Bilateral Internal Mammary Artery Grafting Research Articles

Thoracoscopic (non-robotic) harvesting of bilateral internal mammary artery grafts

Minimally invasive coronary surgery offers benefits to the patient. Harvesting the internal mammary artery remains a challenging part of this procedure. We describe our technique for thoracoscopic harvesting of the left and right mammary arteries using routine endoscopic instruments. This is a non-robotic technique that might facilitate a more widespread growth of minimally invasive coronary surgery.

Effect of skeletonisation and pedicled bilateral internal mammary artery grafting in coronary artery bypass surgery on post-operative wound infection: A meta-analysis.

The results showed that different internal thoracic artery (ITA) was associated with the rate of postoperative wound infection and the severity of pain following coronary artery bypass grafting (CABG). In order to ascertain if there was any genuine difference in the rate of postoperative infection and severity of the pain, we conducted a meta-analysis to evaluate if there was any actual difference in the wound complication that had been identified with the ITA method. Through EMBASE, Cochrane Library and Pubmed, and so forth, we systematically reviewed the results by August 2023, which compared the impact of skeletonised versus pedicled internal mammary artery (IMA) on wound complications following CABG. The trial data have been pooled and analysed in order to determine if a randomisation or fixed-effect model should be applied. The meta-analysis of data was performed with Revman 5.3 software. The results of this meta-study included 252 related articles from four main databases, and nine articles were chosen to be extracted and analysed. A total of 3320 patients were treated with coronary artery transplantation. Based on current data analysis, we have shown that the rate of postoperative wound infections is reduced by the use of the skeletonised internal mammary artery (SIMA) (OR, 1.84; 95% CI, 1.13, 3.01; p = 0.01). But the results showed that there were no statistically significant differences in the post-operation pain score of the patients (MD, 0.09; 95% CI, -0.58, 0.76; p = 0.79). Furthermore, the duration of the operation was not significantly different between the SIMA and pedicled internal mammary artery (PIMA) (MD, 3.30; 95% CI, -3.13, 9.73; p = 0.31). Overall, the SIMA decreased the rate of postoperative wound infection in CABG patients than the PIMA.

Sternal wound infections following internal mammary artery grafts for a coronary bypass: A meta-analysis.

The meta-analysis aims to evaluate and compare the sternal wound infections following internal mammary artery grafts for a coronary bypass. Examinations comparing bilateral internal mammary artery to single internal mammary artery for coronary artery bypass grafting were among the meta-analyses from various languages that met the inclusion criteria. Using dichotomous random- or fixed-effect models, the results of these investigations were examined, and the Odd Ratio (OR) with 95% confidence intervals (CIs) was computed. A total of 31 examinations from 2001 to 2023 were recruited for the current analysis including 181 503 personals with coronary artery bypass grafting. Bilateral internal mammary artery had significantly higher sternal wound infection (OR, 1.51; 95% CI, 1.37-1.68, p < 0.001), superficial sternal wound infection (OR, 1.72; 95% CI, 1.16-2.56, p = 0.007), deep sternal wound infection (OR, 1.62; 95% CI, 1.41-1.86, p < 0.001), sternal wound infection in diabetics (OR, 1.48; 95% CI, 1.16-1.90, p = 0.002), sternal wound infection in elderly (OR, 1.38; 95% CI, 1.22-1.57, p < 0.001), sternal wound infection in pedicled preparation (OR, 1.70; 95% CI, 1.30-2.23, p < 0.001) and sternal wound infection in skeletonized preparation (OR, 1.40; 95% CI, 1.09-1.81, p = 0.009) compared to single internal mammary artery in personals with coronary artery bypass grafting. Bilateral internal mammary artery grafting is linked to a higher risk of impaired wound healing, particularly in diabetic individuals, elderly, pedicled preparation, and skeletonized preparation. Nevertheless, caution should be exercised while interacting with its values since examinations were performed by different surgeons with different skills on different types of personals.

