Background: "Off Pump" coronary artery operations are done with increasing frequency in the treatment of coronary artery disease. Although an extensive body exists to support current heparinization practices for CABG using cardiopulmonary bypass (CPB), standards for heparinization during OPCAB are lacking. Similarly, there are no established standards for antiplatelet therapy before or after OPCAB. The aim of this study was to determine current practices and standards for both antiplatelet and heparin therapy in OPCAB using national survey. Methods: A postal, multiple-choice survey questionnaire was sent to 800 randomly chosen cardiothoracic surgeons in the US and Canada. Responses were tabulated and analysed. Results: The overall response rate was 38% (304 surgeons). The respondents performed CABG in centers that had an overall volume between 240 and 1250 procedures per year (average 380 procedures per year). The number of OPCAB procedures within the same institutions ranged from 20 and 375 cases per year. The per cent of CABG performed as OPCAB in these institutions ranged from 3% to 94%. The respondents routinely administer antiplatelet therapy preoperatively and 88% of the respondents routinely administer antiplatelet therapy after OPCAB. Although 18% of the respondents use Clopidogrel (Plavix) preoperatively, 24% administer Clopidogrel postoperatively. Aspirin use decreased from 80% preoperatively to 74% postoperatively. Anticoagulation protocols during OPCAB were more variable with 28% administering full dose of heparin, 54% administer half dose heparin, and 13% administer 1/3 dose of heparin. Although 10% of surgeons maintain and activated clotting time above 400 seconds, 70% are content with an ACT above 300 seconds and less than 400 seconds, and 18% responded as "other". 84% believe that partial heparinization is associated with less intraoperative bleeding during OPCAB, and 16% believe that it does not affect the amount of intraoperative bleeding. The average intraoperative bleeding reported with with OPCAB was 500 ml (range 300 ml and 1 l). 40% of the surgeons administer protamine at half dose, and 60% administer a full dose of protamine for reversal of heparin effect. Conclusion: The results of this survey suggest that there is a wide range of antiplatelet therapy protocols for OPCAB. Although the vast majority of surgeons use antiplatelet therapy postoperatively, a minority of surgeons administer preoperative antiplatelet agents for OPCAB. The heparinization practices are more varied with a majority of OPCAB procedures performed using full dose heparinization with ACT above 300 sec (>80%). More studies are necessary to determine the short and intermediate effects of antiplatelet therapy and heparinization doses of OPCAB surgery on postoperative outcomes and graft patency .

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