Although the average number of coronary anastomoses was 2.7 in the off-pump group and 2.8 in the on-pump group (P < 0.001), this is highly unlikely to be of any

clinical significance. The only remaining question now would appear to be whether off-pump Histone Methyltransferase inhibitor surgery in association with a no-touch aortic technique significantly reduces the risk of perioperative stroke. It Inhibitors,research,lifescience,medical is noteworthy that in the GOPCABE Trial the most common reason for conversion from on-pump to off-pump CABG after the skin incision was a calcified ascending aorta. In summary, the postulated benefits of off-pump surgery have not materialized in clinical practice for most patients, possibly due to the fact that advances in extracorporeal perfusion have made cardiopulmonary bypass much safer. For most patients undergoing CABG today the use of bilateral internal mammary arteries is far Inhibitors,research,lifescience,medical more important than whether surgery is performed on or off pump. MINIMALLY INVASIVE DIRECT CORONARY ARTERY BYPASS GRAFTING Minimally invasive direct coronary artery bypass grafting (MIDCAB) utilizes a small anterior left thoracotomy incision and harvesting of the left internal mammary artery with an anastomosis performed to the left anterior descending artery without cardiopulmonary bypass. MIDCAB was initially described for single-vessel bypass to the left anterior descending (LAD) artery.28 Inhibitors,research,lifescience,medical Many variations have

been described, including Inhibitors,research,lifescience,medical the single left internal mammary artery (LIMA) to LAD bypass, the multivessel complete revascularization, and the saphenous vein graft from the

axillary artery to the LAD. Mammary harvest variations include robotic and thoracoscopic takedown. Finally, MIDCABs have been done with and without cardiopulmonary bypass (CPB).29 Patients for the MIDCAB approach are to be selected carefully; the ideal candidate Inhibitors,research,lifescience,medical would have severe stenosis or complete occlusion of the proximal LAD. It is imperative that the distal LAD is visualized either by collateral filling or by computed tomographic angiography in cases in which the patient has complete occlusion. Importantly, obesity is a relative contraindication; although the LIMA takedown is technically possible in obese patients, the pressure placed on the wound edges by the retractor can lead to tissue necrosis and wound infections. Similarly, oxyclozanide female patients with large breasts are at increased risk of wound necrosis.30 The most pivotal factors in the postoperative management of MIDCAB patients are analgesia and early mobilization30; many patients are extubated on the table, but if a period of postoperative ventilator support is required, the endotracheal tube is changed to a single-lumen tube. Non-steroidal anti-inflammatory medications are used in addition to narcotics, and occasionally a thoracic epidural catheter is placed for pain control. Intravenous fluids are restricted, and patients are usually allowed to get out of bed the same evening.