Technique:  Careful re-opening of sternum and release of steinum from the underlying adhesion is done. Femoral artery and vein are exposed for going on femoro fenioral bypass, if there is torrential bleeding. Arterial conduits are prepared for re grafting. (IMA or RA) Availability of a cell saver is a good idea.

Careful dissection to release the heart from pericardium is done. At times, last part of the dissection can be done on bypass with an empty beating heart.

Careful preservation of LIMA, which is functioning, and minimal handling of runctioning vein grafts is important. Good myocardial protection by antegrade and retrograde cardioplegia is important. The operation can also be done off pump (OPCAB).

If only left sided grafts are to be done, a left thoracotomy is useful in OCPAB. Radial artery niay be used from descending thoracic aorta to OM or PDA. If LIMA is available it csul be used for LAD or OM. Mortality is 3-6 per cent. Peri operative MI 6-7 per cent.