Awake off-pump no-touch aorta coronary artery bypass grafting under high thoracic epidural anaesthesia is 'a viable strategy for elderly patients with severe interstitial lung disease who face substantial risks from general anaesthesia and cardiopulmonary bypass.'
Key Findings
Background
A 71-year-old male with chronic interstitial pulmonary fibrosis successfully underwent awake off-pump no-touch aorta double coronary artery bypass grafting under high thoracic epidural anaesthesia (TEA).
The patient had a 10-year history of chronic interstitial pulmonary fibrosis and presented with exertional dyspnoea.
Coronary angiography and transthoracic echocardiography revealed two-vessel disease.
Preoperative pulmonary function tests indicated high risk of prolonged endotracheal intubation, leading to the patient being deemed a high-risk candidate for general anaesthesia.
The procedure was performed in July 2020 during the COVID-19 pandemic.
Arterial revascularisation was used for the double coronary artery bypass grafting.
Results
The patient's postoperative recovery was uneventful following awake OPCABG under TEA.
The patient was discharged on the fifth postoperative day.
No complications related to the avoidance of general anaesthesia or cardiopulmonary bypass were reported.
The no-touch aorta technique was employed, avoiding aortic manipulation.
Discussion
Awake OPCABG under TEA was identified as an alternative to conventional general anaesthesia for patients with advanced respiratory disease or serious cerebral infarction history.
High thoracic epidural anaesthesia (TEA) was used as the anaesthetic technique instead of general anaesthesia.
The approach avoids the risks associated with prolonged endotracheal intubation in patients with severe chronic respiratory conditions such as interstitial lung disease.
Severe chronic respiratory conditions 'are known to significantly complicate perioperative management and long-term survival.'
The authors note this complex approach 'should be restricted to referral centres with extensive experience in advanced off-pump surgery and thoracic epidural anaesthesia techniques.'
Methods
The no-touch aorta technique was incorporated into the awake OPCABG procedure to reduce surgical trauma during myocardial revascularisation.
Off-pump coronary artery bypass grafting (OPCABG) is described as 'favoured to reduce surgical trauma during myocardial revascularisation.'
The no-touch aorta approach avoids manipulation of the aorta, which may reduce embolic risk.
The combination of awake surgery, off-pump technique, and no-touch aorta approach represented a multi-faceted risk-reduction strategy for this high-risk patient.
What This Means
This research describes a case report of a 71-year-old man with a serious lung scarring condition (interstitial pulmonary fibrosis) who needed heart bypass surgery but was considered too high-risk for standard general anaesthesia and the heart-lung bypass machine. Instead, surgeons performed the operation while the patient was awake, using a type of regional anaesthesia injected near the spine (high thoracic epidural anaesthesia), and without stopping the heart or using a bypass machine. The surgery was performed in July 2020 during the COVID-19 pandemic, adding further complexity to the case.
The patient underwent a double coronary artery bypass using only arterial vessels (considered higher quality grafts) and recovered without complications, leaving the hospital on the fifth day after surgery. The combination of techniques — awake surgery, off-pump approach, and avoiding manipulation of the aorta (the large artery near the heart) — was used together to minimize risks for this particularly vulnerable patient.
This research suggests that for elderly patients with severe lung disease who cannot safely undergo conventional heart bypass surgery with general anaesthesia, this specialized combination of techniques may offer a feasible alternative. However, the authors caution that this highly complex approach should only be performed at specialized centers with extensive experience in both advanced off-pump heart surgery and thoracic epidural anaesthesia, as it requires considerable technical expertise.
Ates M, Demirozu Z. (2026). Awake off-pump no-touch aorta coronary artery bypass grafting in a patient with interstitial lung disease during the COVID-19 pandemic.. Cardiovascular journal of Africa. https://doi.org/10.5830/CVJA-2026-039