Preoperative Serum Albumin Levels and Postoperative Acute Kidney Injury in Off-Pump Coronary Artery Bypass Surgery: A Single-Center Study in Bangladesh

Background: Serum albumin, a vital plasma protein, helps maintain intravascular colloidal osmotic pressure, cardiac output, and renal function. Low preoperative serum albumin is linked to poor outcomes, including acute kidney injury (AKI), after off-pump coronary artery bypass (OPCAB) surgery. This study aimed to assess the relationship between preoperative serum albumin levels and early postoperative renal injury. Methods: This prospective comparative cross-sectional study was conducted from August 2019 to February 2021 at the National Heart Foundation Hospital & Research Institute, Bangladesh. It included 160 adult patients with normal preoperative renal function undergoing OPCAB. Patients were divided into two groups: Group A (serum albumin ≥ 4.0 gm/dl) and Group B (serum albumin Results: Preoperative serum albumin was significantly different between groups (Group A: 4.21 ± 0.05 gm/dl, Group B: 3.69 ± 0.04 gm/dl, p = 0.028). Group B had a higher incidence of hypertension (71.25% vs. 51.25%, p st and 3rd postoperative days were higher in Group B (p th day. Postoperative AKI occurred in 18.75% of Group A and 36.25% of Group B. Multivariate regression indicated that low preoperative serum albumin is an independent risk factor for postoperative AKI (p = 0.012, OR = 1.815, CI: 0.675 - 1.162). Conclusion: Preoperative serum albumin level is a valuable predictor of postoperative renal function. Ensuring high normal serum albumin levels before surgery can help minimize the risk of postoperative AKI.

Off-Pump Coronary Artery Bypass Grafting in Patients with Left Ventricular Dysfunction: Short-Term Results from a Single Center in Bangladesh

Background: Off-pump coronary artery bypass grafting (OPCAB) is considered a safer alternative to on-pump surgery, especially in patients with left ventricular dysfunction (LVD). Objectives: This study assessed short-term outcomes and functional improvements in LVD patients post-OPCAB. Methods: The study included 200 coronary artery disease patients who underwent isolated off-pump coronary artery bypass grafting (OPCAB) at the National Heart Foundation Hospital and Research Institute between January 2019 and June 2020. Patients were categorized into Group 1, with a left ventricular ejection fraction (LVEF) of 30% - 39%, and Group 2, with an LVEF of 40% or higher. Echocardiographic assessments of left ventricular dimensions and ejection fraction were performed preoperatively, at discharge, and one month postoperatively. Results: In Group 1, preoperative left ventricular internal dimensions during diastole (LVIDd) and systole (LVIDs) were 53.48 ± 4.40 mm and 44.23 ± 3.93 mm, respectively, with a left ventricular ejection fraction (LVEF) of 35.28% ± 2.26%. At discharge, these values improved to 51.58 ± 4.04 mm (LVIDd), 41.23 ± 5.30 mm (LVIDs), and 39.25% ± 3.75% (LVEF). One month postoperatively, further improvements were observed: 46.29 ± 3.76 mm (LVIDd), 37.45 ± 3.68 mm (LVIDs), and 43.22% ± 4.67% (LVEF). Group 2 showed similar positive outcomes, with preoperative values of 47.09 ± 5.06 mm (LVIDd), 35.11 ± 5.25 mm (LVIDs), and 50.13% ± 7.25% (LVEF), improving to 42.37 ± 4.18 mm (LVIDd), 31.05 ± 4.19 mm (LVIDs), and 55.33% ± 7.05% (LVEF) at one month postoperatively. Both groups demonstrated significant improvements in left ventricular function and NYHA class, with most patients moving from class III/IV to I/II. Complications were minimal, and no mortality was observed. Conclusion: OPCAB is safe and effective for patients with LVEF 30% - 39% and LVEF ≥ 40%, providing significant short-term functional improvements without increased risk.

