“On” or “Off” pump coronary artery bypass grafting – Is the last word out?

A glance at the history of the development of Coronary Artery Bypass Surgery (CABG) throws up the interesting finding that the first milestones were without cardiopulmonary bypass (CPB) support.Off-pump CABG (OPCAB), having predated Onpump surgery, has had a roller coaster ride for want of a clean, still and bloodless field, culminating in the introduction of CABG on CPB (On-pump) by Favaloro in 1967.This development profoundly "democratised" the CABG procedure in that now a broad number of surgeons could achieve better and reproducible results with considerably more optimum operating conditions.The initial enthusiasm for On-pump CABG gradually gave way to concerns regarding its safety, especially with regard to complications arising from CPB, and not CABG per se.Foremost of these relate to microembolic showering during manipulation of the aorta and neurocognitive dysfunction.In addition, CPB triggers a whole-body inflammatory response caused by contact activation of the complement cascade.This leads to multiple organ dysfunction affecting the kidneys, liver, lungs, brain and heart itself. 1 Studies published over a decade and a half ago questioned the safety of On-pump CABG.The proportion of patients recovering without any complication was found to be only 64.3%. 2 In addition, health insurance data and data from clinical studies showed that 10.2% did not leave the hospital within 14 days after the operation and 3.6% of the patients were discharged to a non-acute care facility.3 These and other observations, pari passu with the development of mechanical and pharmacological organ stabilizers and intracoronary shunts, resurrected OPCAB in the early 1990s.As regards surgical technique, the actual suture anastomosis of the vessels follows the same technique both in Onand Off-pump surgery.The difference is that unlike On-pump surgery, where the heart is arrested by means of cardioplegia,