Coronary artery bypass grafting on the beating heart: changing the paradigm

Over the past decade coronary artery bypass grafting (CABG) on the beating heart (off-pump or OPCAB) has become a standard procedure in many centres worldwide; however, the practice of OPCAB ranges from 0% to 100% of cases, even between surgeons operating in the same unit. This variation is the result of several interrelated factors, the most important of which is the question of graft patency. Some surgeons express concern about the quality of distal anastomoses performed on a moving field, and question the need to alter their practice from the perceived gold standard of conventional coronary artery surgery with cardiopulmonary bypass and cardioplegic arrest. This scepticism is self perpetuating, since a lack of familiarity reinforces the perception that OPCAB is technically too demanding or gives worse outcomes. Another major consequence is a paucity of adequate training in OPCAB techniques. In truth, the evidence to date indicates that OPCAB, when compared with conventional CABG, is associated with at least equivalent clinical outcome at lower cost.1-11 Furthermore, training in OPCAB techniques, as part of a structured programme, has been shown to be safe and successful.12,13 Existing evidence challenges the paradigm that conventional on-pump CABG represents the gold standard in surgical revascularization. This has important implications for the future practice of cardiac surgery. In particular, are current cardiothoracic training programmes in the UK and elsewhere capable of training the next generation of surgeons in OPCAB techniques?