Implications of Elevated Serum Cortisol in the Onset of Postoperative Delirium Following Off-Pump Coronary Artery Bypass Grafting: Insights from a Bangladesh-Based Single Center Experience

Background: Following coronary artery bypass grafting (CABG), delirium emerges as a prevalent complication. This study aimed to assess the correlation between elevated serum cortisol levels and the occurrence of postoperative delirium subsequent to off-pump CABG. Methods: Conducted in the Department of Cardiac Surgery at BSMMU from October 2020 to September 2022, this comparative cross-sectional study included a total of 44 participants. Subjects, meeting specific criteria, were purposefully assigned to two groups based on off-pump CABG. Group A (n = 22) consisted of patients with normal serum cortisol levels, while Group B (n = 22) comprised individuals with high serum cortisol levels on the first postoperative day. Delirium onset was assessed at the bedside in the ICU on the 1st, 2nd, 3rd, 4th, and 5th postoperative days using standard tools, namely the Richmond Agitation Sedation score (RASS) and The Confusion Assessment Method (CAM-ICU). Data were collected based on the presence or absence of delirium. Statistical analysis utilized SPSS version 26.0, employing an independent Student’s t-test for continuous data and chi-square and Fischer’s exact test for categorical data. A p-value ≤ 0.05 was considered statistically significant. Results: Group-A had a mean age of 54.50 ± 17.97, and Group-B had a mean age of 55.22 ± 15.45, both with a male predominance (81.81% and 86.36% respectively). The mean serum cortisol level was significantly higher in Group B (829.71 ± vs. 389.98 ± 68.77). Postoperative delirium occurred in 27.3% of Group B patients, statistically significant compared to the 4.5% in Group A. However, patients in Group B who developed delirium experienced significantly longer postoperative ICU and hospital stays (79.29 ± 12.27 vs. 11.44 ± 2.85, p ≤ 0.05). There was one mortality in Group B, which was statistically not significant. Conclusion: This study observed a significant association between elevated serum cortisol levels in the postoperative period and the occurrence of postoperative delirium after off-pump coronary artery bypass grafting.

The Treatment of Ostial Coronary Arteriopathy Secondary to Thoracic Irradiation With Off-pump Coronary Artery Bypass Grafting: A Case Report and Review of Literatures

Objectives We report a case in which a patient who suffered from angina secondary to mediastinal irradiation and have been treated by off-pump coronary artery bypass （OPCAB） in our hospital since 3 years ago. A 34-year-old man presented with angina for 8 years after receiving radiation therapy for Hodgkin＇s lymphoma. We retrospectively reviewed all the cases of OPCAB in our hospital and followed-up data for up to 3 years post-operatively. Mediastinal irradiation is probably the cause of significant ostial stenosis of left main coronary and right coronary artery. OPCAB grafting was performed on this patient 3 years ago. His angina disappeared after operation, and he recovered well during follow-up. Conclusions Patients with malignancies who have received mediastinal irradiation should be carefully followed up and routinely screened for the premature development of coronary artery disease. OPCAB may be an appropriate treatment for coronary artery disease caused by mediastinal irradiation.

Clopidogrel improves aspirin response after off-pump coronary artery bypass surgery

We sought to assess the incidence of aspirin resistance after off-pump coronary artery bypass （OPCAB） surgery, and investigate whether clopidogrel can improve aspirin response and be safely applied early after OPCAB surgery. Sixty patients who underwent standard OPCAB surgery were randomized into two groups. One group （30 patients） received mono-antiplatelet treatment （MAPT） with aspirin 100 mg daily and the other group received dual anfiplatelet treatment （DAPT） with aspirin 100 mg daily plus clopidogrel 75 mg daily. Platelet aggregations in response to arachi- donic acid （PLAA） and adenosine diphosphate （ADP） （PLADP） were measured preoperatively and on days 1 to 6, 8 and 10 after the antiplatelet agents were administered. A PLAA level above 20% was defined as aspirin resistance. Postoperative bleeding and other perioperative variables were also recorded. There were no significant differences between the two groups in baseline characteristics, average number of distal anastomosis, operation time, postoperative bleeding, ventilation time and postoperative hospital stay. However, the incidence of aspirin resistance was significantly lower in the DAPT group than that in the MAPT group on the first and second day after antiplatelet agents were given （62.1% vs, 32.1%, 34.5% vs. 10.7%, respectively, both P 〈 0.05）. There was no significant difference in postoperative complication between the two groups. DAPT with aspirin and clopidogrel can be safely applied to OPCAB patients early after the procedure. Moreover, clopidogrel reduces the incidence of OPCAB-related aspirin resistance.

