CABG anaesthesia: on-pump and off-pump

Meet the patient

A 68-year-old diabetic with three-vessel disease and an ejection fraction of 35 percent is listed for CABG. The surgeon proposes off-pump to avoid the inflammatory hit of cardiopulmonary bypass. But a lateral-wall graft on a beating heart means verticalising and compressing a ventricle that is already struggling — and the perfusionist is standing by in case the blood pressure collapses (taught OPCAB vignette; displacement causes biventricular systolic and diastolic dysfunction).^[6]

The discriminator on this topic is whether you can quote the exact heparin-ACT-protamine numbers for on-pump work and describe the conversion ladder for OPCAB without hesitation. Both techniques share TOE as the integrating monitor, and both end in the cardiac ICU with fast-track targets.^[4][2]

References8ShowHide

1. [1]Mazer CD, Whitlock RP, Fergusson DA, et al. Restrictive or Liberal Red-Cell Transfusion for Cardiac Surgery. N Engl J Med, 2017.PMID 29130845
2. [2]Hahn RT, Abraham T, Adams MS, et al. Guidelines for performing a comprehensive transesophageal echocardiographic examination: recommendations from the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists. J Am Soc Echocardiogr, 2013.PMID 23998692
3. [3]Levy JH, Ghadimi K, Kizhakkedathu JN, Iba T What's fishy about protamine? Clinical use, adverse reactions, and potential alternatives. J Thromb Haemost, 2023.PMID 37062523
4. [4]Pereira RM, Guerra N, Ferreira R, et al. Contemporary Clinical Practices in Anticoagulation Management During Cardiopulmonary Bypass: A Europe-Wide Survey. Interdiscip Cardiovasc Thorac Surg, 2026.PMID 41787968
5. [5]Chassot PG, van der Linden P, Zaugg M, et al. Off-pump coronary artery bypass surgery: physiology and anaesthetic management. Br J Anaesth, 2004.PMID 14970136
6. [6]Shim JK, Kim KS, Couture P, et al. Hemodynamic management during off-pump coronary artery bypass surgery: a narrative review of proper targets for safe execution and troubleshooting. Korean J Anesthesiol, 2023.PMID 36824043
7. [7]Paparella D, Brister SJ, Buchanan MR Coagulation disorders of cardiopulmonary bypass: a review. Intensive Care Med, 2004.PMID 15278267
8. [8]Engelman DT, Ben Ali W, Williams JB, et al. Guidelines for Perioperative Care in Cardiac Surgery: Enhanced Recovery After Surgery Society Recommendations. JAMA Surg, 2019.PMID 31054241