Outcomes of Coronary Artery Bypass Grafting With Bilateral Internal Mammary Artery in Obese Patients

BackgroundThe purpose of this study was to evaluate postoperative outcomes with the use of bilateral internal mammary artery (BIMA) conduits in obese patients. MethodsBetween January 2003 and December 2018, 8109 patients underwent isolated coronary artery bypass grafting, including 7218 (89%) treated with single internal mammary artery (SIMA) and 891 (11%) treated with BIMA grafts. Patients were divided into 3 groups according to preoperative body mass index (BMI): normal, BMI <25 kg/m2 (22.2%); overweight, BMI of 25 to <30 kg/m2 (37.2%); and obese, BMI ≥30 kg/m2 (40.6%). In each group, BIMA and SIMA patients were compared to investigate 30-day mortality and postoperative complications. Significant baseline differences were observed between the 3 BMI groups, and such differences were adjusted by inverse probability weighting matching. ResultsThirty-day mortality, deep sternal wound infection (DSWI) rates, and length of hospital stay were 1.4%, 0.5%, and 6.0 ± 9.1 days for the normal group; 0.2%, 1.0%, and 5.5 ± 4.2 days for the overweight group; and 0.9%, 1.8%, and 5.5 ± 4.0 days for the obese group. There was no significant difference in 30-day mortality, incidence of DSWI, and hospital stay between BIMA and SIMA groups, except in the obese group, in which the rate of DSWI was significantly higher in the BIMA patients (3.4% vs 0%; P = .02). ConclusionsBIMA grafts in obese patients can be used without an increase of the 30-day mortality and hospital stay. However, the use of BIMA grafts in obese patients may lead to an increase of postoperative DSWI.

Long-term survival of single versus bilateral internal mammary artery grafting in patients under 70.

OBJECTIVESAs definitive data from randomized controlled trials comparing the effect on long-term survival of using single internal mammary artery (SIMA) or bilateral internal mammary artery (BIMA) grafting are not yet available, observational studies allow for long-term follow-up in large and representative populations, which might complement the information potentially derived from randomized trials. To compare long-term survival in patients under 70 years of age undergoing SIMA or BIMA grafting.METHODSRetrospective analysis of 3384 consecutive patients under 70 years undergoing primary isolated coronary artery bypass grafting, performed from 2000 to 2015, in a Portuguese level III Hospital. We identified 2176 and 1208 patients from the study population who underwent SIMA and BIMA grafting, respectively. The primary end point was all-cause mortality at 10 years. We employed inverse probability weighting to restrict confounding by indication.RESULTSThe mean age of the study population was 59.4 (± 7.6) years, and 567 (16.8%) were females. Inverse probability weighting was effective in eliminating differences in all significant baseline characteristics. Follow-up was 99.88% complete. The median follow-up time was 12.82 (interquartile range, 9.65, 16.74) years: the primary end point of all-cause mortality at 10 years occurred in 463 patients (21.3%) and 166 (13.7%) in the SIMA and BIMA grafting groups, respectively (hazard ratio, 0.78; 95% confidence interval, 0.66–0.92; P = 0.004).CONCLUSIONSBilateral internal mammary grafting is associated with lower long-term mortality than single internal mammary grafting. Moreover, this survival benefit comes at no increased perioperative morbidity or mortality cost.

What is the best choice for third conduit when using bilateral internal mammary arteries for coronary artery bypass grafting-radial artery or saphenous vein graft?

SummaryA best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was ‘What is the best choice for third conduit when using bilateral internal mammary arteries for coronary artery bypass grafting—radial artery or saphenous vein graft?’. Altogether >525 papers were found using the reported search, of which 7 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Overall, there was no survival benefit demonstrated with the use of a radial artery over the use of a saphenous vein graft as a choice of third conduit following bilateral internal mammary artery grafts for coronary artery bypass grafting. The main limitation of the current evidence available is the restricted follow-up periods and the high attrition rates with small sample sizes affecting the strength of conclusions that can be drawn beyond 10 years of follow-up. We conclude that despite previous evidence supporting improved long-term patency of radial arterial grafts, there is no strong evidence that the use of a radial artery, over a saphenous vein graft, has any survival benefit when used as the third conduit following bilateral internal mammary artery grafts.

