Thank you, chairpersons. Ladies and gentlemen, it is a greathonor to have this opportunity to report and discuss thecurrent status of off-pump CABG in Japan. And again. I would
like to thank Dr Puskas and Dr Woo very much on behalf ofthe following two associations.

12

I will introduce two associations specific for CABG in Japan.
JACAS was established in 1996 and collects the data on
CABG and reports it every year. JAOPCAB was establishedin 1999 for prevalence of off-pump CABG.

3

This graph shows the proportion of off-pump technique forprimary elective CABG. In 1999, the off-pump rate was only
17%, when Japanese association for OPCAB was established,
but It has increased gradually and since 2001 when theassociation first began live demonstration of off-pump CABG,
the proportion has increased rapidly.
In 2004 the off-pump CABG rate exceeded 60% and it has
been so for six consecutive years.

4This is the latest report from the JACAS . The total numberof CABG was 1,262, including isolated CABG 10,659 and 3,603
were CABG combined with other cardiac surgery.
Of the isolated CABG, 8,974 cases were the number ofprimary elective CABG and 1,685 cases were redo and /oremergency.

5

While 66% of primary elective CABG was performed by offpump technique, 50% of redo and/or emergency CABG wasperformed by off-pump technique. In this slide, off-pump
CABG includes the cases in which, for whatever reason, theoff-pump technique was converted to the on-pumptechnique.

6

This slide shows the detail of proportion of techniques. As I
mentioned, 66% underwent off-pump CABG
but 1% had conversion to on-pump for some reason.
So among the off-pump group, 98.2% had the completion ofprocedure, but 1.8% had pump conversion.
On the other hand, 24% had on-pump CABG with cardiolegicarrest and about 10% had on-pump beating CABG.

7

This is the detail of the previous slide.
The hospital mortality of the primary, elective case is shownin this slide. The total hospital mortality was 1.2%. Hospitalmortality of the on-pump CABG with cardioplegic cardiac
arrest was 0. 6% and on-pump beating CABG was 1.98%. As tooff-pump CABG, the total hospital mortality was1.3% andhospital mortality of conversion case was 6.4%.

8

How many grafts were used in different techniques? The
average of number of grafts in all primary elective CABG was3.0/patient. In on-pump CABG with cardioplegic arrest it was3.2/patient and 2.9/patient in off-pump technique. There wasno considerable difference.

9

The hospital mortality of isolated CABG , including primaryelective and redo and/or emergency was 2.1%. The hospitalmortality of primary elective CABG, on-pump CABG withcardioplegic arrest , and on-pump beating CABG were 1.2%,0.6% and 2.0% respectively. As for off-pump CABG, 1.2% for
the completion group and 6.4% for conversion group.

10We can see the hospital mortality of three different techniqueover the past 6 year period when off-pump rate for theprimary, elective CABG constantly exceeded 60%. The dark
blue line shows the mortality of on-pump with cardiac arrest
and the light blue line shows that of off-pump CABG. The
mortalities of on-pump and off-pump have been stable around
1% and the mortality of on-pump beating which is shown by
red line has been at the level of near 2%.

11

This slide shows the conversion rate and its hospital mortality
over the past 6 years.
Both the conversion rate and the mortality have tended todecrease but the mortality increased from 1.2%
to 6.4% from 2008 to 9. So it is certain that pump conversion
is still an important problem in off-pump CABG.

12

This slide shows the incidence of perioperative stroke inprimary elective CABG. The off –pump CABG had the lowest
incidence of 0.7%. This was statistically lower than that of onpump CABG with cardioplegic arrest which was 1.5%.
But the incidence of the conversion group was 2.9% which
was the highest.

13

So I will take up the pump conversion issue here. I asked
several questions to 39 cardiac surgeons, most of whom haveeach performed more than 100 cases of off-pump CABG in ayear. The first question was “What were the common causesof pump conversion in off-pump CABG?”. The results areshown here. For the first question it should be noted thatpoor communication with anesthesiologists accounted for 18%.

14

The second question was “ Why did you avoid off-pump
CABG intentionally?”
The most common reason was coexistence of mitral
regurgitation of 25%. It followed by low ejection fraction. of23%.
And cardiomegaly account for 20%. These results were quite
reasonable.

