What is Opcab

8/3/2019 What is Opcab

1/17

What is OPCAB?

The off-pump technique, also known as OPCAB, is very

similar to the conventional Coronary Artery Bypass Grafting

(CABG) procedure. OPCAB still utilizes a medial sternotomy,

however the important difference is that the cardiopulmonary

bypass pump is no longer employed.

Procedure:

OPCAB was developed from the minimally invasive

school of thought, so the basic premise is to reduceincision sizes. A surgeon will perform median

sternotomy of varying sizes (depending on the

physiology of the patient, the smallest incision will be

made). Arteries or veins can be harvested from the

patients chest wall, arm, and or leg.

To aid the surgeon in operating on the beating

heart, drugs such as Adenosine and Esmolol are

used to slow the heart rate. To allow for access tothe entire heart, there must be a sufficient amount

of cardiac displacement. This is accomplished by

deep pericardial sutures and the use of specialized

instruments to prop the heart in a position that will

allow the surgeon to access occluded arteries.

Once within the pericardial sac, sponges are used to

reduce free blood in the region being operated on. The

sponges also serve as a way to displace the heart,

allowing a clear view of the region for anastomosis.

With the heart still beating, there is a greater difficulty

in performing a bypass on the posterior and lateral wallsof the heart. Surgeons have found many ways to

stabilize the heart in order to bypass the necessary

arteries. Along with sponges, some surgeons will use

slings to prop the heart in the necessary positions and

then utilize a stabilizer to focus on a particular occluded

artery. Biotechnical firms have also developed products

such as the Octopus that help to stabilize pertinent

regions of that heart during surgery. Some surgeons will

prepare the patient for attachment to the

cardiopulmonary bypass pump in case of an emergency

or accident that might occur during the operation. This

is precautionary and not all surgeons will choose to doso.


2/17

The length of the operation depends on a number of variables. Much like CABG, the number of occlusions can

greatly effect the length of time on the operating table. The removal of the cardiopulmonary bypass pump does

reduce time since it does not need to be attached and the heart does not need to be reanimated. However, the beating

heart must be handled with a great amount of care. To reach an artery on the lateral wall of the heart, the heart must

be propped and stabilized, all of which can add to the length of the operation.

Techniques and Instrumentation used to Operate on a Beating Heart

Minimally invasive procedures which are done on a beating heart and do not use cardiopulmonary bypass (the heart-lung machine), such

asMIDCABand OPCABoperations, are called off-pump procedures. These off-pump procedures require special techniques andinstrumentation in order to perform efficient and reliable anastomosis on the beating heart. Click on the heading for a page describing these

techniques and instrumentation.

Surgery Comparisons

Click on the heading for a page with a table comparing the basics between all minimally invasive surgeries, or continue for in-

depth analysis of OPCAB vs. CABG and OPCAB vs. MIDCAB.

OPCAB vs. CABG

There are a number of studies being done on all types of minimally invasive surgeries. The studies in progress offer a short-term

look at the reliability of minimally invasive procedures.

In a study performed by the Cardiac Surgical Associates, P.A. in Minneapolis, Minnesota, the comparison of OPCAB to CABG

patients showed that (by percentage) OPCAB had similar or better results.

Stroke

N (%)

New Renal

Failure N (%)

New Atrial

Fib N (%)

Mortality

N (%)

Low Risk On PumpN=2360

30 (1.3) 99 (4.2) 500 (21.2) 27 (1.1)

0-2.59 Off Pump

N=216

2 (0.9) 7 (3.2) 26 (12.0) 3 (1.4)

N=2576 P-value 1.0 0.499 0.001 0.736

MediumRisk

On PumpN=688

29 (4.2) 71 (10.3) 187 (27.2) 45 (6.5)

2.6-9.9 Off Pump

N=95

3 (3.2) 9 (9.5) 17 (17.9) 6 (6.3)

