My experience in off-pump surgery counts for about 250 cases, in the majority of them I have placed one graft to the lateral wall. Considering the RIM I basically enucleate and position the heart using a deep pericardial "Lima" stitch as for the OM branch. Rarely, I position the heart as for the LAD with a little bit of enucleation.

My experience based on several hundreds of multi-vessels OPCABG is quite similar to that of Tomas Holubec. Generally I prefer two left sided pericardial stiches, instead of the "Lima" one. If my target is RIM, on the proximal part of it, the use of Starfish (or similar) could be facilitated.

As you know, off-pump CABG is a standard technique in Japan, I have done about 1500 off-pump CABG. Grafting the intermediate branch is a bit tricky and unexpectedly difficult.. Grafing to the intermediate artery should be performed in the way similar to the left circumflex artery, not in the way to the diagonal branch. Therefore, the apex of the heart should be lifted up and rotated towards the right side. To this end, I am using a heart positioner called Tentacles which was invented by a Japanese cardiac surgeon, Prof. Arai. To further facilitate the heart positioning without compromising hemodynamics, I lift the right sternum up with a special retractor, and try to put the apex of the heart under the right sternum to get a wide working space over the lateral wall.

I have a large experience in off-pump CABG sence 1991. In 1993 I began use the deep pericardial suture. At the begging I used several sutures but several years later I change for just one and works well sence then. To graft ramus intermedius is not dificult. You can use "Lima" suture, heart positioner or even ope the rigth pleura and move the heart apex into the rigth chest. You can use these manouver isoleted or combined. Important is have work space and no hemodynamics changes.

I am very impressed with a famous Dr. Lima's comment..　I realized that he has an almost same concerpt as I do for exposure of the lateral wall; the apex of the heart should be moved to the right chest cavity to get a wide working space for LCx. To this end, he opens the right pleura and uses Lima stitches, while I lift the right sternum up and use a heart positioner.

In my clinic 85% of CABG cases are done OPCAB wich ads up to ca. 2000 OPCAB procedures per anum. I can ad a few more "tricks" to better exposition and haemodynamic stabilty: The right side of the Pericardium should be left hanging down and the Patient should be positioned head down and turned to the right so that the right heart can get unobstructed filling. The left side of the Pericardium can be stiched up on the Sternum with two stiches and the retractor can be put on top of the Pericardium. The retractor will now push the Pericardium away form the heart giving you "maneuvering room" and the heart wil roll slightly to the right exposing the lateral wall. Now you can add two deep pericardial Lima stitches: one opposite the left appendage and the other 3 cm left of vena cava inferior. By tiying down a longette on these stiches you get two reins to maneuver the Heart in any desired position. Important is that by pulling the pericardium a kinking af the pulmonary veins is avoided and blodflow to the atria is unobstructed. If the patient is on beta blockers(usually) and the heart rate is low the heart will get quite large in diastole. Atrial pacing at 80 bpm results in a smaler Heart, will create more room in the pericardium and simultanously improve cardiac output and haemodynamic stability.

Thanks to all my seniors. all these tips really helped.

I agree with al the above comments. I use two stay sutures on left side and no sutures on right side star fish is used to lift the heart. However when the octopus fixatio shou bo done cautiouly.

In my experience of doing more that 2000 of pump CABGs , grating RIM is one of the trickiest. I usually use two deep pericardial stiches on the left and two large sponge pad so that the apex of the heart is positioned to the right and upwards.Even a star fish can be used. Space is limited and i do use both the hands to do the anastomosis.Heart should not be two slow to avoid diastolic distension.With experience it becomes easier and speed matters to do a quick job.

According to previous opinions including mine, it is interesting to know that everyone agrees that grafting the intermediate artery should be performed in the same way as grafting the circumflex artery.

I do the intermediate and circunflex artery by The same way.

We do all our cases off pump and have an experience of over 5000 OPCABs. We do not use Starfish or any positioner, primarily because of the costs but now with over 5000 cases we do not feel their necessity. We also do not agree with packing the apex in right chest or under right sternal edge. Such moves impair the haemodynamics. Infact we feel strongly that both pleural integrity should be maintained. In fact the cases where pleura is opened versus those where pl cavity is intact can be easily guessed on a chest X ray based on al least the costophrenic angles getting blunted in the former, besides other pulmonary issues like basal atelectasis etc.

Yes we treat RI as a circumflex but we verticalise the heart with very little twist to right and the balance exposure is improved by tilting the table head down and rotation to right. We just use one pack in the pericardial cavity and the Octopus to position the heart - no pericardial or LIMA stitches.

OPCAB can be made as complex as one wants by doing all kinds of ancillary support manoeuvres but if one gets it right in ones head, one is committed and willing to strain ones neck out then very minimal handling is required and virtually no haemodynamic impairment.

