Off-Pump Coronary Artery Bypass Surgery

What is off-pump CABG?

Coronary artery bypass surgery (CABG) is a type of heart surgery. Surgeons do this type of surgery to bypass blockages in the coronary arteries. An off-pump CABG is a CABG done without the use of a heart-lung machine (cardiopulmonary bypass). This means the heart continues to send blood to the rest of the body during the surgery. It's sometimes called beating heart surgery. With another type of surgery used, a machine takes over the functions of the heart and the lungs, and the heart is still.

The coronary arteries deliver nutrients and oxygenated blood to the heart. Atherosclerosis is a disease that can cause hardened plaque to build up in the coronary arteries. Over time, plaque causes the arteries to narrow. This narrowing can limit blood flow to the heart muscle and cause chest pain (angina). The plaque can also make blood clots more likely to form. These clots may fully block the blood flow through 1 of the arteries and cause a heart attack.

Off-pump CABG is a procedure that surgeons use to restore blood flow to the coronary arteries. The surgeon takes an artery or a vein from another place in the body. The surgeon then uses the vessel to bypass the blocked part of the vessel and restore normal blood flow to the heart. Your healthcare provider may plan the surgery in advance. Or you might need it in an emergency if a vessel suddenly becomes blocked.

Sometimes surgeons do off-pump CABG with the traditional, standard surgical approach. In this type of CABG, the surgeon makes a large cut (incision) down the front of the chest through the breastbone (sternotomy). Recently, some surgeons have started using smaller cuts to do off-pump CABG. In this case, the surgeon makes a much smaller cut through the ribs to do the surgery. This is a type of minimally invasive surgery. It's done to reduce pain and recovery time.

Why might I need off-pump CABG?

If you have coronary artery disease (CAD), you may be able to manage your condition with lifestyle changes and medicines. Sometimes a nonsurgical procedure called coronary angioplasty (or coronary stenting) may be a choice.

If you have severe coronary artery disease, you're more likely to need coronary angioplasty or some type of CABG surgery. These treatments can help reduce chest pain and the risk for a heart attack as well as improve survival. It's possible that your type of blockages won't respond as well to treatment with angioplasty. In this case, you may need CABG surgery. Certain types of blockages may respond better to CABG than to angioplasty. In certain cases, 1 procedure or the other is clearly the best choice. Talk with your healthcare provider about the risks and benefits of both and which surgery is better for you.

Once you and your healthcare provider have decided on CABG, you'll both need to decide what type of surgery is right for you. Some people may be more likely to benefit from off-pump CABG. These include people with advanced atherosclerosis of the aorta, kidney problems, or chronic lung disease. Off-pump CABG may reduce the risks for post-surgery inflammation, infection, and irregular heart rhythms. It's important to have off-pump CABG done by a surgeon with experience in the approach. Different surgical centers and surgeons may prefer 1 method over the other. Ask your provider about your risks and benefits of CABG with or without a heart-lung machine.

What are the risks of off-pump CABG?

Off-pump CABG may have a slightly lower risk of complications than CABG done with a heart-lung machine. Your own risks will vary based on your health condition, your age, and other factors. In the off-pump method, your risk of needing another procedure to improve the heart's blood supply in the future is higher. Talk with your healthcare provider about any concerns that you have.

Most people who have off-pump CABG will have a successful outcome. But there are some possible risks. These include:

Infection
Bleeding
Irregular heart rhythms (arrhythmias) or other heart problems
Blood clots leading to stroke or heart attack
Complications from anesthesia
Kidney failure
Death

Certain factors also increase the risk for complications. These include being older and other health conditions such as diabetes and kidney problems.

How do I get ready for an off-pump CABG?