N=783 P-value 0.787 0.799 0.053 0.934

High Risk On PumpN=123

6 (4.9) 26 (21.1) 34 (27.6) 35 (28.5)

>10 Off Pump

N=39

0 (0) 1 (2.6) 7 (17.9) 3 (7.7)
http://biomed.brown.edu/Courses/BI108/BI108_2000_Groups/Heart_Surgery/Instrumentation.htmlhttp://biomed.brown.edu/Courses/BI108/BI108_2000_Groups/Heart_Surgery/MIDCAB.htmlhttp://biomed.brown.edu/Courses/BI108/BI108_2000_Groups/Heart_Surgery/MIDCAB.htmlhttp://biomed.brown.edu/Courses/BI108/BI108_2000_Groups/Heart_Surgery/Comparisons.htmlhttp://biomed.brown.edu/Courses/BI108/BI108_2000_Groups/Heart_Surgery/MIDCAB.htmlhttp://biomed.brown.edu/Courses/BI108/BI108_2000_Groups/Heart_Surgery/Comparisons.htmlhttp://biomed.brown.edu/Courses/BI108/BI108_2000_Groups/Heart_Surgery/Instrumentation.html


3/17

N=162 P-value 0.337 0.006 0.225 0.008

In another study that was presented at an Annual Meeting of the Society of Thoracic Surgeons,

the following information was found:

The hypothesis for the study was that off-pump surgery would reduce some of the side effects of conventional

cardiopulmonary bypass surgery that stops the heart and restarts it after surgery. There were no hospital deaths in

the off-pump group compared to nine deaths in the CABG group. Off-pump surgery also reduced the averagepostoperative hospital stay from 5.5 days to 3.3 days. Perhaps the most significant statistic was the reduction in the

need for transfusion after the operation. Less than a third of the off-pump patients (29.6 percent) needed

transfusions compared to more than half (56.5 percent) of the CABG group.

The problem is that there is, and will not be for a number of years, any data assessing the outcome of an off pump coronary

artery bypass. The clear problem with the lack of data backing up the OPCAB procedure is why stray from conventional CABG

that has a 99% success rate, as well as success over time.

OPCAB, it is believed, could be performed in 30-40% of coronary artery bypass situations (60-70% of the time, the physiology

of the patient does not allow for an off-pump procedure). Many problems with the procedure have been dealt with over the past

few years of development. For example, there were reports of a decrease in cardiac output by 33%. This was remedied by

volume loading of the right ventricle. Surgeons have also become more familiar with the procedure and learned that during

OPCAB, the systolic pressure should not be allowed to fall below 100 mmHg.

However, there are some questions about the safety of the procedure. Critics of OPCAB have presented several issues that may

make this new procedure a poor alternative to CABG. The underlying problem is the lack of data supporting the patients status

five to ten years down the road following bypass surgery using OPCAB. Another point being made is the sutures may not hold

given that they were made on a beating heart. This point can not be contested since there is no long-term postoperative data that

can show that the sutures held allowing for successful anastomosis. The major risk in OPCAB is that surgeons may not have a

great deal of experience with the procedure. This could lead to poor or even fatal outcomes.

Why Avoid The Heart-Lung Machine?

Since the invention of a crude version of the heart-lung machine in 1955, it has aided surgeons in performing open-heart and

bypass surgeries. Over time, the machine was refined to its current form, allowing surgeons to carry out open-heart procedures

with a success rate of nearly 99%. Though the heart-lung machine has proven to be a major reason for the success of CABG

procedures, there is some pathology associated with its use [17].