Off-pump coronary artery bypass grafting versus optimal medical therapy alone：effectiveness of incomplete revascularization in high risk patients

BackgroundGeriatric patients with multivessel coronary artery disease （CAD） are a challenging group to treat; these cases elicit dis-cussion within heart teams regarding the actual benefit of undertaking major surgery on these patients and often lead to abandon the surgical option. Percutaneous procedures represent an important option, but coronary anatomy may be unfavorable. Off-pump coronary artery bypass （OPCAB） provides good quality graft on left anterior descending （LAD） without exposing the patient to cardiopulmonary bypass, and might be the ideal choice in patients with multiple comorbidities, not eligible to percutaneous or on-pump procedures. The objective of this study was to compare survival during a mid-term follow-up in high-risk patients with no percutaneous alternative, either treated with OPCAB or discharged in medical therapy.MethodsWe retrospectively evaluated from June 2008 to June 2013, 83 high-risk patients with multivessel CAD were included： 42 were treated with incomplete off-pump revascularization using left internal mammary artery （LIMA） on LAD; 41 were discharged in optimal medical therapy （OMT）, having refused surgery. Follow-up ended in March 2015, with a telephonic interview. Primary endpoint was survival from all-cause mortality; secondary endpoints were survival from cardiac-related mortality and freedom from non-fatal major adverse cardiac events （MACEs）.ResultsDuring follow up, 11 deaths in OPCAB group and 27 deaths in OMT group occurred. Death was due to cardiac factors in 6 and 15 patients, respectively. MACEs were observed in 6 patients in OPCAB group and in 4 patients in OMT group. With regards to survival from all-cause mortality, patients who underwent OPCAB survived more than those dis-charged in OMT （Log Rank ＆lt; 0.001）, and OMT group carries a propensity score-adjusted hazard ratio of 3.862 （P ＆lt; 0.001）. With regards to survival from cardiac-related events, patients who underwent OPCAB survived more than those discharged in OMT （Log Rank = 0.002）, and OMT group carries a propensity score-adjusted hazard ratio of 3.663 （P = 0.010）. There is no statistically significant difference concerning freedom from MACEs （Log Rank = 0.273）.ConclusionsFor high-risk patients with multivessel CAD, not eligible to on-pump complete revascularization surgery or percutaneous procedures, incomplete revascularization with OPCAB LIMA-on-LAD offers benefits in survival when compared to OMT alone.

Role of Intra-Aortic Balloon Pump in Off-Pump Coronary Artery Bypass —A Vettath Modification

Objective: Hemodynamic deterioration during positioning of the heart has been the most critical complication of off-pump coronary artery bypass surgery. Pre-operative use of intra-aortic balloon pump has been shown to prevent this complication in high risk patients. The role of balloon pump in high risk patients has been questioned by our group. We modified the role of balloon pump in our patients, thus avoiding the conversion to cardiopulmonary bypass. Methods: 4063 off-pump coronary bypass surgeries were performed by a single surgeon in our center, over thirteen years. 130 intra-aortic balloons used between July 2002 and December 2015 were removed from the the-ater, once the distal anastomosis was performed. We studied this group of patients for—time and need for insertion, duration of balloon used, local insertion problems and survival. Results: Initially, we inserted intra-aortic balloons in high risk patients. We observed that, patients with low ejection fraction and patients with critical left main coronary artery disease were not the ones who actually needed balloon pump support. It was the patients who had ongoing ischemia, with preserved left ventricular function, and ST depression intra-operatively, who needed balloon pump support to perform complete anatomical revascularization. Conclusions: Intra-aortic balloon pump has helped us to position the heart without hemodynamic instability, thereby avoiding conversion to cardio-pulmonary bypass. This enabled us to perform off-pump surgery in virtually all areas of the heart, thus maintaining perfect hemodynamics.

Nutritional supplement drink reduces inflammation and postoperative depression in patients after off-pump coronary artery bypass surgery

