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 reduce incision 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 to the 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 walls of 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 do so.

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 as MIDCABand OPCAB operations, are called off-pump procedures. These off-pump procedures require special techniques and instrumentation 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 indepth 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 (%) Low Risk On Pump N=2360 Off Pump N=216 P-value On Pump N=688 Off Pump N=95 P-value On Pump N=123 Off Pump N=39 30 (1.3) New Renal Failure N (%) New Atrial Fib N (%) Mortality N (%) 27 (1.1)

99 (4.2)

500 (21.2)

0-2.59

2 (0.9)

7 (3.2)

26 (12.0)

3 (1.4)

N=2576 Medium Risk 2.6-9.9

1.0 29 (4.2)

0.499 71 (10.3)

0.001 187 (27.2)

0.736 45 (6.5)

3 (3.2)

9 (9.5)

17 (17.9)

6 (6.3)

N=783 High Risk

0.787 6 (4.9)

0.799 26 (21.1)

0.053 34 (27.6)

0.934 35 (28.5)

>10

0 (0)

1 (2.6)

7 (17.9)

3 (7.7)

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 average postoperative 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

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

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.

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 CPBassociated 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, analgesia and fluid management.
20

) which may facilitate postoperative

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 is very 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.

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

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.

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<1.5), bolus doses of epinephrine (10-20 mcg) are given immediately to avoid progressive cardiac failure. Maintenance of cardiac output appears to be more important than maintaining systemic blood pressure. Proactive and assertive treatment of this ischemia-induced ventricular dysfunction is essential to success during this stressful phase of the surgery.

We monitor arterial blood gases frequently during the distal anastamoses. Metabolic acidosis is treated with sodium bicarbonate to keep the corrected pH greater than 7.30. We have found that with a more physiologic pH it is easier to maintain hemodynamic stability.

To optimize surgical exposure during a distal anastamosis, the anesthesiologist may need to hand ventilate or even stop ventilating for short intervals. This would be most likely, for example, during the anastamosis to a marginal branch of the left circumflex artery. It may be necessary to subsequently reexpand the lungs and hyperventilate to prevent patchy atelectasis and hypercarbia.

Once the anastamosis is complete, the silastic tape is removed, coronary flow is reestablished and both cardiac index and ST segment changes should improve. Assessment of cardiovascular status during this rest period will help determine when the next vessel may be approached. Blood pressure and cardiac output should return

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

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, nonacidotic 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.

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

As beating heart surgery techniques continue to evolve, Medtronic continues to innovate. One such innovation from 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 the same time providing flow through the anastomotic site to the myocardium. With the introduction of the ClearView shunt, Medtronic is proud to offer further innovation the first 1 mm intracoronary shunt.

Off-center line Clear shaft Beveled tip allows placement allows allows for a clear for atraumatic for easy removal view of flow insertion and through the removal anastomotic site

Ordering Information Catalog Code Bulb Size 31100 31125 31150 31175 31200 31225 31250 31275 31300 1.00 mm 1.25 mm 1.50 mm 1.75 mm 2.00 mm 2.25 mm 2.50 mm 2.75 mm 3.00 mm Length Between Bulbs 14 mm 14 mm 14 mm 14 mm 14 mm 14 mm 14 mm 14 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 system for beating heart surgery. The new Octopus System II (Octopus4 and Starfish2) features significant innovations in ease of use and performance that make it the obvious choice for access to, and stabilization of, all vessels -- even the tough-to-reach OMs. FREE VIDEO: Click here to register to receive a copy of our new video Octopus System II: Complete Multivessel Revascularization.

Octopus4 Innovations
The Octopus4 retains the clear, malleable, spreading pods surgeons have become accustomed to, combined with new enhancements:

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 offpump grafting. The OctoBase retractor allows for the highest performance of both the Starfish and Octopus by making multiple mounting options available. The following graphic illustrations represent suggested mounting and positioning options for the Medtronic Octopus 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 lateral wall exposure. Integrated Bellows Suspension allows for natural heart movement throughout the cardiac cycle. Three-appendage silicone head design allows for multiple attachment options to optimize 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-leading suction stabilzer. Malleable stabilizer pods can be formed to the unique contours of the patient's anatomy. A unique tissue-spreading mechanism enhanced stabilization of the anastomotic site and presentation of the coronary.

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 Positioning Options

Anterior Wall Positioning Options

[ Click to Enlarge ]

[ Click to Enlarge ]