The surface of the tubes that carry the blood to and from the heart-lung machine are capable of injuring blood cells

While in the tubes of the machine, the blood is subjected to a considerable amount of external stress forces

Many substances may be caught in the blood stream such as air, plastic particles, and small blood clots

All of these factors leads to what some doctors call a "whole body inflammation". Doctors believe complications will increase

with the amount of time a person is left on the cardiopulmonary pump. Complications inculde:

Swelling of the brain

Infections

Arrhythmia

Kidney stress

Blood vessel damage

Need for transfusion

Low output syndrome

Weight gain

Difficulty planning out complex actions

Release of cytokines leading to a variety of physiologic events

Irritability

OPCAB vs. MIDCAB

The main reason why a patient may receive OPCAB as opposed to MIDCAB is the number of vessels that need to be replaced.

In the earlier days of OPCAB, surgeons were only able to reach blocked arteries on the front wall of the heart. As this surgical
http://biomed.brown.edu/Courses/BI108/BI108_2000_Groups/Heart_Surgery/MIDCAB.htmlhttp://biomed.brown.edu/Courses/BI108/BI108_2000_Groups/Heart_Surgery/MIDCAB.html


4/17

method has evolved over the past few years, new devices have been developed to allow the heart to be displaced from the

protective pericardium. Once exposed, the heart is stabilized through various methods in various positions. This gives surgeons

the ability to access arteries on anterior and lateral walls of the heart. Given this advantage, patients that suffer from multiple

occlusions may receive OPCAB.

The safety of these two procedures is still in question. OPCAB and MIDCAB have not been around for more than a few years,

and the long term results are not known. The short-term studies done on the two procedures have given similar results, both

showing promise of a safe alternative to conventional CABG. However, the physical condition as well as the number of

occlusions to be removed will be a determinant in choosing OPCAB over MIDCAB (an over weight patient or a patient with

multiple occlusions would not be eligible for MIDCAB).

Cost:

OPCAB will be a cheaper operation relative to conventional CABG in several ways. Cost reduction occurs due to:

Cardiopulmonary bypass pump is not used

Shorter postoperative hospital stay due to avoidance of heart-lung machine

Faster recovery

Note to the Reader

This article is a descriptive summary of anesthetic techniques for off-pump coronary

artery bypass (OPCAB) surgery. We describe our management strategies in order to

assist our colleagues who may be encountering OPCAB surgery for the first time, or

who are interested in different perspectives on management. This article is not

intended to be a dogmatic approach to the topic, but rather, to suggest management

strategies in these challenging cases.

Introduction

The anesthetic management for off-pump coronary artery bypass surgery is

particularly demanding and requires an approach specifically tailored to the procedure.

OPCAB cases require vigilant anticipation of surgical steps, skilled hemodynamic

management and close communication with the cardiothoracic surgeon. Furthermore,

optimal management in OPCAB surgery involves a considerable learning curve, for the

surgeon, the anesthesiologist and the entire cardiac team. We present our experience

in the anesthetic management of over 350 cases involving four different surgeons and

twelve anesthesiologists at our two institutions.

This article will present a brief description of OPCAB surgery along with some historical

references. Following this is a summary of the advantages of OPCAB over the

traditional on-pump coronary artery bypass grafting (CABG) procedure, with pertinent


5/17

references to the growing literature. Next, the various anesthetic considerations and

techniques will be described in some detail, with references to the OPCAB procedure,

as it is relevant. We expect that these particular techniques will be modified to fit the

experience of individual clinicians, and we anticipate that the anesthetic management

of these cases will evolve over time.

OPCAB Procedure

Aortocoronary bypass without the use of cardiopulmonary bypass (CPB) was first

performed by Kolesov (1) in 1964. Others subsequently reported on the technique,

(2,3,4,5) but it was largely abandoned with the widespread adoption of cardiopulmonary

bypass (CPB) and cardioplegic arrest. Surgery on the beating heart re-emerged with

the introduction of so-called minimally invasive procedures. These surgeries, such as

the minimally invasive direct coronary artery bypass (MIDCAB), are usually performed

using limited parasternal incisions, special devices to provide exposure and stabilize

the epicardium, and most often a one or two vessel bypass on a beating heart, without

the use of CPB. (6,7) However, the use of MIDCAB surgery is limited because it does not

readily allow for the performance of multiple vessel bypass.

