Improving outcomes for coronary artery bypass surgery
perfusionist next to heart-lung bypass machine
If you have coronary artery disease (CAD), in which one or more of the main blood vessels feeding your heart is blocked, you may be facing coronary artery bypass surgery. A desire to improve outcomes after surgery and advances in technology have led surgeons to perform coronary artery bypass surgery without cardiopulmonary bypass, called off-pump bypass (also called "beating heart") surgery.
Traditionally, coronary artery bypass surgery is performed with the assistance of cardiopulmonary bypass. The heart-lung machine allows the heart’s beating to be stopped, so that the surgeon can operate on a surface which is blood-free and still. The heart-lung machine maintains life despite the lack of a heartbeat, removing carbon dioxide from the blood and replacing it with oxygen before pumping it around the body. The heart-lung machine has saved countless lives.
Off-pump coronary artery bypass surgery differs from traditional coronary artery bypass surgery, because the heart-lung machine is not used. Rather than stopping the heart, technological advances and new kinds of operating equipment now allow the surgeon to hold stabilize portions of the heart during surgery. With a particular area of the heart stabilized, the surgeon can go ahead and bypass the blocked artery in a highly controlled operative environment. Meanwhile, the rest of the heart keeps pumping and circulating blood to the body.
Off-pump coronary artery bypass surgery may be performed in certain patients with coronary artery disease. With present technology, all arteries on the heart can be bypassed off-pump. It may be ideal for certain patients who are at increased risk for complications from cardiopulmonary bypass, such as those who have heavy aortic calcification, liver cirrhosis, or compromised pulmonary or renal function. Not all patients are a candidate. The selection of patients who undergo off-pump surgery is made at the time of surgery when the patient's heart and arteries are evaluated more closely.
Off-pump coronary artery bypass surgery is now possible, but is it better?
The aims of off-pump bypass surgery is to decrease the morbidity of coronary artery bypass surgery, such as stroke, renal failure and need for blood transfusion. Also of great interest is the possibility that the off-pump approach may lessen the risk of what are called cognitive changes that have been seen in many patients who underwent CABG with cardiopulmonary bypass.
Surgeons at The Cleveland Clinic completed a study comparing the results of on- and off-pump coronary artery bypass surgery. The researchers matched 406 off -pump and 406 on-pump patients for comparison.
They found that the results of both on- and off-pump surgeries were excellent. The risk of stroke, heart attack during surgery, and death were similar and low in patients undergoing both on- and off-pump CABG. One concern that emerged from recent multi-center studies is that off-pump patients had more incomplete revascularization, meaning that less patients had blood flow fully restored than on-pump patients. In fact, a review of the national trends in bypass surgery demonstrated that fewer surgeons are now performing off-pump CABG. However, Joseph Sabik, M.D. , the Chair of the Department of Thoracic and Cardiovascular Surgery and the lead author of the Cleveland Clinic study, states that with present day technology and focused surgical expertise, patients should not worry. "We should be able to completely revascularize almost all patients."
"It’s important to remember that the results of both on- and off-pump coronary bypass operations are excellent," states Dr. Sabik. "Both have a very low risk of death, stroke, and myocardial infarction (heart attack)." He adds, " It is exciting to find with off-pump surgery, we can significantly reduce the morbidity of coronary artery bypass in appropriately selected patients. We tailor the operation to the patient’s specific needs and circumstances " The end result equals better outcomes for patients.
The good news for heart patients: Coronary bypass surgery is already extremely safe and effective, and becoming even more so.
Are there patients who might benefit from off-pump surgery?
Patients at high risk for complications from cardiopulmonary bypass, such as people with vascular (blood-vessel) disease, previous strokes or liver disease may benefit from off-pump revascularization.
Surgeons are continually looking at ways to improve the outcomes in both kinds of surgery. For example, in on-pump surgery, improvements are being made to the heart-lung machine, and a filtration device that can capture tiny emboli before they do any damage has been designed and is being tested. In off-pump surgery, different ways of stabilizing small portions of the heart are being researched.
Doctors vary in quality due to differences in training and experience; hospitals differ in the number of services available. The more complex your medical problem, the greater these differences in quality become and the more they matter.
Clearly, the doctor and hospital that you choose for complex, specialized medical care will have a direct impact on how well you do. To help you make this choice, please review our Miller Family Heart and Vascular Institute Outcomes.
Cleveland Clinic Heart and Vascular Institute Cardiologists and Surgeons
Choosing a doctor to treat your coronary artery disease depends on where you are in your diagnosis and treatment. Surgeons in the Cardiothoracic Surgery Department have expertise in on- and off-pump coronary artery bypass surgery.
Click on the following links to learn about Sections and Departments who also treat patients with Coronary Artery Disease:
The Miller Family Heart and Vascular Institute offers specialty centers and clinics for patients whose treatment requires the expertise of a group of doctors and surgeons who focus on a specific condition.
See: About Us to learn more about the Sydell and Arnold Miller Family Heart & Vascular Institute.
If you need more information, click here to contact us, chat online with a nurse or call the Miller Family Heart and Vascular Institute Resource & Information Nurse at 216.445.9288 or toll-free at 866.289.6911. We would be happy to help you.
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Diagnostic tests are used to diagnose coronary artery disease and the most effective treatment method.
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Additional information and resources
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Why choose Cleveland Clinic for your care?
Our outcomes speak for themselves. Please review our facts and figures and if you have any questions don’t hesitate to ask.
- Sabik JF, Gillinov AM, Blackstone EH, Vacha C, Houghtaling PL, Navia J, Smedira NG, McCarthy PM, Cosgrove DM, Lytle BW. Does off-pump coronary surgery reduce morbidity and mortality? J Thorac Cardiovasc Surg. 2002 Oct;124(4):698-707.
- Sabik JF. On-pump coronary revascularization should be our preferred surgical revascularization strategy. J Thorac Cardiovasc Surg. 2014 Dec;148(6):2472-4. doi: 10.1016/j.jtcvs.2014.10.068. Epub 2014 Oct 17.
- Bakaeen FG, Shroyer AL, Gammie JS, Sabik JF, Cornwell LD, Coselli JS, Rosengart TK, O'Brien SM, Wallace A, Shahian DM, Grover FL, Puskas JD.Trends in use of off-pump coronary artery bypass grafting: Results from the Society of Thoracic Surgeons Adult Cardiac Surgery Database.J Thorac Cardiovasc Surg. 2014 Sep;148(3):856-3, 864.e1; discussion 863-4. doi: 10.1016/j.jtcvs.2013.12.047. Epub 2014 Jan 15.