Chasing the Wrong Villain

Off-pump surgery was expected to be the saviour of coronary surgery when introduced in the late nineties.  The reason for it's failure is hotly debated by the protagonists of the on- and off-camps and certainly the big disappointment was  the failure of most OPCAB series to show a reduction in neurological complications.  In addition, the technique was too hastily adopted by too many  inadequately prepared surgeons with inevitable disastrous results. Nevertheless, those who persevered gradually solved  the problems of a new and demanding method and are able to reproduce results at least equivalent to conventional coronary surgery. But why make an operation more difficult for equivalent results? Indeed the majority of coronary surgeons haven't bothered and who can blame them?

The real villain of conventional surgery, however, is not the pump but the aorta with it's load of unpredictable atheroma. The failure to understand this is why OPCAB has failed to reduce the incidence of stroke.  The persistence of this devastating complication together with it's partner: cognitive decline is, after all, the only real failure of  arterial coronary  bypass surgery apart from the incision.

By following the no aorta (anaortic) principle many surgeons are providing complete revascularization, often all arterial, without touching the aorta. This is achieved by using arterial inflow from the chest wall and abdomen with the occasional proximal anastomosis achieved  with a no-clamp technique.  If there is any hint of instability before or during the operation, the patient is put on pump. But  crossclamp and cardioplegia  are assiduously avoided and if the aorta not needed for a proximal, the cannula can be placed anywhere to avoid echo detected atheroma and is threaded well past the carotids. The case then proceeds as planned using all the OPCAB techniques with the heart happily beating at normothermia.

For many years my practice, like many today, has been heavily biases by invasive cardiology towards the elderly, diabetic with bad coronaries and unstable angina, yet in the last seven years I have only used the crossclamp in a handful of coronary cases  (complicated redos). For the last five years, no other clamp has been applied the aorta. Of the 1375 beating heart coronary cases, there have been two minor, fully recovered, neurological events.

Where are the randomised trials?  There are none and it will forever remain so because I and my ilk will never put a patient to the unnecessary risk of an aortic clamp.

My plea is for the cardiac surgical community to carefully revisit beating heart coronary surgery aiming to, this time, banish the real villain.