Off-pump bilateral internal mammary artery grafting in patients over 65 years old

<h3>ЦЕЛЬ ИССЛЕДОВАНИЯ</h3> Анализ ближайших результатов бимаммарной реваскуляризации миокарда на работающем сердце у пациентов старше 65 лет. <h3>МАТЕРИАЛ И МЕТОДЫ</h3> Работа основана на ретроспективном анализе результатов хирургического лечения 100 пациентов, оперированных в отделении кардиохирургии в период с 2013 по 2019 г. Всем пациентам было выполнено коронарное шунтирование на работающем сердце с использованием в качестве шунтов обеих внутренних грудных артерий. В зависимости от возраста все больные были стратифицированы на две группы. В 1-ю группу вошли пациенты моложе 65 лет (<i>n</i>=47), 2-я группа представлена пациентами старше 65 лет (<i>n</i>=53). Проанализировали предоперационные, интраоперационные и послеоперационные показатели, периоперационные осложнения и госпитальную летальность. <h3>РЕЗУЛЬТАТЫ</h3> Госпитальная летальность отсутствовала во всех группах. Отсутствовали статистически значимые различия по периоперационным инфарктам миокарда, острым нарушениям мозгового кровообращения. В послеоперационном периоде отсутствовали различия между группами по наличию почечной недостаточности, глубокой раневой инфекции грудины. Анализ показал более высокую частоту дыхательной недостаточности у больных старше 65 лет. <h3>ВЫВОД</h3> Бимаммарная реваскуляризация миокарда на работающем сердце у пациентов старше 65 лет не увеличивает риск периоперационных осложнений и госпитальной летальности в сравнении с группой пациентов моложе 65 лет, однако сохраняется более высокий риск дыхательной недостаточности.

Comparison between Bilateral Internal Mammary Artery Graft and LIMAG in Patients Undergoing CA Bypass Grafting

Background: Increasing evidence continues to demonstrate a survival advantage for bilateral internal mammary artery (BIMA) over Left internal mammary artery for coronary artery bypass grafting (CABG). However, there are still uncertainties about which surgical approach is the best one to use with BIMA grafting. Objective: To compare Bilateral Internal Mammary Artery (BIMA) Grafting with Left Internal Mammary Artery (LIMA) Grafting during Coronary Artery Bypass Grafting (CABG) in terms of early mortality and sternal wound infections. Materials &amp; Methods Randomized: control trialtechnique enrolled. The study was conducted at the Cardiac Surgery Department, King Edward Medical University (KEMU), Mayo Hospital Lahore Results: Total 96patients undergoing CABG were included in this study. Patients were randomly divided into 2 groups; each group contains 48 patients. Group A included patients having Left IMA to LAD; second and third graft by Great Saphenous Vein and Group B included patients having Bilateral Internal Mammary Arteries with Left IMA to LAD or OM and Right IMA to RCA, LAD or Ramus Intermedius. The superficial and deep sternal wound infections was recorded along with the different risk factors including diabetes, obesity, hypertension, smoking and use of inotropes intra-operatively and post operatively. The incision site over the sternum was being evaluated on daily basis throughout the stay of the patients (from 5–8 days). Diagnosis of Sternal infections was based on the presence of positive cultures, dehiscence of the sternum incision, fever, redness pain, and infected (purulent) secretions. Sternal instability and discharge, ventilation time, length of ICU stay, chest drainage, re-exploration and length of hospital stay was also recorded. Results:Not any of the patients included in these two treatment groups suffered from mortality (LIMA: 0%, BIMA: 0%). Deep sternal wound infection [LIMA: 4.17% &amp; BIMA: 6.25%, p-value=0.646] and superficial wound infection [LIMA: 4.17% &amp; BIMA: 6.25%, p-value=0.646] did not show any statistically significant association towards both grafts type. Patients who underwent BIMA grafting suffered from higher in hospital stay as compared to patients who underwent LIMAgrafting. i.e. [LIMA: 7.02 &amp; BIMA: 8.02, P value = 0.000] Conclusion: Results of the study showed no significant difference for deep sternal wound infection and superficial wound infection between the two grafts BIMA and LIMA. However, patients who underwent BIMA grafting had significantly higher hospital stay as compared to patients who underwent LIMA grafting. Keywords: Bilateral, Internal, Mammary Artery, Grafting, Left, Internal Mammary Artery, Coronary Artery, Bypass, Grafting, Mortality, Sternal wound infections.

