Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA. Electronic address: [Email]
Cardiopulmonary bypass (CPB) has been one of the most important additions to the field of heart surgery in the past century. However, significant morbidity associated with CPB has led to the increasing implementation of off-pump coronary artery bypass (OPCAB). The use of OPCAB has broadened surgical revascularization for patient populations at high risk for undergoing CPB, including the very elderly and patients with impending end-organ failure. Intraoperative hemodynamic instability requires expeditious correction of hypotension with various medical and surgical techniques that require the close attention and skill of both the anesthesia and surgical teams. Technical skill at performing and interpreting transesophageal echocardiography is essential to help differentiate regional wall motion abnormalities from coronary ischemia and external compression from manipulation of the heart, which require different management strategies to resolve hemodynamic collapse. Flawless communication between the anesthesiologist and surgeons, with frequent intraoperative adjustments, is paramount for the completion of successful OPCAB.