I would like congratulate Dr. Yadava for the great experience. Doing OPCAB there is no a unique way to do it. The important is the undesrtanding to move the heart with no haemodynamic impairment. The important is perform complete revascularization without extracorporeal circulation. If you use or not pericardial or LIMA stiches and Starfish positioner is not important. I understood Dr. Yadava do not use Starfish because is expensive but use Octopus. In my country both are very expensive.

Thx Dr Lima, yes both are expensive, that is why we have done away with one totally, that is the Positioner ( Starfish). Stabilisation to get good anastomosis is mandatory and hence we do use Octopus as a stabiliser in every case and by default it also acts as a positioner to a fair extent. Being a poor country, we do recycle our Octopus about 30 to 40 times on an average to make the procedure a little more affordable.

May I invite you to visit our centre whenever you are on this side of the world and it shall be our pleasure and indeed an honour to play host.

I would like to congratulate all the surgeons presenting here their great experience. As I see here, "the OPCAB should definitely not be abandoned" ;-), as postulated by Dr. Lazar from Boston, of course when it is performed by skilled and experienced hands. I have definitely much smaller experience in doing OBCAP, but while keeping my personal concept, have very good results. I actually do a bit combination of all abobe mentioned techniques. One modified LIMA stich placed to the corner between IVC and lower right pulmonary vein. I place a long sponge in this stich and tigh it with turnique. Than I used this to elevate and position the heart as kind of support. Never open the right pleura and try to freely verticalized/enuclate the heart. Despite of workikg in quite rich country, we basically don't use Starfish as well. Following our concept we almost don't need it.

We have been doing OPCABS  in   90- 95%  of  all coronary revascularisations. With experience of over 2000 OPCABS,my exposure of Ramus and circumflex vessels is deep trundlenberg position with right tilt of table with strong retraction of left pericardial stay sutures ,

packing pericardial cavity with gauzes,using Octopus and intoropes support during this brief period . Almost all cases can be done and I agree with Dr. Yadav  that Starfish,Lima stitch,opening of right pleural spaces are  other options which may be needed in initial stages,but with experience ,they may not be needed

Interesting read; most contributors have sized up the situation in excellent fashion.

I merely wish to state that opening the right pleural ad pericardial reflection right down to the IVC affords excellent mobility to the heart without unduly compromising hemodynamics when positioning the heart for the Ramus grafting. This is easy and our go-to option with minimal morbidity if any at all. In addition using the table maneuvers viz., head low etc and optimizing pre-load are helpful adjuncts. Vital to have the presence of a Staff Anesthesiologist in the room! 

I did not see mention of the A-med RV assist catheter.....

While on the one hand we have to attempt a scientific response to the problem the same has to handled pragmatically with available resources.

This is the interesting thread. I have done more than 1,600 OPCAB since 1997.

I personally make anastomosis to Rams intermedius same fashion to Diagonal and Marginal. The answer to your question is “verticalization of the heart”. I use 2 deep pericardial sutures and no suction divide. It is obvious and many reasons to do this way. But seeing is believing. Please take a look at my video in YouTube as follows:

“Off-pump CABG exclusively with skeletonized insitu arterial conduits ”

https://www.youtube.com/watch?v=aZHlC7RTeLU&list=UUXmnSCAmVizBHvqK1K5d28Q&index=27

This demonstrates how the verticalization works in OPCAB well.

Any comments are welcome.

Tohru 

thanks alot sir Tohru Asai 

The intermediate vessels (or high OM branches) are frequently the most awkward to revascularise off-pump due to torquing/twisting of the heart and therefore the fibrous skeleton resulting in a reduction in cardiac output along with AV valve deformation and regurgitation. I perform grafts in a clockwise fashion, beginning with the anterior targets (LAD) and work my way around to the PDA. ThIs means that the anterior wall and septum (at very least) are revascularised prior to any significant enucleation of the heart.

Prior to draping, the patient is strapped to the table across the hips/waist with a padded strap overlying the anterior superior iliac spine.

The pericardium is widely opened to the left of the midline and hitched up on the left to rotate the heart towards the surgeon. At this point the distal targets are assessed, and conduit choices finalised.  Two deep pericardial sutures are placed, 1 where the posterior, inferior (diaphragmatic) and lateral pericardiae meet, the second about 1cm inferoposterior to the left inferior pulmonary vein.  These 2 sutures form either end of a 'hammock' which lies roughly at the level of the AV groove, and which lifts the heart towards the surgeon without compressing any chamber. This, combined with the movement of the operating table allows for a good view high on the oblique margin allows good access to the vessels sited there.

The technique lends itself well to an opcabp strategy.

andrew.