177 Pedicled Or Skeletonized Bilateral Internal Mammary Artery Harvesting - A Meta- Analysis and Trial Sequential Analysis

Abstract Objective There is varying evidence on the role of skeletonization of internal mammary artery in reducing the risk of sternal wound infections and ischemia following bilateral internal mammary artery grafting. We opt to compare post-operative clinical outcomes of skeletonized bilateral internal mammary artery versus pedicled bilateral internal mammary artery harvesting in patients undergoing coronary artery bypass surgery. Method A comprehensive electronic search was conducted using PubMed/MEDLINE, Scopus, EMBASE, Cochrane database and Google Scholar from inception until 15th June 2020. All studies directly comparing skeletonized and pedicled bilateral internal mammary artery harvesting were included. Meta-analysis and trial sequential analysis was conducted. Results Ten studies consisting of 3728 patients (2098 patients with skeletonized bilateral internal mammary artery grafting and 1630 patients with pedicled bilateral internal mammary artery grafting) were included. Pooled effects analysis and trial sequential analysis reported significantly lower risk of sternal wound infection with skeletonized bilateral internal mammary artery harvesting (OR 0.32, 95% CI 0.20 – 0.51, p &amp;lt; 0.00001). S-BIMA may be associated with lower late mortality, but more information is required to confirm this. Conclusions Skeletonization reduces the risk of sternal wound infections by preserving vasculature as much as possible. This makes it an important technique for use in bilateral internal mammary artery grafting for high-risk patients.

Impact of some intraoperative factors on wound infection in cardiac surgery

Relevanc. Surgical Site Infection (SSI) after open heart surgery is a significant problem in clinical, social, and economic aspect which causes the need to identification of the preferred procedures for successful prevention of the SSI.Objectives. To determine risk of the SSI in cardiac surgery depending on complexity of intervention, using of cardiopulmonary bypass (CBP) and use of both internal mammary arteries (IMA).Methods. Prospective observations study from 2010 to 2019 in cardiac surgery department of the Ural Institute of Cardiology, where in total 4993 open heart surgery procedures were consecutively performed. All SSI cases were recorded up to 90 days after surgery. The analysis was performed to identify risk of cardiopulmonary bypass (CPB), bilateral IMA grafting and combined procedures on the risk of the postoperative wound infection.Results. During the investigation period, total 220 cases of the SSI (4,5%) have been registered of the 4993 patients undergoing open heart surgery. It included 42 cases of deep sternal infection (0,9%) and 178 cases of superficial infection (3,6%). The main pathogen identified was Staphylococcus epidermidis (56,4%). During the hospital period, 151 cases (66,5%) of SSI have been detected, with the median time to detection of the complication 6 days. The relative mortality risk in deep sternal infection group was 4,4 times higher than in the group without SSI (HR 4,6, 95 % CI 1,5-13,9, p=0,003624). CABG increases the relative risk of SSI in compare with non-CABG procedures (OR 3,086169; 95%CI 1,281 – 7,437), while the complexity of the operation (combined versus isolated interventions) does not significantly increase the risk (OR 0.972283; 95% CI: 0.696 - 1.359). The incidence of SSI in the group of in situ BIMA grafting was 8.8%, significantly increasing the likelihood of the SSI in compare to those with SIMA (OR 2.167983, 95% CI 1.463 - 3.212; p =0,000057). CBP significantly increases the risk of postoperative wound infections (OR 1.523890, 95% CI 1.149 - 2.022, p = 0.001742).Conclusions. Refusal of cardiopulmonary bypass, simultaneous procedures and bilateral coronary artery bypass does not allow completely to avoid postoperative wound infections. Nevertheless, the technical features of the preparations and use of grafts, including skeletonization, prevention of coagulation and the preference for sequential composite CABG, can reduce the risk associated with the type of the open heart surgery.