The OPCAB procedure is a natural extension of the more limited MIDCAB surgery and is

gaining in popularity with the development of devices to better stabilize the beating

heart. The key surgical features of OPCAB surgery are the absence of CPB, operation

on a beating heart, use of an epicardial stabilizer, temporary interruption of coronary

blood flow during microsurgical anastamosis of distal vessels, and extubation either in

the operating room or shortly thereafter. Rather than a single (or at most three) vessel

bypass, which would characterize a MIDCAB, our surgeons have been bypassing as

many as seven vessels during OPCAB.

Advantages of OPCAB

The key advantage of OPCAB surgery is avoidance of the pump. This fact alone has

numerous ramifications and has been essential in popularizing both MIDCAB and

OPCAB procedures.


6/17

In terms of morbidity and mortality, the clearest advantage of OPCAB is that the

neuropsychologic impairment associated with CPB may be significantly reduced.

Numerous recent OPCAB studies report fewer than 1% severe neurologic deficits, such

as completed strokes and coma. (8,9,10) This compares with incidences of 2-3% for

CABG surgery, depending on preoperative risk factors. (11,12,13) In addition, we have

observed a decrease in minor neurologic disturbances, most notably persistent

confusion, after OPCAB surgery. Most off-pump patients are clearly more alert, and

many of them are ready to sit up and take liquids a few hours postoperatively.

While OPCAB involves periods of transient coronary ischemia, this procedure avoids the

potential global myocardial ischemia that may be associated with CPB. Studies

measuring troponin I levels, a specific marker of myocardial damage, report that

OPCAB surgery is associated with significantly less release of the protein. (14,15,16). We

have found, in agreement with published reports, that fewer inotropes are needed after

the revascularization, there are fewer dysrhythmias (especially atrial fibrillation) and

there is less need for post-procedure cardiac pacing. (8, 10,17)

In providing anesthesia for OPCAB, we have experienced far fewer problems with

hemostasis and perioperative bleeding. Use of a lower dose of heparin, lack of CPB-

associated hemodilution, and absence of pump-related platelet dysfunction have a

significant effect on perioperative blood loss. The use of prophylactic antifibrinolytics,

such as aminocaproic acid and aprotinin, is largely unnecessary. At our institutions, the

transfusion of heterologous blood has been reduced nearly by one-half, in agreement

with several published reports. (9, 17,18)

Avoiding extracorporeal circulation confers a number of other advantages. Respiratory

problems are reduced, and even patients with fairly severe COPD are being extubated

shortly after the procedure. Renal function is better preserved with OPCAB, as

demonstrated by fewer instances of postoperative renal insufficiency. (14, 17)

Pharmacokinetics are more predictable since there is no uptake of drug from the

pump, and there are fewer metabolic perturbations, especially in glucose, potassium

and calcium. Lastly, OPCAB avoids complement activation and the systemic

inflammatory response associated with CPB, (19, 20) which may facilitate postoperative

analgesia and fluid management.


7/17

Preoperative Considerations

Since early awakening and extubation is an anesthetic goal in OPCAB surgery,

preoperative sedation should not be heavy. We use relatively small doses of

benzodiazepines preoperatively and supplement with intravenous midazolam and

fentanyl in the operating room and during placement of invasive lines.

To help maintain normothermia, we assure that our OPCAB patients are warm

preoperatively, even if active warming is necessary. Once in the operating room, the

patient is placed on a circulating-water mattress and then covered with a forced-air

warming blanket (BairHugger, WarmAir). All rapidly infusing intravenous fluids are

warmed. Using these measures, we have not found it necessary to raise the ambient

room temperature. This emphasis on maintaining normothermia may facilitate

hemodynamic management and expedite tracheal extubation shortly after the case.

