Anaortic, off-pump coronary artery surgery: should it be the standard-of-care?

Recent trials have shown that coronary artery bypass grafting remains the standard-of-care for multivessel coronary artery disease. However, the main criticism of surgery in these trials has been the higher rate of stroke. Off-pump coronary artery bypass grafting (OPCAB) has been suggested as a technique to reduce the rate of stroke. However, large randomized trials comparing coronary artery bypass grafting with OPCAB have failed to show any neurological benefit, most probably because surgeons in these trials fail to avoid manipulation of the ascending aorta. Herein, the authors review a technique of OPCAB surgery where manipulation of the ascending aorta is completely avoided – ‘anaortic OPCAB’ – facilitated by the use of composite and in situ grafts using bilateral internal mammary arteries.