STS Adult Cardiac Surgery Database: 2021 Update on Outcomes, Quality, and Research

The Society of Thoracic Surgeons Adult Cardiac Surgery Database is the most mature and comprehensive cardiac surgery database. It has been the foundation for quality measurement and improvement activities in cardiac surgery, facilitated the generation of accurate risk adjusted performance benchmarks and serves as a platform for novel research. Recent enhancements have added to the database's functionality, ease of use, and value to multiple stakeholders. This report is the sixth in a series of annual reports that provide updated volumes, outcomes, database-related developments, quality improvement initiatives, and research summaries using the Adult Cardiac Surgery Database in the past year.

Eleven-year outcomes of U-clips in totally robotic coronary artery bypass grafting versus standard hand-sewn running suture in robotic-assisted coronary artery bypass grafting.

The aim of this study was to evaluate the clinical outcomes of patients undergoing off-pump robotic coronary artery bypass grafting (CABG) with either interrupted nitinol U-Clips in totally endoscopic coronary artery bypass (TECAB) or standard running suture anastomosis in robotically assisted direct coronary artery bypass (RADCAB) over a decade. From January 2007 to December 2017, 280 patients underwent robotic off-pump CABG using the da Vinci S/Si Surgical System in our centre. TECAB with interrupted nitinol U-Clips anastomosis was performed in the left internal mammary artery (LIMA) to LAD grafting in 126 patients and RADCAB (n = 154) of the LIMA to LAD was completed with standard running suture. After discharge, patients were contacted through telephone interview and were invited to attend the outpatient clinic every 6 months or 1 year. The graft patency was assessed by coronary angiography or computed tomography angiography. All cases were completed without conversion to median sternotomy or cardiopulmonary bypass. A total of 275 single internal mammary artery (IMA) grafts (271 LIMAs, 4 right internal mammary arteries) and 5 bilateral IMA grafts were used as single graft or composite grafts. All the patients were discharged without in-hospital mortality or adverse outcomes. The average follow-up was 89.7 ± 30.4 months (range, 14-143 months). The cumulative survival rates (P = 0.53), the cumulative IMA patency rates (P = 0.83), and the rates of freedom from major adverse cerebrovascular and cardiovascular events (P = 0.41) between TECAB and RADCAB all showed no significant difference in the follow-up. Robotic off-pump CABG using IMA grafts is safe and can provide reliable long-term outcomes. Compared with the standard hand-sewn running suture technique in RADCAB, interrupted suture with the nitinol U-Clips in TECAB showed similar long-term clinical results and graft patency in LIMA to LAD bypass grafting.

Left or bilateral internal mammary artery employment in coronary artery bypass grafting: midterm results.

The gold standard for coronary artery bypass grafting to the left anterior descending artery is use of the left internal mammary artery. Better long-term survival has been reported using bilateral internal mammary arteries compared to left internal mammary artery only, but many surgeons are reluctant to employ bilateral internal mammary arteries in coronary artery bypass grafting. This study aimed to evaluate the effectiveness and safety of bilateral internal mammary artery use. From 2014 to 2017, 1703 patients underwent coronary artery bypass grafting in our institute. Of these, 772 met the inclusion criteria and were randomly assigned to receive bilateral (n = 387) or left (n = 385) internal mammary artery grafts. The mean age was 67.1 ± 6.0 years (range 48-85 years) and 474 (61.4%) were male. The mean number of diseased vessels was 3.1 ± 0.9, and mean EuroSCORE II was 3.4% ± 1.1%. Hospital mortality was 1.2% in the left internal mammary artery group vs. 1.8% in the bilateral internal mammary artery group (p = 0.55). There was no difference in procedure-related complications between groups. Mean follow-up was 65.9 months. Survival in the bilateral internal mammary artery group at 1, 3, and 5 years was 98.7%, 98.7%, and 94.8% vs. 98.1%, 98.1%, and 90.9%, respectively, in the left internal mammary artery group (p = 0.63). Application of bilateral internal mammary arteries in coronary artery bypass grafting is safe and effective, with comparable midterm results to those with the left internal mammary artery only.