(21)

As with all cardiac cases, large-bore intravenous access and central access to the

circulation is necessary. Because these cases often involve unstable hemodynamics,

especially during distal anastamoses, ready access to the central circulation is

essential for both bolus dosing and infusions.

Our use of monitoring for OPCAB cases has evolved over time. ST-segment analysis

has been particularly useful, especially in assessing the tolerance of the heart for

coronary occlusion during the distal anastamoses. A non-invasive BP cuff is used to

back up and verify the arterial tracing. The plethysmograph on the pulse oximeter isvery helpful in assuring adequate perfusion.

While a pulmonary artery catheter may not be warranted on the basis of a patients

cardiac status, we have found that preoperative ventricular function does not

adequately predict any patients response to heart positioning and coronary occlusion.

Accordingly, it is our current practice that all OPCAB patients are monitored with

pulmonary artery catheterization and themodilution cardiac outputs.


8/17

The use of transesophageal echocardiography (TEE) is limited in OPCAB cases by the

difficulty in obtaining useful information while the heart is retracted for many of the

distal anastamoses. With the use of frequent cardiac output monitoring, we have found

that the TEE has not changed overall management to any significant degree.

Induction and Initial Maintenance

Because hemodynamic changes occur rapidly and unexpectedly in OPCAB surgery, we

routinely have a vasodilator and vasopressor/inotrope ready for immediate infusion.

The choice of these drugs has evolved over time. While nitroglycerin is used universally

for vasodilation, the selection of vasopressor remains varied, the most common

choices being phenylephrine, norepinephrine and dopamine. Likewise, it is useful to

have a number of vasoactive medications readily available for bolus administration.

The medications we have found most helpful are ephedrine, phenylephrine (40-100

mcg/ml), epinephrine (10 & 100 mcg/ml), calcium and lidocaine.

The induction of anesthesia is determined by the patients status at the time and the

aim to extubate the trachea at the end of the case. Etomidate or propofol are most

often used for induction, along with a loading dose of opioid. For most patients a

fentanyl dose of 7.5 to 10 mcg/kg (or sufentanil 0.5-1.0 mcg/kg) has been adequate to

help blunt the surgical stimulus of incision and sternotomy, yet also allow for timely

tracheal extubation. Anesthesia is maintained using a volatile agent, and occasionally,

a propofol infusion is also used. Any of the intermediate-acting neuromuscular blockers

adequately provide muscle relaxation, while also being readily reversible.

The heparin dose we use for OPCAB is 1.5-2 mg/kg, aiming to keep the activated

clotting time (ACT) greater than 300 seconds during vessel anastamoses. Reports of

systemic anticoagulation vary considerably in the literature, with heparin doses varying

between 1 and 3 mg/kg, and ACTs usually targeted in the 200-300 range. (17, 22, 23)

While we initially checked the ACT every 20 minutes, we have found that less frequent

measurements are reasonable.

We have found it to be advantageous to keep the patient well hydrated for OPCAB

surgery, a practice differing from that in CPB cases where we attempt to minimize fluid


9/17

administration. Generous hydration, guided by the pulmonary artery catheter, helps

alleviate the reduction in preload that occurs when the heart is retracted, thereby

aiding hemodynamic management. It may also help reduce oliguria during this period.

After procurement of saphenous vein and skin closure, we place a sterile forced-air

warmer at the highest setting over the lower part of the body. This has made a

significant difference in assuring normothermia during the remainder of the procedure.

To prevent dysrrhythmias during manipulation of the heart and coronary occlusion, we

routinely give prophylactic doses of bolus lidocaine (1-1.5 mg/kg) and infused

magnesium (2 gm) prior to the first distal anastamosis. (24) We have a low threshold for

running a lidocaine infusion (2-3 mg/min) and use it routinely for right coronary artery

grafting. If nitroglycerin is not already infusing, a nitroglycerin infusion is usually

started prior to suturing the distal anastamoses and is most often continued

throughout the procedure. In patients with serum potassium less than 4.0, we routinely

infuse potassium during this period. (25) Lastly, a pacemaker is readily available in case

pacing on the field is required, especially to treat bradyarrhythmias associated with the

right coronary artery anastamosis.

