Introduction
Off-pump coronary artery bypass graft (OPCABG), also known as “beating heart surgery”, refers to coronary artery bypass grafting performed without cardiac arrest or cardiopulmonary bypass hemodynamic [1, 2]. The technique is most commonly employed in patients with isolated proximal left anterior descending coronary artery (LAD) disease without or without associated proximal right coronary disease [2]. The procedure requires the expertise of a surgeon having undergone additional training in the performance of OPCABG. While it can be performed in individuals with low predicted risk of surgical morbidity or mortality, it is a technique that is appealing to offer in those at high risk from such comorbidities as hostile aorta, severe myocardial dysfunction, or underlying renal or pulmonary disease [3-5]. Meta-analysis and trials have shown no difference between on-pump CABG and OPCABG with respect to all-cause mortality but did find a 28% decrease in risk of stroke with the use of OPCABG [6, 15].
While high-risk patients are those that may derive the greatest benefit from OPCABG, they are the most vulnerable to intra-operative decompensation without circulatory support. Currently no percutaneous device is approved for mechanical circulatory support during OPCABG procedure. Use of micro-axial mechanical circulatory devices during OPCABG may prove to be a promising alternative. Currently Impella device (Abiomed, Danvers, MA, USA) considers manipulations of the heart that would be used during cardiothoracic surgery to be a contraindication to the use of the device [7, 8]. Despite the concern, select cases have been describing the use of Impella Recover LP 5.0 during OPCABG [9, 10]. Impella 5.0 delivers upwards of 5.0 L/min support at the consequence of a 21 French inner diameter sheath through a surgically cannulated axillary arteriotomy.
We describe the use of the smaller caliber Impella CP (Abiomed, Danvers, MA, USA) with maximum output of 3.7 L/min, in a case of OPCABG with favorable intraoperative and post-operative results.