Early Hospital Outcome of Using Both Internal Mammary Arteries in Cairo University Hospital

Background: Long-Using both mammary arteries in coronary artery bypass surgery has a good term results, but it is not recommended in old patients due to its technical difficulty and increased incidence of sternal wound complications. Several studies declared that bilateral internal mammary arteries (BIMA) grafting has a great benefit in patients aged 50–60 years, but this benefit does not extend to patients aged > 60 years. This study was designed to analyze the early hospital results, and experience in preventing sternal wound complications for BIMA grafting in patients 50–60 years old. Objective: To detect early outcome of using both internal mammary arteries in patients aged 50-60 years in Cairo University Hospital. Patients and Methods: Clinical data and echocardiographic and coronary angiography data of 100 patients who underwent BIMA grafting for coronary artery disease between 2017 and 2019 were analyzed retrospectively to detect the early hospital results. 100 patients aged 50 to 60 years. The operation time, aortic clamp time, and cardiopulmonary bypass time were studied to analyze the operation difficulty. The flow and P.I were studied to analyze the coronary artery graft function. The left ventricular end-diastolic dimension (LVEDD) and left ventricular ejection fraction (LVEF) were studied to detect heart function. Results: The operation time, aortic clamp time, and cardiopulmonary bypass time as well as the flow and pulsatility index were recorded. There was no incidence of sternal wound complications or graft occlusion. Furthermore, there was no significant difference in LVEF post-operation. Conclusions: Using both mammary arteries in coronary artery bypass surgery is safe and effective for patients 50– 60 years old similar to younger patients (< 50 years).

Early Hospital Outcome of Using Both Internal Mammary Arteries in Cairo University Hospital

Background: Long-Using both mammary arteries in coronary artery bypass surgery has a good term results, but it is not recommended in old patients due to its technical difficulty and increased incidence of sternal wound complications. Several studies declared that bilateral internal mammary arteries (BIMA) grafting has a great benefit in patients aged 50–60 years, but this benefit does not extend to patients aged > 60 years. This study was designed to analyze the early hospital results, and experience in preventing sternal wound complications for BIMA grafting in patients 50–60 years old. Objective: To detect early outcome of using both internal mammary arteries in patients aged 50-60 years in Cairo University Hospital. Patients and Methods: Clinical data and echocardiographic and coronary angiography data of 100 patients who underwent BIMA grafting for coronary artery disease between 2017 and 2019 were analyzed retrospectively to detect the early hospital results. 100 patients aged 50 to 60 years. The operation time, aortic clamp time, and cardiopulmonary bypass time were studied to analyze the operation difficulty. The flow and P.I were studied to analyze the coronary artery graft function. The left ventricular end-diastolic dimension (LVEDD) and left ventricular ejection fraction (LVEF) were studied to detect heart function. Results: The operation time, aortic clamp time, and cardiopulmonary bypass time as well as the flow and pulsatility index were recorded. There was no incidence of sternal wound complications or graft occlusion. Furthermore, there was no significant difference in LVEF post-operation. Conclusions: Using both mammary arteries in coronary artery bypass surgery is safe and effective for patients 50– 60 years old similar to younger patients (< 50 years).

Obesity and Preoperative Anaemia as Independent Risk Factors for Sternal Wound Infection After Coronary Artery Bypass Graft Surgery with Pedicled (Non-Skeletonized) Internal Mammary Arteries: The Role of Thoracic Wall Ischemia?

