influence of intact pleura on postoperative respiratory dysfunction after coronary artery bypass grafting [CABG] using bilateral internal mammary arteries [BIMA]

Bilateral internal mammary artery harvesting for coronary artery bypass graft had shown to be superior compared to venous grafts in regard to cardiac events, however the major drawbacks from such technique is early postoperative complications; namely bleeding, wound infection [deep or superficial] and impairment of respiratory function. We tested the hypothesis of modifying the surgical technique when harvesting bilateral mammary arteries with maintaining pleural integrity [Npo group A n=25] and conventional technique with pleura opened [po group B n=25] and its effect on early postoperative complications. Patients in group A [Npo] had demonstrated more favorable early postoperative outcome compared to group B [po] evidenced by better PaO2/FiO2, dynamic spirometry function [FEV1 72.5% versus 59.9% of expected and FVC 64.5% versus 52.3% of expected], less morbidities [4 incidences versus 10 incidences], less postoperative bleeding [461 ml versus 570.8 ml] and better cough score. Meticulous harvesting of bilateral internal mammary artery with preservation of pleura could dramatically decrease early postoperative complications associated with such technique

Composite arterial bypass grafting of the left coronary circulation using left Internal thoracic and radial arteries versus bilateral skeletonized internal thoracic arteries: early results of a multi-center study

Total arterial revascularization offers a potential to avoid the problems associated with vein graft failure. We aimed to evaluate the benefits of using composite grafts in T or Y fashion: free RA implanted on intact full-pedicle LIMA; versus using skeletonized RIMA implanted in T or Y fashion on intact skeletonized LIMA for adequate revascularization of the left coronary artery branches. This randomized prospective comparative study was performed in the Departments of Cardiothoracic Surgery, Kasr El Aini Faculty of Medicine of Cairo University and lmhaba National Heart Institute; the Cardiology Department, El Faioum University; and the Departments of General surgery Cairo university and Anaesthesiology department Am Shams University between 2004 and 2007. The study enrolled 100 male ischemic heart disease patients who were submitted for elective isolated CABG Surgery using conventional CPB and antegrade intermittent warm blood cardioplegia. Mean age was 48 +/- 2.4 years [range 41-64 years], Patients were allocated into two equal groups: Group A encompassed 50 patients in whom a intact full-pedicle left internal mammary artery [LIMA] was grafted to the LAD coronary vessel, and free pedicled RA grafts to revascularize left coronary branches from the LIMA in a T or Y fashion, and a free SVG from the aorta to branches of the right coronary system. In group B, 50 patients received a free skeletonized RIMA graft between the left coronary branches and LIMA which was skeletonized and implanted to the LAD. The RA grafts were managed according to the Hong- Kong University Protocol. Follow-up was complete for all cases. Data were prospectively collected in both groups. Results were analyzed by clinical assessment and special investigations as ECO, Lab Enzymes, and echocardiography, both intraoperatively and during the in-hospital patient stay. The mean total operative time was 3 +/- 0.7 hours [range 3-4.5 hours] for group A, versus 4.5 0.6 hours [range 4-5.5 hours] for group B. The mean cardiopulmonary bypass time was 70 +/- 30 minutes [range 65-120 minutes], versus 75 +/- 25 minutes [range 69-127 minutes] in group B. The mean aortic occlusion [ischemic] time was 48 +/- 4 minutes [range, 33-99 minutes] for group A, versus 52 +/- 6 minutes [range 40-102 minutes] for group 13. In group A, 3 +/- 0.02 distal anastomotic points were fashioned in each patient versus 3 +/- 0.04 in group B. There was no incidence of new isehemic pain: perioperative MI; cerebral stroke, or neurovascular hand complications. Patients of group B needed a longer ICU time [statistically-significant] with a mean of 42 +/- 3.2 hours [range 30-49 hours]; versus 33 +/- 3.5 hours [range 24 - 38 hours]. The time spent by the patient on mechanical ventilation was longer [statistically-significant] in group B patients with a mean of 8 +/- 1.5 hours ranging between 6.10 hours; versus mean of 13 +/- 4.5 hours ranging between 8-14 hours for group A patients. The amount of pleuro-mediastinal blood loss was more [statistically- significant] in group B patients with mean of 900 +/- 150 mls ranging between 750-1100 mIs; versus 1400 +/- 350 mis ranging between 1000- 1800 mIs. The total hospital time was longer [statistically-significant] in group B patients ranoing from 5-12 days with a mean of 5 +/- 2.2