postop LMWH,dual antiplatelet therapy. It

To continue ,nobody will advocate that opcabg is superior than oncabg in terms of anastomosis,BUT the truth is very technical!!! So opcabg MUST reach the same tech.level as the oncabg IF we get more experienced to do it....some tips and tricks will come over day by day,case by case,without risking the outcome... Good luck...

I have been noticing results of on pump and off pump trials ... which keep insisting that offpump results are inferior and the patency of the grafted vessels are low compared to on pump etc... I think by now the division among the surgeons are very clear and its high time that only surgeons who can deliver results in terms of mortality, morbidity and patency should attempt performing OPCAB.. Its not meant for every cardiac surgeon...as of now OPCAB surgeons perform all their CABG without pump, and only if the surgeons reach that level of expertise, will the results be comparable or better in terms of stroke rate etc. we have been performing OPCAB for the last 12 yrs at the present setup... and only for the last 7 yrs and over 2800 patients have we been able to avoid conversions on to the Heart lung machine...today if some one wants us to do a trial of on pump and off pump surgeries in our place its not feasible, as no one goes on pump... Hence if we are able to do this in a private hospital and still get patients to come over to get their coronaries bypassed, then I guess thats the way to go... earlier I thought if I can do, everyone can do.... but after 12 yrs I have realised that OPCAB is not for everyone....its for each one to decide...

Being the main author of the paper in question, I do not necessarily see the results as an "OPCAB-killer". We documented what has been seen as trends or results in most of the earlier trials, namely that graft numbers and graft patency is inferior after OPCAB compared to CCABG when operations are performed by reasonably experienced surgeons. We added that this is still the case if heparinization protocols are equal in the two groups. It is logical to assume that the quality of anastomes performed in a motionless, blood-less field is better than that of anastomoses performed under less ideal conditions. This is as true as the fact that, logically a bypass is better than a stent because it makes the complexity of the lesion irrelevant and protects against the consequences of development of the underlying disease in the by-passed vessel segment. It is also logical to assume that results get better with experience, although it should be taken into consideration that if the learning curve is very prolonged, this will, in itself pose a risk to many patients. Efficacy is, however, only one side of the balance. Safety is the other. The trends towards fewer perioperative strokes seen among OPCAB-patients in most trials results in a significant difference in meta-analyses. This may improve further with a consequent no-touch aorta technique. We looked further into the details of why the DOORS-study did not result in significantly fewer strokes in the OPCAB group compared ti CCABG. Among the 10 patients randomized to OPCAB who suffered a stroke, 3 had been converted to on-pump perioperatively, and 5 were operated on with an site biting clamp. One patient operated on with a HeartString suffered a stroke on the third postoperative day after electro-conversion of atrial fibrillation. Another patient operated on with no-touch aorta technique suffered a stroke 28 days after surgery. No cardiac cause for this stroke was suspected. We find it reasonable to believe that these results can be improved with more experience - hence fewer conversions - and a consequent no-touch aorta protocol. No doubt that patients with porcelain aorta should still be offered OPCAB. The higher the risk of stroke and the fewer grafts needed, the higher is the chance that an individual patient will benefit from OPCAB. Where the balance lies will depend on the results and experience of the individual surgeon.

As others have said OPCBG is a matter of skill and experience. I personally do not find any difference in the quality of my Off and On CABG. OPCABG requires a little more time, but with the help of the intracoronary shunt all the time is needed is taken, with no compromise to the perfection of the anastomosis. If some difficulties are foreseen a CPB is undertaken. It is only a matter of knowing how and when. That is not all that easy, so bad results are explained. It would be easy for every surgeon on training just to pretend OPCABG surgery does not exist, but it is not possible. It has already taken its place. To those who pretend to limit it to the calcified aorta patients I just say that I would not like to be that patient in their hand. It is not a procedure a surgeon can do only once in a while. So I believe there has at least to be someone in a Institution doing that job, let the best guys do it and your problem is solved.