PurposeObesity remains statistically associated with coronary artery disease, for which coronary artery bypass graft surgery (CABG) remains the standard of care. However, obesity is also associated with sternal wound infection (SWI) which is a severe complication of CABG despite advances in surgery and in infection prevention and control. Strategies to reduce the incidence of SWI are still being investigated, and we therefore conducted a retrospective study to revisit factors other than obesity associated with SWI after CABG.Patients and MethodsData were extracted from the medical records of 182 patients who underwent elective on-pump CABG using one or both pedicled internal mammary artery grafts in Reims University Hospital between May 2015 and May 2016. All preoperative or perioperative variables with a p value<0.10 in univariate analysis were entered into a stepwise logistic regression model.ResultsAmong the 182 patients (145 male (79.6%), median age 68.0 [45.0–87.0] years), 138 (75.8%) underwent CABG using bilateral internal mammary artery grafts. Median BMI was 27.7 [18.7–50.5] kg/m2, and there were 51 (28.0%) and 79 (43.4%) patients with obesity and overweight, respectively. Twenty-three out of the 182 patients (12.6%) developed SWI. In-hospital mortality was not statistically different between patients with and without SWI but the median length of stay was (6.0 [2.0–38.0] versus 5.0[3.0–21.0] days in the intensive care unit, p=0.03, and 26.0 [9.0–134.0] versus 9.0 [7.0–51.0] days in hospital, p<0.0001). Obesity and preoperative anaemia were independently associated with SWI, as was the number of red blood cell (RBC) units transfused (OR 14.61 [2.64–80.75], OR 4.64 [1.61–13.34] and OR 1.27 [1.02–1.58], respectively).ConclusionThe independent association of SWI with the number of RBC units transfused and the existence of preoperative anaemia and obesity suggests a mechanism of thoracic wall ischemia in SWI after CABG, thus leaving insufficient perfusion of the thoracic wall in patients with obesity. Medical strategies are warranted to try to prevent this costly complication.

Branched internal mammary conduit permits non-sequenced total arterial revascularization.

Recent trends in cardiac surgery have encouraged total arterial coronary revascularization, citing advantages in long-term patency and overall mortality. Often relying on sequenced, composite, and free-graft strategies, total arterial coronary revascularization is limited by conduit availability and surgical complexity. We present the use of bilateral internal mammary artery grafts to achieve nonsequential 3-vessel total arterial coronary revascularization using the preserved distal bifurcation of the right internal mammary artery. Utilization of distal internal mammary artery branches should be considered a viable strategy in select patients and can broaden the opportunities for total arterial coronary revascularization in patients with multivessel coronary disease.

Wound complications and 30-day readmissions after single and bilateral internal mammary grafting: Analysis of the Nationwide Readmissions Database.

This study compares the postoperative outcomes, 30-day readmission rates, and incidence of sternal wound infection-related readmissions between patients receiving bilateral internal mammary arteries (BIMA) and single internal mammary artery (SIMA) grafting during coronary artery bypass graft (CABG) surgery. We utilized the weighted 2013-2014 National Readmission Database claims to identify all US adult patients who underwent CABG utilizing SIMA (n = 279,891) or BIMA (n = 11,651). Thirty-day overall and wound-related readmissions, in-hospital outcomes, costs, lengths of stay (LOS) at readmissions were compared between the two groups. Predictors of 30-day readmission were assessed using multivariable Cox proportional hazards analysis. After propensity matching (n = 10,339 pairs), there were no significant differences between the two groups during the index hospitalization, except for higher total hospital costs in the BIMA group (p = .02). The incidence of wound infections was also comparable between BIMA and SIMA (1.1% vs. 1.2%; p = .50). At 30-days, the overall readmission rate was elevated in SIMA patients (9.5% vs. 8.8%; p < .01), primarily impacted by cardiovascular causes. While the proportion of 30-day readmissions due to infections was significantly higher among BIMA versus SIMA patients (20.4% vs. 15.9%; p < .01), wound infections during the index hospitalization did not predict all-cause 30-day readmission among BIMA patients (p = .24) in the risk-adjusted analysis. Among the readmitted patients, LOS (6.4 vs. 6.2 days), costs ($14,440 vs. $16,461), and in-hospital mortality (2.4% vs. 1.7%) were comparable between the two groups (all p > .05). BIMA grafting is not an independent predictor of all-cause 30-day readmissions. Cardiovascular causes remain the primary driver of 30-day readmissions among SIMA and BIMA patients after CABG.

