Bilateral Internal Mammary Artery Bypass Research Articles

Impacts of Skeletonized Bilateral Internal Mammary Artery Bypass Grafting on the Risk of Deep Sternal Wound Infection.

This single-center study aimed to evaluate the incidence of deep sternal wound infection (DSWI) following skeletonized bilateral internal mammary artery (BIMA) harvest in a Chinese cohort. Using propensity score matching, this study also provided a present-day assessment of the impacts of skeletonized BIMA grafting versus skeletonized single internal mammary artery (SIMA) grafting on early outcomes.From January 2014 to December 2017, 2403 eligible patients were entered into either a BIMA group (n = 368) or a SIMA group (n = 2035). The incidence of DSWI was recorded. Analysis of early outcomes was further performed for propensity score-matched (1:1) cohorts.The BIMA group received a similar incidence of DSWI as did the SIMA group (1.6% versus 0.9%, P = 0.247). No significant differences between subgroup diabetic-BIMA, subgroup nondiabetic-BIMA, subgroup diabetic-SIMA, and subgroup nondiabetic-SIMA were found regarding the incidence of DSWI (2.0%, 1.4%, 1.0%, and 0.7%, respectively; P > 0.05 between groups). After matching, treatment type (skeletonized BIMA grafting versus skeletonized SIMA grafting) was not an independent risk factor for postoperative DSWI (OR = 1.309, 95% CI 0.897-2.714, P = 0.704) or predictors of other early outcomes. Additionally, the two matched groups shared similar early outcomes (including postoperative DSWI), regardless of whether or not the merger with diabetes (all P > 0.05).Skeletonized BIMA harvest as compared with skeletonized SIMA harvest was not associated with an increased risk of DSWI, regardless of whether or not the merger with diabetes. Patients with skeletonized BIMA grafting received similar surgical mortality and major postoperative morbidity as did matched patients with skeletonized SIMA grafting.

P4567Do women benefit from bilateral internal mammary artery bypass grafting?

P4567Do women benefit from bilateral internal mammary artery bypass grafting?

Bilateral Internal Mammary Artery Bypass Grafting: Sternal Wound Infection in High-Risk Population. Should Sternal Infection Scare Us?

Background:Bilateral internal mammary arteries (BIMAs) remain underused in coronary artery bypass grafting (CABG), especially in elderly, diabetic, and obese patients. This study investigated incidence of sternal wound infection (SWI), sternal instability (SI), and reintervention for bleeding (RIB) in this high-risk population.Methods:A single-center retrospective observational study was performed in “Grand Hôpital de Charleroi, Gilly, Belgium.” A total of 319 patients undergoing CABG from December 2011 to December 2015 were included. Three main outcome measures (SWI, SI, and RIB) were investigated in obese vs nonobese, diabetic vs nondiabetic, and elderly vs younger patients.Results:In all, 14 SWI, 11 SI, and 6 RIB were discounted. Death rate was as follows: SWI: 2/14 vs 17/305 (P = .178), SI: 2/11 vs 17/308 (P = .081), and RIB: 2/6 vs 17/313 (P = .004). In obese (n = 113) vs nonobese (n = 206) patients, there was no difference for SWI (P = .263), SI (P = .565), and RIB (P = .332). In diabetic (n = 118) vs nondiabetic (n = 201) patients, there was no difference for SWI (P = .642), SI (P = .497), and RIB (P = .298). In elderly (n = 62) vs younger (n = 257) patients, there was no difference for SWI (P = .619), SI (P = .915), and RIB (P = .385).Conclusions:Obesity, age, and diabetes treated by insulin (or not) do not seem to be risk factors for developing SWI, SI, or RIB in patients receiving a CABG using BIMA. Nevertheless, mortality was higher in RIB group.

Bilateral internal mammary artery bypass grafting: long-term clinical benefits in a series of 1000 patients

ObjectiveBilateral internal mammary arteries (BIMA) remain widely underused in coronary artery bypass grafting (CABG). In this study, we aim to investigate the early and long-term outcomes of BIMA grafts in...

307: Bilateral internal mammary artery bypass grafting: long-term clinical benefits of a consecutive series of 1000 patients

Bilateral internal mammary arteries (BIMA) remain still widely underutilized in coronary artery bypass grafting (CABG). This historical cohort study evaluated the early and long term outcomes of BIMA grafts in isolated CABG in a single institution. Between 1996 and 2008, we performed elective, isolated, primary, multiple CABG using bilateral internal mammary artery (IMA) grafts and supplemental venous grafts for multivessel coronary disease in 1000 consecutive patients. The mean age of the overall population was 64±15 years. 20% of patients were diabetics with a left ventricular ejection fraction (LVEF) ≤45% in 28% of patients. Comorbidities were represented by chronic renal failure, chronic obstructive pulmonary disease and peripheral artery disease in 11%, 11,5% and 26,9% of cases respectively. Acute coronary syndrome represented the initial clinical presentation in 41% of cases. The 30-day mortality rate was 2.8%. Early postoperative morbidity included myocardial infarction (2,2%), stroke (0,9%), mesenteric ischemia (0,7%), sternitis requiring reintervention (6,7%) and supraventricular arrhythmia (23,1%). The follow-up (between 3 and 14,8 years; mean follow up: 6,4±5 years) revealed 103 deaths. Kaplan-Meier 8-year survival rates for patients <65 and 65 to 74 years of age were 88% and 66% respectively (p<0,01). Multiple regression analysis showed that age ≥ 65 years at baseline (odds ratio (OR): 2,3; 95% confidence interval (CI): 1,3 to 4, p<0,001), acute coronary syndrome (OR: 1,9; 95% CI: 1,1 to 3,4, p=0,02), chronic renal failure (OR: 2,7; 95% CI, 1,4 to 5,2, p<0,001), peripheral artery disease (OR: 3,1; 95% CI, 1,8 to 5,5, p<0,001) and LVEF ≤45% (OR: 2,6; 95% CI, 1,4 to 4,5, p<0,001) were independent predictors of long term cardiovascular mortality. Our longitudinal analysis demonstrates that bilateral IMA grafting has a low operative risk and provides excellent long-term survival.

