Coronary artery bypass grafting off-pump or on-pump: another brick in the wall

Off-pump coronary bypass grafting (OPCAB) was reintroduced in the early 90’s to limit what was perceived the drawbacks of the cardiopulmonary bypass (CPB). The development of left anterior descending artery via a left anterior small thoracotomy (1) increased the interest in myocardial revascularization via a median sternotomy as an important strategy to limit the use of CPB. The first years of the surgical experience were dominated by observational studies aimed to evaluate more the technical aspects and the advantages of OPCAB versus on-pump coronary artery bypass (ONCAB). We have to take into account that exposure of the lateral wall was difficult if not impossible at the early beginning. Our group first described a technique to safely graft the branches of the circumflex artery and of the right coronary artery (2). As a second step, introduction of the stabilizers and of the apical suctions by different Companies improved the exposure and stability of the operative field, representing a great result of the collaboration between Companies and Surgeons.