Talk with your healthcare provider about how to get ready for your upcoming surgery. Remember the following:

Follow any directions you are given for not eating or drinking before surgery.
If you smoke, try to stop smoking before your surgery.
Tell your healthcare provider if you're sensitive to or are allergic to any medicines, iodine, latex, tape, or anesthesia (local and general).
Tell your provider about all the medicines you're taking. This includes prescription and over-the-counter medicines, vitamins, herbs, and other supplements.
You may need to stop taking certain medicines, such as warfarin, aspirin, or other blood-thinning medicines that affect blood clotting before your surgery. Tell your healthcare provider if you have a history of bleeding disorders. You may need blood tests before the procedure to find out how long it takes your blood to clot.
Follow your provider’s instructions regarding medicine use before surgery. This includes which medicines to stop, and when, as well as which medicines to keep taking.
Tell your provider right away if you're pregnant or think you could be pregnant.
Tell your provider if you have a pacemaker, other implanted cardiac device, or another implanted device.

You may need some routine tests before the procedure to assess your health before surgery. These may include:

Chest X-ray
Electrocardiogram (ECG), to assess the heart rhythm
Blood tests
Echocardiogram, to assess the structure and pump function of the heart
Cardiac stress testing, to evaluate the blood perfusion to the heart

If needed, someone will shave your skin above the area of the surgery. About 1 hour before the procedure, someone will give you medicines to help you relax.

What happens during an off-pump CABG?

Check with your healthcare provider about the details of your procedure. In general, during your off-pump CABG:

A healthcare provider will give you anesthesia before the surgery starts. This will cause you to sleep deeply and painlessly during the procedure. Afterwards you won’t remember it.
The surgery will take a few hours.
Your surgeon will make an incision to remove a vessel. Often this is a vessel taken from your chest wall or your leg. An artery inside the chest wall is typically used as the first bypass vessel of choice because it's been shown to stay open the longest.
If you're having traditional off-pump CABG, your healthcare provider will make an incision down the middle of your chest to separate your breastbone.
If you're having a minimally invasive off-pump CABG, your surgeon may make a small incision down the middle of your chest and separate part of your breastbone. Sometimes surgeons use special tools and a camera to do the surgery. In this approach, your provider will make several small holes in your chest, between the ribs. Some surgeons use robot-controlled arms to do the surgery.
Your heart will keep beating during the surgery.
Your surgeon will surgically attach (graft) the vessel removed from the chest wall or leg to the aorta. The aorta is the main blood vessel going out to the body. Your surgeon will attach the other end of the vessel to the blocked coronary artery, to bypass the blockage.
Once the bypass grafts are complete, a surgery team will connect your breastbone back together (if needed).
The surgery team will then close the incision with stitches or staples.

What happens after an off-pump CABG?

In the hospital

You might wake up a bit confused at first. You might wake up a couple of hours after the surgery, or a little later.
The surgery team will carefully watch your vital signs, such as your heart rate. You may be hooked up to several machines to assist in monitoring these continuously.
You may have a tube in your throat to help you breathe. This may be uncomfortable, and you won’t be able to talk. The tube will usually be removed within 24 hours.
You may have a chest tube to drain excess fluid from your chest.
You will feel some soreness, but you shouldn’t feel severe pain. If you have pain, you can ask for pain medicine.
Soon after surgery, you'll be encouraged to get up and sit in a chair. In 1 or 2 days, you should be able to do this with help.
You may do breathing therapy to help remove fluids that collect in your lungs during surgery.
You'll likely be able to drink fluids once the breathing tube is removed. This is often the day after surgery. You can have regular foods as soon as you can handle them.
You'll likely need to stay in the hospital for a few days. But this can vary from person to person.

At home

Make sure you have someone to drive you home from the hospital. For a while, you'll also need some help at home.
You may still tire easily, but you'll slowly start to get your strength back. It may be a few weeks before you fully recover.
Don't drive until your healthcare provider says it's safe for you to do so.
Don't lift anything heavy for a few weeks. Ask your healthcare provider about what is safe for you to lift, and when you can resume your normal activities.
Follow all the instructions your provider gives you for medicines, exercise, diet, and wound care.
Keep all follow-up appointments. You'll likely have your stitches or staples removed in a follow-up appointment in 7 to 10 days.
Your provider may suggest that you begin a cardiac rehab (rehabilitation) program. This program slowly gets you back to a normal lifestyle. Cardiac rehab begins in the hospital with simple walking. The program moves on to a regular exercise routine and a nutritious diet. Sticking to healthier habits can prevent future heart problems.