15

I summarized the key points for how to avoid pumpconversion. All these points have been considered many times
and at many places. However I here would like to emphasize
the last three points.

16

For a good exposure I will show you the advanced Japaneseheart positioning device, the Tentacles, which comprises
three traction silicon strings with a suction cup on the oneend. This device was invented by Professor Arai. As you see,using three silicon strings in a step by step fashion any
aspects of the heart can be exposed without blood pressure
drop while avoiding the distortion or compression of the heart.

17Moreover, intra-operative graft validation is so important not
only for avoidance of pump conversion but also for the highquality of off-pump bypass grafting. There are three usefulmodalities for this purpose.

18

Again I asked 39 surgeons the way to validate grafts intraoperatively. 95% of the surgeon routinely perform graft
validation, 54% use transit time flow measurement system and
25% use ICG IPY system and 13% use flow-meter.

19

SPY is the graft validation modality to visualize the bypassed
graft intra-operatively.
I show you some cases in which SPY revealed the technicalerror of grafting.
December 12, 2002 was the first day when SPY was used inJapan by Dr Takahashi.

20

In this case, the left anterior descending artery (LAD) wasbypassed with the in situ left internal thoracic artery (ITA),
but the graft and the LAD could not be well visualized evenafter ICG injection via the central vein. But after revising theanastomosis，the graft and the LAD could be visualized withimprovement of graft flow.

21

This is another case of revising the anastomosis. The
sequential vein graft to the posterior descending artery andthe distal branch by the SPY system. Both bypassed arteries
could be visualized via the graft after the revision of the distal
graft anastomosis.

22

Now we can use an effective graft validation modality,
VereiQc system, which has the functions, B-mode, and color
flow mapping.

23

The flow probe of VeriQc is very small and can be put on thesurface of the heart and the bypassed graft itself.

24

In this case VeriQc detected the embedded LAD most ofwhich ran in the inside of the inter-ventricular septum.

25

According to the findings by VeriQc, the anastomosis site of
LITA to LAD was chosen at a more distal site where the LAD
ran superficially. You can see the LAD ran deeply, very close
to the cavity of the right ventricle.

26

After the anastomoisis was performed, we could see thestructure of the graft anastomosis clearly and the flow
direction by VeriQc

27

VeriQc can be used to examine the ascending aorta to detect
small atheroma plaque and calcification inside of theascending aorta which can not be diagnosed by CT scanning.

28

Let’s see what the Japanese cardiac surgeons perform toreduce the incidence of CVA
95% perform pre-operative chest CT scanning and 68% use
contrast material.
50% perform it routinely periaotic ultrasound examination tocheck the ascending aorta and other 21% do in case ofplanned aorto-graft anastomosis. Ｆor the aorto-graftanastomosis, 39% apply a partial clamp for aorto-graft
anastomosis but other 56% use less invasive anastomosisdevices.
29

This slide show the answers to the question” why has offpump CABG become the platinum standard in Japan?”Now I will explain the first reason of competition between
CABG and PCI..

30

In Japan PCI/CABG ratio has been increasing over the lastten years, especially so since 2004 when the use of Drug
Eluting Stent was approved. The advent of DES was theimportant stimulator for keeping the high proportion of offpump
CABG. The estimated PCI/CABG ratio was 13 in Japan in2009.

31

Other than the two major associations activities, there has
been the other novel bottom-up activities to keep high level
off-pump CABG in Japan.
One is a Wet Lab contest using pig hearts. The other is a Dry
Lab training using beating heart simulator. .

32

The wet lab. contest was mainly organized by Professor
Yaku. This is a two-stage conpetition held for under 33 year
old young surgeon.

33

In the contest, young surgeon’s surgical skill and manner
were checked and scored by top off-pump surgeons.

34

35

The summaries of this presentation are shown here.

36

Before going to the conclusion, I will show you this year’s
Live operation performed by Professor Asai at the annual
meeting of Japanese Association for OPCAB. The operation
was a quadruple off-pump CABG using the bilateral ITAs andthe right gastro-epliploic artery as the bypass grafts.

37

These are conclusions.

38

These Doctors are all my friends and the contributors of thepresentation.
Than you, chairpersons and all audiences.

39