Invited Commentary

Abstract

In this review, Cheng and colleagues [1Cheng K. Rehman S.M. Taggart D.P. A review of differing techniques of mammary artery harvesting on sternal perfusion: time for a randomized study?.Ann Thorac Surg. 2015; 100: 1942-1953Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar] summarize the effect of internal mammary artery (IMA) harvesting on sternal perfusion. In particular, they review the consequences on sternal perfusion of 1) single IMA harvesting, 2) single versus bilateral IMA harvesting, and 3) pedicled versus skeletonized harvesting. Although the findings of the reviewed studies vary, the authors conclude that single IMA harvesting transiently decreases sternal perfusion, particularly in diabetic patients; that bilateral compared with single IMA harvesting does not significantly reduce sternal perfusion; and that skeletonized IMA harvesting results in better sternal perfusion than pedicled harvesting. They suggest that it may be time for a randomized trial.Why does sternal perfusion after IMA harvesting matter? Adequate sternal perfusion is necessary for sternal healing, and inadequate perfusion may increase sternal wound infection. Fear of sternal wound infection is an important deterrent to the widespread adoption of bilateral IMA grafting, despite multiple studies demonstrating that it increases survival and reduces late ischemic events. Another deterrent is that deep sternal wound infection is a “never event” in quality reporting and a metric used in The Society of Thoracic Surgeon’s star rating. Coronary surgeons are caught in the middle. They want to do what is best for their patients; however, the fear of a deep sternal wound infection and its resultant consequences on public reporting, hospital cost, and patient morbidity sway surgeons away from bilateral IMA grafting. In light of these fears, the review by Cheng and colleagues is encouraging. Bilateral IMA harvesting does not appear to result in worse sternal perfusion than single IMA harvesting, and the skeletonized method of harvesting IMAs leads to less devascularization. It may be time for a randomized study, but at least coronary surgeons wanting to do what is best for their patients have a way forward. In this review, Cheng and colleagues [1Cheng K. Rehman S.M. Taggart D.P. A review of differing techniques of mammary artery harvesting on sternal perfusion: time for a randomized study?.Ann Thorac Surg. 2015; 100: 1942-1953Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar] summarize the effect of internal mammary artery (IMA) harvesting on sternal perfusion. In particular, they review the consequences on sternal perfusion of 1) single IMA harvesting, 2) single versus bilateral IMA harvesting, and 3) pedicled versus skeletonized harvesting. Although the findings of the reviewed studies vary, the authors conclude that single IMA harvesting transiently decreases sternal perfusion, particularly in diabetic patients; that bilateral compared with single IMA harvesting does not significantly reduce sternal perfusion; and that skeletonized IMA harvesting results in better sternal perfusion than pedicled harvesting. They suggest that it may be time for a randomized trial. Why does sternal perfusion after IMA harvesting matter? Adequate sternal perfusion is necessary for sternal healing, and inadequate perfusion may increase sternal wound infection. Fear of sternal wound infection is an important deterrent to the widespread adoption of bilateral IMA grafting, despite multiple studies demonstrating that it increases survival and reduces late ischemic events. Another deterrent is that deep sternal wound infection is a “never event” in quality reporting and a metric used in The Society of Thoracic Surgeon’s star rating. Coronary surgeons are caught in the middle. They want to do what is best for their patients; however, the fear of a deep sternal wound infection and its resultant consequences on public reporting, hospital cost, and patient morbidity sway surgeons away from bilateral IMA grafting. In light of these fears, the review by Cheng and colleagues is encouraging. Bilateral IMA harvesting does not appear to result in worse sternal perfusion than single IMA harvesting, and the skeletonized method of harvesting IMAs leads to less devascularization. It may be time for a randomized study, but at least coronary surgeons wanting to do what is best for their patients have a way forward. A Review of Differing Techniques of Mammary Artery Harvesting on Sternal Perfusion: Time for a Randomized Study?The Annals of Thoracic SurgeryVol. 100Issue 5PreviewThe use of internal mammary artery (IMA) grafts for coronary artery bypass may devascularize the sternum. We performed a literature review by searching the PubMed database for studies that assessed sternal perfusion after IMA harvesting. The majority of papers describe various techniques and compared (1) IMA harvest versus no IMA harvest, (2) single versus bilateral, and (3) skeletonized versus pedicled. Evidence is inconclusive as to whether single harvesting causes significant devascularisation and whether this is increased with bilateral harvesting. Full-Text PDF