Training for Multiple Arterial Grafting: A Thoracic Surgery Resident Survey

Utilization of multiple arterial grafting (MAG) in the United States is less than 10%. Trainee experience with MAG has not previously been examined. A total of 497 thoracic surgery residents in accredited training programs in March 2019 and 115 who completed residency in 2018 were electronically surveyed regarding their experience with MAG using a radial artery (RA) graft or bilateral internal mammary artery (BIMA) grafts with a skeletonized mammary (SM). Eighty-four (14%) trainees responded: 54% had completed 2+ years of training and 87% declared their focus as cardiac, undecided, or both cardiac and thoracic (CUB). Of all 84 respondents, 76% (n= 64 of 84) had no experience with RA harvest. A total of 35% (n= 29 of 84) had no experience with SM harvest. The majority, 68% (n= 57 of 84), used BIMA grafting in 0% to 5% of cases. A total of 61% (n= 51 of 84) used RA conduit in 0% to 5% of cases. Among trainees with 2+ years of experience, 56% (n= 25 of 45) had performed more than 6 SM takedowns, 18% (n= 8 of 45) had no experience. In trainees with 2+ years, 20% (n= 9 of 45) performed more than 5 RA harvests, while 80% (n= 36 of 45) had no experience. Examining integrated 6-year residents with greater than 3 years of experience, only 33% (n= 5 of 15) performed more than 5% RA grafting. A total of 90% of CUB trainees wanted to perform MAG in practice and 75% felt prepared to do so. Despite substantial variation in MAG training, respondents expressed an overwhelming interest in performing MAG. These data and the reality of MAG utilization in the United States indicate that a more rigorous, standardized approach to MAG training may be required.

Short-Term Risk of Bilateral Internal Mammary Artery Grafting in Diabetic Patients

This study compares the morbidity and mortality at 30 days following the use of bilateral internal mammary arteries (BIMA) vs a single internal mammary artery (SIMA) at the time of coronary artery bypass grafting (CABG) in patients with a preoperative HbA1c. Patients undergoing CABG from January 2008 to December 2016 reported to the Society of Thoracic Surgeons database were retrospectively reviewed. The patients were divided into 2 groups: use of BIMA or use of SIMA and propensity matched. To assess the effect of preoperative HbA1c, both groups were further divided into 5 subgroups: patients without diabetes mellitus (DM), or patients with DM and a preoperative HbA1c level in one of four groups (< 7%, 7-9%, 9-11%, or >11%). The postoperative outcomes in both the BIMA and SIMA groups were compared. There were 700,504 and 28,115 patients with measured preoperative HbA1c levels in the SIMA and BIMA groups, respectively. Propensity score matching identified 23,635 comparable patients in each group for analysis. There was no difference in postoperative mortality between the BIMA and SIMA groups (1.3% vs 1.2%). The incidences of sternal wound infection (SWI) in patients undergoing placement of BIMA vs SIMA were: 0.8% vs 0.4% with no DM (P < 0.0001), 1.9% vs 1.0% with HbA1c < 7% (P < 0.001), 2.4% vs 1.2% with HbA1c 7-9% (P < 0.001), 2.8% vs 1.4% with HbA1c 9-11% (P = 0.02), 4.1% vs 1.5% with HbA1c > 11% (P = 0.01). Based on the incidence of SWI, BIMA is a reasonable approach with an HbA1c<7%.