20 Years of Off-Pump Coronary Bypass Surgery in Clinical Routine: An Evolution with Contribution by the Leipzig Heart Center
02 March 2017
02 March 2017
07 April 2017 (online)
The use of cardiopulmonary bypass (CPB) enabled coronary artery bypass surgery to become the most successful therapy to treat coronary artery disease until now. To perform coronary artery bypass surgery, however, neither CPB nor an arrested or fibrillating heart are required. Use of CPB and cardiac arrest may lead to enhanced surgical safety and an increased comfort for the surgeon during the procedure, however, off-pump techniques may provide similar functionality in experienced hands.
In the late 1990s, cardiac surgeons were stimulated by the evolution of minimally invasive surgery and interventions in other surgical disciplines; hence in the analogy, they evaluated new techniques for potential applications when treating heart diseases, such as mitral valve and coronary artery disease. For the latter, pioneering work was undertaken by Benetti from Argentina and Subramanian from the United States, who avoided the sternotomy approach, harvested the internal mammary artery via a minithoracotomy on the left side, and performed an anastomosis to the left anterior descending coronary artery on the beating heart without using the heart-lung machine (minimally invasive direct coronary artery bypass [MIDCAB]-procedure). 
At the same time, a group of technicians and surgeons in Utrecht, The Netherlands, developed a vacuum stabilization device to expose different coronary arteries. With this technique, all significant targets could be addressed, thus enabling a complete “off-pump” coronary revascularization via sternotomy (off-pump coronary artery bypass [OPCAB] procedure).
Soon after, a small community of surgeons who aimed for less-invasive techniques and approaches in cardiac surgery met at conventions to exchange their experience. During those days Prof. Mohr gave me the task to follow this evolution and to implement it into the surgical program in Leipzig, Germany. This was a mission rather than a task. The group of minimally invasive pioneering surgeons grew vastly; the conventions became bigger and attracted the attention of an increasing number of cardiac surgeons. In 1997, the International Society for Minimally Invasive Cardiothoracic Surgery (ISMICS) was founded in Minneapolis, United States. By following the mission of his mentor, Prof. Mohr, the author became a member of ISMICS soon after its establishment and had the honor to serve as the president of the society in 2010. After an initial training at the Stanford University ([Fig. 1]) the team from Leipzig tried out different approaches and devices for the MIDCB and OPCAB procedure (  ).
Leipzig was of course not the only center in Germany joining the minimally invasive track in cardiac surgery. Minimally invasive coronary surgery was successfully implemented by Hermann Reichenspurner in Munich (now in Hamburg), Vasillios Gulielmos in Dresden (now in Thessaloniki), and Jochen Cremer in Hannover (now in Kiel). Surgeons from other centers accompanied this evolution during this early period. Falk et al implemented the totally endoscopic coronary artery bypass by using the IntuitiveT telemanipulator (Mountain View, California, United States). He spent 12 months in California working at Stanford University and the research and development department of the company to find technical solutions enabling endoscopic coronary artery bypass grafting on the arrested and beating heart. This also included the development of an endoscopic stabilizer.
Today, both techniques, the MIDCAB and the OPCAB, have been fully implemented in the surgical treatment of coronary artery disease. To this end, several scientific trials had to be performed to ensure the safety and efficacy of both techniques. Some of the first clinical trials were conducted in Leipzig, and a randomized “landmark” trial was set up for the MIDCAB technique to compare the minimally invasive surgical approach with percutaneous coronary intervention (PCI).
During the past 20 years, hundreds of further scientific trials have dealt with questions surrounding OPCAB. Nonetheless, there is still a lack of evidence that specific patient populations benefit from the OPCAB technique. At the same time, drug-eluting stents improved the results after PCI of the left anterior descending coronary artery (LAD) and displaced the MIDCAB approach in most of the cases, resulting in the decline of MIDCAB procedures in most centers. The following review aims to give a comprehensive update on both surgical techniques and strategies.
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