Article Text

  1. Peter P Th de Jaegere1,
  2. Willem J L Suyker2
  1. 1Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
  2. 2Department of Cardiothoracic Surgery, Isala Clinics, Weezenlanden Hospital, Zwolle, The Netherlands
  1. Correspondence to:
    Peter P.Th. de Jaegere, MD, PhD, University Medical Center Utrecht, Department of Cardiology (Hpn. E 01.207), PO Box 85500, 3508 GA, Utrecht, The Netherlands; p.p.t.

Statistics from

Coronary revascularisation plays an important role in the management of patients with ischaemic heart disease. Its principle builds on restoring antegrade flow thereby relieving angina. As a result, the need for medication is reduced which, in turn, may improve quality of life and socioeconomic independency. Also the prognosis is beneficially affected. This is not only true for patients with severe coronary atherosclerosis such as patients with left main or three vessel disease, but also for patients with less advanced disease.w1–3


The first milestones in coronary revascularisation were surgical. It all started after the second world war with the implantation of the internal mammary artery indirectly into the cardiac muscle (the Vineberg procedure). A few years later, procedures for direct coronary artery revascularisation were designed, initially including endarterectomy, followed by the construction of an anastomosis between a donor artery or vein and the coronary artery. Interestingly, these first operations were performed on the beating heart without the use of extracorporeal circulation and cardiac arrest.w4 The results of these early initiatives were generally unpredictable, preventing general acceptance and widespread use. It became clear that the safety and efficacy of surgical coronary revascularisation in terms of in-hospital complications and immediate and long term clinical outcome greatly depends, among other factors, on the quality of the anastomosis between the donor graft and recipient coronary artery. To predictably create these delicate and very precise hand sewn anastomoses, the surgeon needs a still and bloodless field with full exposure of the target area, enabling the required complex and coordinated manipulation of the microsurgical instruments.

In this respect, the introduction of cardiopulmonary bypass (CPB) and cardiac arrest by Favaloro in 1967 proved to be a tremendous step forward. Because basic surgical requirements could now be properly addressed, consistent high quality anastomoses could be produced …

View Full Text

Supplementary materials

    Off-pump coronary artery bypass surgery
    Peter P Th de Jaegere and Willem J L Suyker

    Web-Only References

    [View as PDF]

    Caracciolo E, Davis K, Sopko G, et al. Comparison of surgical and medical group survival in patients with left main equivalent coronary artery disease. Long-term CASS experience. Circulation 1995;91:2335-44.

    Muhlbaier L, Pryor D, Rankin J, et al. Observational comparison of event-free survival with medical and surgical therapy in patients with coronary artery disease: 20 years of follow-up. Circulation 1992;86 (Suppl 2);198-204.

    Davis R, Goldberg A, Forman S, et al. Asymptomatic cardiac ischemic pilot (ACIP) study two year follow-up. Circulation 1997;95:2037-43.

    Benetti F, Naselli G, Wood M, Geffner L. Direct myocardial revascularisation without extracorporeal circulation. Chest 1991;100:312-16.

    Cameron A, Davis K, Green G, Schaff H. Coronary bypass surgery with internal thoracic artery grafts: effects on survival over a 15 year period. N Engl J Med 1996;334:216-19.

    The Veterans Administration Coronary Artery Bypass Surgery Cooperative Study Group. Eleven-year survival in the Veterans Administration randomized trial of coronary artery bypass surgery for stable angina. N Engl J Med 1984;311:1333-39.

    Pocock S, Henderson R, Rickards A, et al. Meta analysis of randomized trials comparing coronary angioplasty with bypass surgery. Lancet 1995;346:1184-89.

    The Bypass Angioplasty Revascularization Investigation (BARI) Investigators. Comparison of coronary bypass surgery with angioplasty in patients with multivessel disease. N Engl J Med 1996;335:217-25.

    Bonchek L, Ullyot D. Minimally invasive coronary bypass: a dissenting opinion. Circulation 1998;98:495-97.

    Borst C, Gründeman P. Minimally Invasive Coronary Artery Bypass Grafting. An experimental perspective. Circulation 1999;99:1400-03

    Cowper P, Peterson E, DeLong E, et al. Impact of early discharge after coronary artery bypass graft surgery on rates of hospital readmission and death. J Am Coll Cardioll 1997;30:908-13.

    Koutlas T, Elbeery J, Williams J, et al. Myocardial revascularizsation in the elderly using beating heart coronary artery bypass surgery. Ann Thorac Surg 2000;69:1042-47.

    Kirklin J, Westaby S, Blackstone E, et al. Complement and the damaging effects of cardiopulmonary bypass. J Thorac Cardiovasc Surg 1983;86:845-57.