BACKGROUND Coronary artery bypass grafting is a surgical treatment for ischemic heart disease.Although development in surgical technique and improvement of perioperative management reduced the postoperative complications,some patients still delayed in progress of postoperative rehabilitation.In this study,we aimed to investigate the effect of daily intake of an herbal medicine-containing drink for rehabilitation after surgery in patients with ischemic heart disease.AIM To investigate the effect of taking an herbal medicine-containing,commercially available drink for postoperative rehabilitation in those patients.METHODS Patients who underwent isolated off-pump coronary artery bypass(OPCAB)surgery were divided into two groups depend on the timing of the admission to the hospital:the Yunker(YKR)group,that consumed one bottle of a caffeine-free nutritional supplement drink on a daily basis and the control group(CTL)that underwent regular rehabilitation.RESULTS A total of 229 patients(CTL=130,YKR=99)were enrolled.No significant differences were observed in the baseline characteristics between the two groups.The YKR group had a significantly increased number of daily steps postoperatively(P<0.05)and had significantly lower postoperative serum tumor necrosis factor-alpha levels(P<0.01),while no significant differences were observed in the levels of other inflammatory or stress-related cytokines(interleukin-6,adiponectin,superoxide dismutase,and urine 8-hydroxy-2′-deoxyguanosine)between the two groups.Also,the YKR group showed a significant improvement in the Hospital Anxiety and Depression Score(P<0.05).Moreover,there were no differences in postoperative complications and the duration of postoperative hospital stay between the two groups.CONCLUSION Our results demonstrated that the daily intake of an herbal medicine-containing drink after OPCAB surgery may have beneficial effects on cardiac rehabilitation by reducing inflammation markers and depression.

The perioperative effects of metabolic syndrome on the off-pump coronary artery bypass

Objective Metabolic syndrome (MS),a disorder involving multiple metabolic abnormalities such obesity,hypertension,diabetes or abnormal glucose tolerance anddyslipidemia,has been observed in many patients receiving coronary artery bypass procedures. In this study we try to examine the perioperative effects of metabolic syndrome on the off-pump coronary artery

Stroke following off-pump coronary artery bypass in patients with prior stroke

Objective To analyze the risk factors and clinical features of stroke following off-pump coronary artery bypass grafting in patients with prior stroke. Methods From January 2006 to July 2009,the clinical information of 437 patients undergoing OPCABG in Anzhen Hospital

The prediction of early mortality in off-pump coronary artery bypass surgery:SinoSCORE versus EuroSCORE

Objective To compare the validation of the Sino System for Coronary Operative Risk Evaluation (SinoSCORE) with the European system for cardiac operative risk evaluation (EuroSCORE) in patients undergoing off-pump coronary artery bypass (OPCAB) surgery in China. Methods Data of patients who underwent OPCAB between 2004 and 2005 in

Comparison of long-term graft patency of on-pump versus off-pump coronary artery bypass grafting

Objective Off-pump coronary artery bypass grafting (OPCAB) is used more widely in recent years in China. However,there is an argument on benefits and risks of off-pump surgery. Many studies shown that OPCAB had more benefits in short-term outcomes than conventional coronary artery bypass grafting (CCABG) .

Off-pump coronary artery bypass grafting using a bilateral internal mammary artery Y graft

Objective To evaluate the outcome of off-pump coronary artery bypass grafting （OPCABG） using a bilateral internal mammary artery （BIMA） Y configuration graft to achieve total arterial myocardial revascularization. Methods From October 2002 to December 2008, 208 patients （196 males and 12 females） underwent OPCABG using a BIMA Y configuration graft. The average age of the patients was 56.5 ± 11.3 years, with an age range of 33-78 years. A total of 167 （80.2%） cases had triple-vessel disease. Left main stem disease was found in 33 （15.9%） cases, and double-vessel disease was found in 8 （3.9%） cases. The semi-skeletonization technique was used to harvest the two internal mammary arteries （IMAs）, and then the free right internal mammary artery was connected end-to-side to the left internal mammary artery （LIMA） in situ to complete the Y configuration graft. Off-pump and sequential anastomosis methods were used to perform coronary artery bypass surgery in all patients. Graft patency was assessed intm-operatively with the HT311 transit time flowmeter. Results A total of 728 distal anastomoses were performed in 208 patients, with the average being 3.5± 1.3 per person. No one died or experienced recurrent angina within 30 days after the operation. Conclusions OPCABG using the BIMA Y graft was safe and effective to achieve total arterial revascularization. This method avoids surgical operation on the ascending aorta and other incisions.

