Dr. Huda Ismail , MD Consultant Department of Adult Cardiac Surgery PSCC , Riyadh
OPCAB
was introduced > 30yrs ago, adopted mainly by developing countries then gradually introduced in developed countries where patients are older with comorbidities in an attempt to reduce the risk of CPB The
debate between OPCAB proponents and critics is still unchanged even after 25ys Currently
OPCAB plateaued to 15-20% in the west but still popular in the far-east (70-100% in China)
Circulation.2010;121:498-504
Ann. Thorac surg 2005;80: 2141-7

6665pts & Follow up 4.5yrs
Circulation.2012;121:1800-1808
Conclusion: OPCAB is associated with minimal short term benefits and high long term risk of repeat revascularization and major vascular adverse events specially among high risk pts. OPCAB is less cost effective in the long run
Hu et al.Circulation.2012;121:1800-18
Observational (8yrs) 297pt ONCAB & 298pt OPCAB Conversion rate 1.1% Acutely converted pts. tended to have higher in hospital mortality & morbidity Acute conversion appeared to lead to an increased risk of death or serious cardiac related events up to 2-3yrs postop
Conclusion: The experience of the surgeon is the main factor
J. Cardiothoracic Surgery,2006 (29).941-947
59 RCT (8961pts) Mean age 63yrs (16% ♀) All cause mortality showed no statistically significant difference OPCAB benefits were thought to be more when more graft were performed
Afilalo et al, Euro Heart Journal, Oct. 2011
Myocardial infarction showed no difference Afilalo et al, Euro Heart Journal, Oct. 2011
Stroke there was a 30% reduction in OPCAB Afilalo et al, Euro Heart Journal, Oct. 2011
 To assess the benefits & harm of OPCAB vs. ONCAB  86 RCT trials (10,716pt) OPCAB vs. ONCAB
Result
All cause mortality
75trial ,OPCAB significantly increased mortality P=0.04
Myocardial infarction
55trials,no difference
Stroke
64trials , a significantly greater risk of stroke in ONCAB however in the trials with low risk of bias no statistically significant differences were observed
Atrial fibrillation
34trials ,significant effect of OPCAB P=0.008
Coronary Revascularization
19trial ,no statistical significant differences
Renal impairment
21 trials ,no significant difference
Number of distal anastomosis
OPCAB resulted in fewer distal anastomosis(p<.00001) Mollar et al. Cochrane review 2012(3)
Conclusion: OPCAB
has no significant benefit regarding mortality ,MI &
stroke OPCAB
may be an acceptable option when ONCAB is contraindicated Based
on current evidence ONCAB is the standard treatment option for CAD
Circulation. 2012;125:2827-2835
NEJM,2012;366:1489-97
NEJM,2012;366:1489-97
Adopting OPCAB is hindered by long learning curve
High risk pts. are included in registries that report clinical and statistical benefits in term of mortality and all major postoperative complications
Most OPCAB RCT are conducted on low risk pts.
No supportive evidence to the superiority of OPCAB
OPCAB outcome depends on the experience of the surgeon
OPCAB still shrouded in controversy Need for large RCT mainly in the high risk and elderly patients Limit OPCAB in the hands of experienced centers or surgeons to achieve complete revascularization