CABG: Is Beating Heart Surgery or the Heart-Lung Machine a Better Option for You?

On-pump vs. off-pump bypass surgery
Beating Heart Surgery

Do you need coronary artery bypass grafting (CABG) because of a blockage in your arteries? Heart surgeons will have two options as they get your blood flowing normally again — off-pump CABG and on-pump CABG.

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What’s the difference — and how will your doctors decide which approach is right for you?

How does CABG work?

In CABG (commonly called open heart bypass surgery), “we use a conduit or a blood vessel graft to bypass the blocked coronary arteries,” says cardiac surgeon Faisal Bakaeen, MD.

This graft creates a new path for blood to flow to the heart. Simple enough. The tricky part comes when connecting this graft to an artery.

Doctors either have to stop your heart temporarily or connect the artery as your heart continues to pump blood.

  • On-pump CABG: Here, doctors use medication to stop your heart, but don’t worry. A heart-lung machine temporarily takes over to keep blood moving through your body.
  • Off-pump CABG (beating heart surgery): Here, the surgical team allows your heart to continue to pump but uses stabilizers to keep it as still as possible during surgery.

When is on-pump CABG a better choice?

On-pump surgery is the default strategy for most CABG cases, Dr. Bakaeen says. It’s the best option for the many people who need multiple bypass grafts.

More importantly, when the heart is completely still, it helps simplify things for the surgeon.

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“On-pump surgery allows us to arrest the heart so we can empty it of blood and divert the blood to a heart-lung machine,” he says.

“This gives us perfect exposure of the blood vessels as we perform the procedure. It’s the best way to perform CABG.”

A recent study confirms this. The study’s authors found that, statistically, on-pump CABG offers better long-term survival.

When is beating heart surgery better?

Not everyone is a candidate for on-pump surgery. “Off-pump bypass is useful for patients who do not do well on the heart-lung machine — but these patients are few and far between,” Dr. Bakaeen says.

Sometimes, advancing age and other health concerns can make off-pump bypass the better option. If you’ve had a previous stroke, for instance, or if you have vascular disease or liver disease, the heart-lung machine may be too risky.

“The greatest advantage of off-pump CABG is that it can be utilized in minimally invasive approaches,” he says. The surgeon typically makes a small incision on the left side of your chest and, using special instruments or robotic assistance, attaches the internal thoracic graft to another artery.

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Off-pump CABG is also typically associated with fewer blood transfusions and postoperative rhythm abnormalities, and likely reduces length of stay in the hospital.

Its biggest disadvantage is that — despite using stabilizers — the heart is still moving, and the field is still somewhat bloody. This makes the delicate surgery more challenging for even the most talented surgeon, explains Dr. Bakaeen.

“Also, with the off-pump method, you’re less likely to get all the possible bypasses that you need,” he says. “You may require another procedure to improve to open up diseased blood vessels in the future.”

Some surgeons will have a heart-lung machine on standby as a precaution when they perform off-pump CABG, Dr. Bakaeen notes.

How do the complication rates compare?

The potential major complications are the same, whether you use the heart-lung machine or have beating heart surgery, and include death, stroke, wound infection and kidney failure.

The bottom line is that it’s good idea to ask your doctor about the pros and cons of both approaches to CABG. Then he or she can explain, specifically, how your age and medical history factor into the decision.

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