Off-pump coronary artery bypass grafting versus on-pump coronary artery bypass grafting： which is better in patients with chronic obstructive pulmonary disease？

To evaluate the clinic outcome of off-pump coronary bypass grafting (OPCABG) of patients with coronary heart disease and chronic obstructive pulmonary disease, we collected and analyzed 1998-2002 data on 28 patients with these two diseases who had received off-pump coronary bypass operation in our hospital, and compared with data on those who also had the same two diseases but received on-pump coronary artery bypass at same time. There were no operation-related death;one died of respiratory failure 14 days after operation while staying in hospital; there were more respiratory complications in the conventional coronary artery bypass grafting group (CCABG) than in the OPCABG group; and the PaO2/FiO2 in the CCABG group was higher than that in the OPCABG group during operation because of CPB, but lower than that in the OPCABG group 6-12 hours after operation. OPCABG seemed more suitable than CCABG for coronary artery disease patients with chronic obstructive pulmonary disease due to less damage to their oxygen-exchange capability and the fewer respiratory complications.

Redo Coronary Artery Bypass Grafting: On-Pump and Off-Pump Coronary Artery Bypass Grafting Revascularization Techniques

Objective To analyze the short-term outcomes of redo coronary artery bypass grafting(CABG) using on-pump and off-pump CABG techniques. Methods From January 2003 to August 2013, non-randomized 80 patients were treated with redo CABG in the Department of Cardiac Surgery, Peking University Third Hospital. Among these patients, 40 underwent on-pump CABG technique(redo-ONCAB group) and 40 underwent off-pump CABG technique(redo-OPCAB group). Furthermore, transmyocardial laser revascularization was performed in high-risk patients who were not suitable to conventional grafting. Clinical data of the two groups were recorded and analyzed including operation time, coronary grafts, incomplete revascularization, postoperative ventilation, perioperative stroke, and low output syndrome, etc. Results There were no significantly differences in age, gender distribution, incidences of hypertension, stroke, and other clinical characteristics between redo-OPCAB group and redo-ONCAB group(all P>0.05), except for incidences of renal dysfunction and pulmonary disease(all P<0.05). The number of grafting vessels in the redo-ONCAB and redo-OPCAB groups was 2.1 ± 0.74 and 1.4 ±0.52 respectively. There was significant difference between the two groups(P=0.0243). Compared with the redo-ONCAB group, there was shorter operation time(P=0.0045), postoperative ventilation(P=0.0211) and intensive care unit stay(P=0.0400), as well as fewer use of platelet(P=0.0338) and blood transfusion(P=0.0034) in the redo-OPCAB group. The incidence of incomplete revascularization(P=0.0253) and the use of transmyocardial laser revascularization(P=0.0052) were higher in the redo-OPCAB group than those in the redo-ONCAB group(all P<0.05). However, no significant differences were showed for the incidence of the use of intra aortic balloon pump and continuous renal replacement therapy, perioperative stroke, low output syndrome, and in-hospital mortality between the two groups(all P>0.05). Conclusion Redo CABG is the safety and efficacy surgical procedure, and redo-OPCAB technique with better outcomes is commended especially in high-risk patients.

Off-pump coronary artery bypass grafting: Misperceptions and misconceptions

Coronary artery bypass grafting(CABG) continues to be one of the most commonly performed cardiac surgical procedures worldwide. Conventional CABG performed on cardiopulmonary bypass termed on-pump CABG is regarded as the gold standard. However, on-pump CABG results in several physiologic derangements including but not limited to thrombocytopenia, activation of complement factors, immune suppression, and inflammatory responses leading to organ dysfunction.Furthermore, manipulating an atherosclerotic ascending aorta during cannulation and cross-clamping can predispose to embolization and stroke risk. Recognition of these detrimental effects of on-pump CABG resulted in resurgence of off-pump CABG nearly two decades ago.Off-pump CABG since its resurgence has been a subject of intensive scrutiny and speculation. Despite numerous retrospective nonrandomized studies, prospective randomized trials, and meta-analyses validating the safety and efficacy of off-pump CABG, opponents of the technique have persistently demanded abandonment of off-pump CABG. Several misconceptions and misperceptions are used as an excuse for such demands. This review article examines published scientific evidence to evaluate these misperceptions and misconceptions about off-pump CABG.

