For example:

1) Off pump Y-graft LIMA - LAD + RIMA - circumflex artery with hybrid approach - stent to right coronary artery (RCA)

2) Off pump Y-graft LIMA - LAD + GSV - circumflex artery, RIMA to RCA (on PDA with elongation of RIMA with GSV)

Depending on the general condition of the patient, if the patient is very fit I would add ascending aortic replacement to the  revascularization surgery. Again, if the patient is very fit LIMA-radial artery Y graft for the revascularization of LAD and OM; and RIMA for the revascularization of RCA can be done, off pump without replacement of the ascending aorta. Otherwise in an average patient, I would not push too hard for LIMA + RIMA. Off-pump complete revascularization can be performed  (Y graft with LIMA and radial artery: LIMA-LAD, radial artery to OM and PDA). Hybrid is a good choice if you do not have difficulties of revascularization of OM during off-pump CABG; hence, you can do Y graft with LIMA and radial artery; it is: LIMA-LAD, radial artery to RCA bypass.

I do not like saphenous vein graft on arterial conduits and I rather prefer arterial conduits on arterial conduits. 

OPCAB - no touch technique fully arterial revasc utilizing bilateral IMA + A. radialis graft.

Option I (moderate RCA stenosis, located proximally + high grade Cx / PLA):   RIMA > RCA / RIVP + Y graft LIMA > LAD Y A. rad.> PLA

Option II (high-grade RCA Stenosis, prox Cx / PLA stenosis): LIMA > LAD, RIMA (tunneled) > PLA and A. rad (Y from LIMA) to RIVP

Option III (high grade distal RCA, any type PLA stenosis): LIMA > LAD + sequential A. rad (Y from LIMA) to PLA and RIVP

Actual cath / TEE / LuFu / MRI (hibernating myocardium etc) needed to give individual opinion.  Intramyocardial LAD usually is not an issue.

Best  regards from Leipzig.

DRs Nespor, Ugurlucan, Etz, This patient has EF30% severe MR,intramyocardial LAD.. what is your conversion rate to on pump .

Of course off pump. Hybrid would be a good choice, LIMA to LAD via left mini sternotomi and PCI of other vessels. The patient is 75 yr. old and has severe reduced EF. Depends on euro score one can consider full sternotomi and OPCAB using LIMA and Y graft.

Best Wishes

Aarhus Denmark

I didn' t know about poor EF. In this case just try BIMA (or combination with RA) revascularization and if the patient will be hemodynamically unstable, just perform LIMA-LAD with hybrid approach - stenting of other vessels. In the case of urgent necessity of ECC, how is it with atherosclerosis of subclavian or axillary artery? You can try axillary artery cannulation (direct or via 8mm vascular prothesis) and do the operation on pump without crossclamping. Moreover, in the case of severe peri- or postoperative hemodynamic instability you can use this vascular prothesis for IABC.

Well, in this case I am in favor of hybrid. I would do Y graft with LIMA and radial artery and do the bypasses as LIMA-LAD, Radial-RCA. I would leave Cx to be stented by the cardiologists.