Influence of Mammary Artery as a Bypass Vessel on the Results of Seven Biochemical Assays after Coronary Artery Bypass Surgery

We compared the changes in troponin T, creatine MB isoenzyme mass concentration (CK-MB mass), creatine kinase MB isoenzyme activity (CK-MB activity), creatine kinase (CK), alpha-hydroxybutyrate dehydrogenase (HBD), lactate dehydrogenase (LD) and aspartate aminotransferase (AST) concentrations after coronary artery grafting with saphenous vein grafts, without or in combination with uni- or bilateral internal mammary artery(ies) as bypass vessels in 73 patients. An increase in CK concentration after surgery was highest for the bilateral internal mammary artery bypass patient group and lowest for the group who received only saphenous vein grafts. We present 90th percentile values for the seven tests.

Minimally Invasive Bilateral Internal Mammary Artery Bypass Grafting

We report about a 71-year-old man with coronary artery double-vessel disease who received minimally invasive coronary artery bypass grafting through a 9-cm left lateral chest incision in the third intercostal space. Both mammary arteries were harvested either directly (left internal mammary artery) or thoracoscopically (right internal mammary artery) and anastomosed to the left anterior descending artery and the circumflex artery through this single left lateral chest incision. The postoperative course was uneventful, and the patient was discharged on postoperative day 5.

Sternal Wound Infections

Sternal wound infections are a major cause of morbidity and mortality in patients undergoing cardiac surgery. They occur in 1% to 3% of patients who undergo open-heart surgery and carry a 20% to 40% mortality rate. Sternal infections can range from minor, superficial infections to open mediastinitis with invasion of the sternum, heart, and great vessels. Staphylococcus species are responsible for the majority of sternal infections, but environmental sources can cause infections by other organisms. The common signs and symptoms of mediastinitis are fever, leukocytosis, sternal instability, drainage, and pain. Several risk factors exist for sternal wound infection, with bilateral internal mammary artery bypass grafting in diabetic patients being the most common. Treatment entails surgical debridement with either closed irrigation, open-wound packing, or muscle or omental flap procedures, as well as antibiotic therapy. Some simple procedures help limit the development of sternal infections in certain patients.

Low-dose aprotinin in internal mammary artery bypass operations contributes to important blood saving

The effect on postoperative blood loss and blood use of blood-saving treatment with or without 280 mg of lowdose aprotinin (2 million kallikrein inactivator units) was studied in 200 consecutive patients undergoing either unilateral or bilateral internal mammary artery bypass grafting. Postoperative blood loss and total units of homologous blood products were similar in patients having either bypass procedure without aprotinin treatment. In patients given aprotinin, postoperative blood loss and use of homologous blood products were significantly lower ( p < 0.05). The use of any donor blood product was prevented in 78% of the patients given aprotinin versus only 45% of patients treated without aprotinin. None of the aprotinin-treated patients under went repeat thoracotomy for excessive bleeding; repeat thoracotomy was indicated in 8% of the patients having bilateral internal mammary artery grafting without aprotinin treatment. These results demonstrate that low-dose aprotinin reduces blood loss and blood use significantly and prevents excessive bleeding.

Risks of bilateral internal mammary artery bypass grafting

Although use of one internal mammary artery (IMA) for coronary artery bypass grafting does not appear to be associated with increased risk, the results with both IMAs are less certain; the potential for a higher incidence of sternal wound infection as a result of devascularization of the sternum is a major concern. During a 42-month interval ending July 1988, 1,566 patients had coronary artery bypass grafting alone or in combination with other procedures: 633 received only vein grafts, 687 had unilateral IMA grafting, and 246 had bilateral IMA grafting. The IMA patients were younger, were more often male, had better cardiac function, and underwent fewer emergent, urgent, or combined procedures than the patients receiving vein grafts ( p < 0.05). Thirty-day mortality was lower among the IMA patients (unilateral IMA group, 2.8%; bilateral IMA group, 3.7%; and vein graft group, 7.9%; p = 0.001). With the exception of sternal wound problems, occurrence rates for postoperative complications among the IMA patients did not differ significantly from or were lower ( p < 0.05) than those among the patients with vein grafts. Sternal infections occurred with greater frequency among the bilateral IMA patients (6.9%) than among the unilateral IMA (1.9%) or vein graft (1.3%) patients ( p = 0.001). By univariate analysis, obesity, diabetee, bilateral IMA grafting, and need for prolonged (>48 hours) mechanical ventilation were associated with a significantly higher incidence of sternal infection ( p < 0.05). Multivariate logistic regression analysis identified use of bilateral IMA grafts ( p = 0.0001), obesity ( p = 0.0014), and prolonged mechanical ventilation ( p = 0.0018) as significant risk factors for the development of sternal infection. We conclude that bilateral IMA grafting is an important predictor of sternal infection. It should be used selectively in obese or diabetic patients and in patients who are likely to require prolonged mechanical ventilation postoperatively.