     John Gu Y, Mariani M, van Oeveren W, et al. Reduction of the inflammatory response in patients undergoing minimally invasive coronary artery bypass grafting. Ann Thorac Surg 1998;65:420-4.

    Wan S, Izzat M, Lee T, et al. Avoiding cardiopulmonary bypass in multivessel CABG reduces cytokine response and myocardial injury. Ann Thorac Surg 1999;68:52-7.

    Matata B, Sosnowski A. Gilnames M. Off-pump bypass graft operation significantly reduces oxidative stress and inflammation. Ann Thorac Surg 2000;69:785-91.

    Fransen, Maessen, Dentener M, et al. Systematic inflammation present in patients undergoing CABG without extracorporeal circulation. Chest 1998;113:1290-95.

    Hickey P, Buckley M, Philbin D. Pulsatile and nonpulsatile cardiopulmonary bypass:review of a counterproduction controversy. Ann Thorac Surg 1983;36:720-37.

    Magovern J, Benckart D, Landreneau R, et al. Morbidity, costs and six month outcome of minimally invasive direct coronary artery bypass grafting. Ann Thorac Surg 1998;66:1224-29.

    Subramanian V, McCabe J, Geller Ch. Minimally invasive direct coronary artery bypass grafting: two year clinical experience. Ann Thorac Surg 1997;64:1648-55.

    Shennib H. A renaissance in cardiovascular surgery: endovascular and device based revascularization. Ann Thorac Surg 2001;72:S993-S994.

    Rivetti L, Gandra S. Initial experience using an intraluminal shunt during revascularisation of the beating heart. Ann Thorac Surg 1997;63:1742-47.

    Heijmen R, Borst C, van Dalen R, et al. Temporary luminal arteriotomy seal, II: coronary artery bypass grafting on the beating heart. Ann Thorac Surg 1998;66:471-76.

    Gundry S, Romano M, Shattuck O, et al. Seven-year follow-up of coronary artery bypasses performed with and without cardiopulmonary bypass. J Thorac Cardiovasc Surg 1998;115:1273-78.

    Arom K, Flavin Th, Emery R, et al. Is low ejection fraction safe for off-pump coronary bypass operation? Ann Thorac Surg 2000;70:1021-25.

    Grundeman P, Borst C, van Herwaarden J, et al. Vertical displacement of the beating heart by the Octopus tissue stabiliser: influence on coronary flow. Ann Thorac Surg 1998;65:1348-52.

    Sternik L, Moshkovitz Y, Hod H, et al. Comparison of myocardial revascularisation without cardiopulmonary bypass to standard open heart technique in patients with left ventricular dysfunction. Eur J Cario-Thorac Surg 1997;11:123-28.

    Chitwood W. Endoscopic robotic coronary surgery. Is this reality or fantasy? J Thorac Cardiovasc Surg 1999;118:1-3.

    Abizaid A, Costa M, Centemero M, et al. Clinical and economic impact of diabetes mellitus on percutaneous and surgical treatment of multivessel coronary disease patients. Circulation 2001;104:533-38.

    Diegeler A, Falk V, Matin M, et al. Minimally invasive coronary artery bypass grafting without cardiopulmonary bypass: early experience and follow-up. Ann Thorac Surg 1998;66:1022-25.

    Jansen E, Borst C, Lahpor J, et al. Coronary artery bypass grafting without cardiopulmonary bypass using the Octopus method: results in the first one hundred patients. J Thorac Cardiovasc Surg 1998;116:60-67.

    Tasdemir O, Vural K, Karagoz H, Bayazit K. Coronary artery bypass grafting on the beating heart without the use of extracorporeal circulation: review of 2052 cases.

    Calafiore A, Teodori G, Giammarco G, et al. Multiple arterial conduits without cardiopulmonary bypass: early angiographic results. Ann Thorac Surg 1999;67:450-56.

    Cartier R, Brann S, Dagenais F, et al. Systematic off-pump coronary artery revascularization in multivessel disease: experience of three hundred cases. J Thorac Cardiovasc Surg 2000;119:221-29.

    Varghese D, Yacoub M, Trimlett, Amrani M. Outcome of non-elective coronary artery bypass grafting without cardio-pulmonary bypass. Eur J Cardio-Thorac Surg 2001;19:245-48.

    Yeatman M, Caputo M, Ascione R, et al. Off-pump coronary artery bypass surgery for critical left main stem disease: safety, efficacy and outcome. Eur J Cardio-Thorac Surg 2001;19:239-44.

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

Linked Articles

  • Miscellanea
    BMJ Publishing Group Ltd and British Cardiovascular Society