Tei index evaluates left ventricular function changes after on-pump and off-pump coronary artery bypass surgery

Objective： To compare function recovery of left ventricle after off-pump and on-pump coronary artery bypass （OPCAB and ONCAB） using Tel index. Methods： Twenty-four patients with coronary artery disease were enrolled, twelve of which received OPCAB and the others underwent ONCAB. Left ventricular ejection fraction （LVEF）, E/A ratio at mitral orifice and Tel index were measured using transthoracic echocardiography before surgery and 3-7 days, 1 month, 3 months and 6 months after surgery. Results：Tel index of both groups decreased 3-7 days after surgery, with OPCAB group＇s lower than ONCAB group＇s. The difference between pre-and post-OPCAB was significant （P〈0.01）, but not for ONCAB group （P〈0.05）. Tel index of ONCAB decreased more significant than that of OPCAB 1 month after surgery, there was statistical difference between 3-7 days and 1 month after surgery in ONCAB （P〈0.01）. Afterwards, Tel index of the 2 groups decreased steadily with no significant difference between them at other time points. LVEF and E/A ratio decreased at first, then increased gradually, with no statistical differences between the 2 groups at all time points. Conclusion： The recovery of left ventricular function after OPCAB is earlier than ONCAB. Tel index is more sensitive than LVEF and E/A ratio in detecting cardiac function recoveries and can be considered as an accurate and simple method to evaluate left ventricular systolic and diastolic function.

Anesthetic considerations for the patients with off-pump coronary artery bypass grafting

New surgical techniques for coronary artery bypass graft （CABG） have been explored in order to minimize disfiguring scars, avoid cardiopulmonary bypass and decrease hospital residence and costs etc. Improved surgical expense can perform the procedures in some high-risk patients such as poor left ventricular function, redo CABG, advanced age and renal dysfunction etc. Intraoperatively there is an obligatory period of myocardial ischemia, which may lead to significant hemodynamic consequences. It is a quite challenge to anesthetist in managing the intraoperative patient.

Association of Atrial Fibrillation and Amino-terminal Pro-brain Natriuretic Peptide Concentrations in Patients After Off-Pump Coronary Artery Bypass Grafting

Objectives To investigate the possible role of amino-terminal pro-brain natriuretic peptide （NT-proBNP） in the occurrence of atrial fibrillation （AF） after coronary artery bypass grafting （CABG）. Methods This study group included 70 consecutive patients scheduled for elective off-pump CABG. The patients with ejection fraction （EF） less than 0. 30, history of AF, use of class Ⅰ or Ⅲ antiarrhythmic drug, implanted pacemaker, postoperative myocardial infarction or chest reopening for pericardial tamponade were excluded. Preoperative and postoperative serum NT-proBNP levels were measured by radioimmunoassay technique. Results Postoperative AF occurred in 15 patients （21.4%）; these patients had significantly higher median NT-proBNP levels when compared with those without AF after the operation （ P 〈 0. 01 ）. Using multivariate logistic regression analyses, an increase in NT-proBNP level after CABG was found to be independently associated with AF （ OR = 3.78, 95% IC = 1.81 - 4. 89, P 〈 0. 01 ）. Increased age, diabetes mellitus, preoperative use of β-blocker, proximal right coronary artery involvement, and longer operation time were al- so associated with AF. Conclusions These results indicated that AF was associated with higher NT-proBNP concentrations after off pump CABG; the increase in NT-proBNP after CABG may play an important role in the occurrence of AF after the operation. The further studies are needed to define the reason that lead to higher NT-proBNP concentrations among the patients who present AF after off pump CABG.

Awake off-pump coronary artery bypass surgery in 25 patients

Objectives To test the feasibility of the use of high thoracic epidural anesthesia as a sole anesthetic in patients undergoing off pump coronary artery bypass surgery, avoiding general anesthesia. Methods Between October 2002 to April 2003, twenty five cases underwent beating heart coronary artery revascularization without endotracheal general anesthesia, using high thoracic epidural anesthesia and analgesia. All the patients underwent epidural catheterization on the evening before the surgery. Resuits The patients in all received 71 grafts (single n = 11, double n = 5, triple n = 6, quadruple n = 3). Six patients underwent repeat coronary artery bypass. Except one was converted to general anesthesia and cardiopulmonary bypass, the other patients underwent off-pump coronary artery bypass graft surgery, 2 patients underwent grafting via left thoracotomy (MIDCAB) and the rest through mid sternotomy. There was no mortality. Mean length of stay in the intensive care unit was 16 .2 ( 4.2 hours and hospital was 3.0(1.2 days. Conclusions Our experience confirms the feasibility of performing multiple coronary artery bypasses in conscious patients without endotracheal general anesthesia