We are always prepared to adjust management and maintain hemodynamics for a

semi-elective or more emergent conversion to CPB. As surgical experience has grown

with OPCAB, there have been fewer cases where this was necessary.

Anastamoses

The suturing of the distal anastamoses is by far the most demanding part of the case.

The anesthesiologist must be continually observing the field, watching the monitors

and communicating with the surgeon.

Once the surgeon chooses the first vessel for the distal anastamosis, he places a

silastic tape around it to produce proximal coronary occlusion. If this is reasonably well

tolerated, he then places the epicardial stabilizing device. Once this is in position, he

incises the target site and starts the distal anastamosis.


10/17

During this period of distal anastamosis, there is no turning back. The consequences

of this temporary coronary occlusion may be relatively insignificant or may lead to

severe heart failure and ultimately cardiac arrest. It is helpful to measure serial cardiac

outputs during this period to help determine the need for resuscitative efforts. In our

experience, cardiac indexes have been as low as 0.7 L/min/m2 during this period. In

addition, the ST segments may become severely elevated or depressed.

The key to anesthetic management during a distal anastamosis is to aggressively

maintain hemodynamic stability. In patients where preoperative cardiac function is

impaired, we often use a background infusion of phenylephrine, dopamine or

norepinephrine to maintain blood pressure and cardiac output. Infusion of an inotrope

is also helpful if cardiac output falls significantly after application of the epicardial

stabilizer. If the cardiac index continues to fall during the anastamosis (e.g., CI


11/17

to near baseline levels before the surgeon attempts the next anastamosis, especially if

it involves displacement of the heart. At times the anesthesiologist may need to

interrupt the surgeons progress to allow the heart to recover from a poorly tolerated

period of coronary occlusion.

Subsequent distal anastomoses are carried out in a similar manner. For certain target

sites, such as the branches of the circumflex artery, deep pericardial retractors or a

sling may be used to retract the heart into an optimal position for the surgical

approach. This displacement of the heart, with the apex pointing anteriorly, causes

right ventricular dysfunction and resultant biventricular pump failure. This deterioration

in circulatory status is due primarily to a severe reduction in stroke volume, as the

geometrically distorted right ventricle cannot sufficiently expand during diastole. (26)

During this retraction phase, the ECG tracing is characteristically flat and both rhythm

and ST analysis are often indiscernible. If a TEE is being used, its images of the

retracted heart provide little useful information. Fortunately, cardiac output

measurements are still possible and plethysmography is often a reassuring guide of

peripheral perfusion.

To improve the circulatory status during heart displacement, the patient is placed in

approximately 20-degree Trendelenburg position. As a practical point, we use special

positioners to keep the patient from shifting on the operating room table. Steep

Trendelenburg position causes decreases in pulmonary compliance and functional

residual capacity and may compromise adequate ventilation, especially in obese

patients.

Once the last distal is in place, the surgeon is ready to apply a partial cross clamp to

the aorta for placement of the proximal anastamoses. This step requires a rapid

lowering of blood pressure, usually with volatile agent, nitroglycerin, or nitroprusside.

The following period of relative calm allows the heart to recover from the repeated

insults and the anesthesiologist to prepare for closure and emergence.

Emergence, Extubation, Postop Analgesia


12/17

Once the heart is reperfused with the multiple bypass grafts, we administer protamine

to reverse anticoagulation. Heparin reversal is somewhat controversial and is omitted

in some programs. (23, 27) If the surgeon chooses to perform parasternal intercostal

nerve blocks, they are done at this point. After the sternum is reapproximated, the

muscle relaxant is reversed and cell saver blood is returned.

To be eligible for extubation in the OR, the patient must be awake, normothermic, non-

acidotic and adequately ventilating. If the patient is not ready to be extubated in the

OR, he may usually be extubated a short time later in the intensive care unit.

A key to success here is adequate analgesia. Unless contraindicated, we routinely give

ketorolac (Toradol) to OPCAB patients prior to extubation. Additionally, intravenous

opioids are titrated to effect. We have also used patient-controlled analgesia with

considerable acceptance.

At one of our institutions, intrathecal morphine has been used for postoperative

analgesia. For patients without coagulation abnormalities, preservative-free morphine

(0.2-0.4 mg) is instilled into the subarachnoid space at the lumbar level. This is usually

done in the operating room just prior to placement of invasive lines, but it has also

been done during the postoperative period. Despite reports of prolonged ventilatory

depression and inadequate analgesia in CABG patients, (28) in our situation intrathecal

morphine has been well accepted, safe and effective, with minimal side effects.

Our experience with recovering OPCAB patients in the ICU has been one of slow, but

gradual acceptance by both nurses and respiratory therapists. While our ICU nurses

have been accustomed to receiving anesthetized, intubated cardiac patients, OPCAB

patients often arrive extubated and may be restless and complaining of pain. Nurses

caring for these patients must be skilled in pain management as well as in handling

various airway problems. For them, management of inotropic support and

measurement of chest tube output has been replaced with placement of

nasopharygeal airways, titration of morphine and reassurance of the temporarily

disoriented patient.


13/17

Similarly, respiratory therapists accustomed to ventilator management are most often

called upon to provide enriched oxygenation, bronchodilator treatment and early chest

physiotherapy. With experience, we have eliminated routine ventilator set-up but we

still insist on having a respiratory therapist readily available.

Conclusion

OPCAB surgery is a significant advance in the operative treatment of coronary artery

disease and presents significant challenges for the anesthesiologist. A number of

aspects such as careful preparation, appropriate monitoring, maintenance of

normothermia, specifically tailored drug management, maintenance of hemodynamic

stability, provision of good operating conditions and a goal of early extubation are

important in the management of these cases. As both surgical and anesthetic expertise

with OPCAB surgery grows, we will make further progress toward anesthetic

management that provides the optimum of safety and comfort to our patients.

AccuMist Blower/Mister

Precise coronary suturing requires a clear, bloodless field. The AccuMist device offers advanced fluid/gas mixing

technology, setting a new standard in creating a consistent, predictable blood clearing mist.

The AccuMist Blower/Mister features:

On/off control in hand-piece

Easy-to-hold design

Malleable shaft

Specialized nozzle, utilizing a micro-orifice for fluid delivery and a separate orifice for gas delivery

ClearView Intracoronary Shunt

For a Bloodless Anastomotic Site and Distal Blood Flow


14/17

As beating heart surgery techniques continue to evolve, Medtronic continues to innovate. One such innovationfrom Medtronic is the ClearView Intracoronary Shunt.

The ClearView Shunt is designed to help you perform quality anastomosis on a beating heart.

The ClearView Shunt improves visualization by providing a bloodless field for anastomotic suturing, while at thesame time providing flow through the anastomotic site to the myocardium. With the introduction of the ClearViewshunt, Medtronic is proud to offer further innovation the first 1 mm intracoronary shunt.

Off-center lineplacement allowsfor easy removal

Clear shaftallows for a clear

view of flowthrough the

anastomotic site

Beveled tip allowsfor atraumaticinsertion and

removal

Ordering Information

Catalog Code Bulb Size Length Between Bulbs

31100 1.00 mm 14 mm

31125 1.25 mm 14 mm

31150 1.50 mm 14 mm

31175 1.75 mm 14 mm

31200 2.00 mm 14 mm

31225 2.25 mm 14 mm

31250 2.50 mm 14 mm

31275 2.75 mm 14 mm

31300 3.00 mm 14 mm

New: Octopus System II:

Octopus4 Tissue Stabilizer and Starfish2 Heart Positioner

Medtronic, the leader in suction stabilization, has improved upon what is already the market-leading stabilization systemfor beating heart surgery. The new Octopus System II (Octopus4 and Starfish2) features significant innovations inease of use and performance that make it the obvious choice for access to, and stabilization of, all vessels -- even thetough-to-reach OMs.

FREE VIDEO:Click here to registerto receive a copy of our new video Octopus System II: Complete MultivesselRevascularization.

Octopus4 Innovations

The Octopus4 retains the clear, malleable, spreading pods surgeons have become accustomed to, combined with new enhancements:
http://www.medtronic.com/cardsurgery/products/octosystem_reg.htmlhttp://www.medtronic.com/cardsurgery/products/octosystem_reg.htmlhttp://www.medtronic.com/cardsurgery/products/octosystem_reg.html


15/17

Starfish2 Innovations

The Starfish2 continues to simplify cardiac positioning and minimize hemodynamic deterioration.1

Octopus System Positioning Options

Simplified Positioning, Enhanced Access, Superior Stabilization

The Medtronic Octopus System is designed to maximize access and stabilization of coronary arteries for off-pump grafting. The OctoBase retractor allows for the highest performance of both the Starfish and Octopusby making multiple mounting options available.

The following graphic illustrations represent suggested mounting and positioning options for the MedtronicOctopus System. They are provided solely as guidelines and are not to be interpreted as directions for use.

Proper surgical techniques and procedures are the responsibility of the medical professional.

Introducing the Starfish Heart Positioner

Two attachment options enhance lateralwall exposure.

Integrated Bellows Suspension allows fornatural heart movement throughout thecardiac cycle.

Three-appendage silicone head designallows for multiple attachment options tooptimize placement on the epicardium.

Attachment procedure:

1. Place the Starfish head on the epicardium prior to turning on the vacuum.

2. Turn on the vacuum and position the heart after the vacuum has reached (-)400mm Hg.

3. Avoid placing the device over an epicardial sulcus or crevice to prevent loss of vacuum seal.

4. Orient the bellows perpendicular to the weight and force of the heart.

The Octopus 3-0 Tissue Stabilizer

The pioneering and market-leadingsuction stabilzer.

Malleable stabilizer pods can beformed to the unique contours of thepatient's anatomy.

A unique tissue-spreading mechanismenhanced stabilization of theanastomotic site and presentation ofthe coronary.


16/17

Lateral Wall Positioning Options

[ Click to Enlarge ]

[ Click to Enlarge ]

Apex Under Right Hemisternum

Starfish attached to the left ventricle, immediately lateral to apex.

Even modest rightward movement of apex greatly enhances exposure of proximal OMs and lowers the profile of the device.

Posterior Wall PositioningOptions

Anterior Wall PositioningOptions

[Click to Enlarge] [ Click to Enlarge ]
http://www.medtronic.com/cardsurgery/products/octo_pos.html#lateralhttp://www.medtronic.com/cardsurgery/products/octo_pos.html#apexhttp://www.medtronic.com/cardsurgery/products/octo_pos.html#posthttp://www.medtronic.com/cardsurgery/products/octo_pos.html#posthttp://www.medtronic.com/cardsurgery/products/octo_pos.html#posthttp://www.medtronic.com/cardsurgery/products/octo_pos.html#posthttp://www.medtronic.com/cardsurgery/products/octo_pos.html#lateralhttp://www.medtronic.com/cardsurgery/products/octo_pos.html#apexhttp://www.medtronic.com/cardsurgery/products/octo_pos.html#posthttp://www.medtronic.com/cardsurgery/products/octo_pos.html#post


17/17

Documents

What is Opcab