Bilateral Internal Mammary Artery Research Articles

Continuous postoperative insulin infusion reduces deep sternal wound infection in patients with diabetes undergoing coronary artery bypass grafting using bilateral internal mammary artery grafts: a propensity-matched analysis.

Deep sternal wound infection (DSWI), especially in patients with diabetes mellitus (DM), is a major concern after coronary artery bypass grafting (CABG) with bilateral internal mammary artery (BIMA) grafts. We evaluated the risk of DSWI and other clinical outcomes between continuous insulin infusion therapy (CIT) and insulin sliding scale therapy (IST) in a cohort of DM patients who underwent CABG with BIMA. The clinical records of DM patients who underwent isolated CABG with BIMA were retrospectively reviewed. The study population consisted of 95 patients who received CIT and 126 patients who received IST. Furthermore, a one-to-one matched analysis based on estimated propensity scores for patients who received CIT or IST yielded two groups comprising 58 patients each. The proportion of patients with DSWI, overall survival rates and major adverse cardiac events were compared between the two groups in the overall and the propensity-matching cohort. The prevalence of DSWI requiring debridement and closure was significantly reduced in the CIT group compared with that in the IST group [1/95 (1.1%) vs 9/126 (7.1%), P = 0.031]; these results were not attenuated even after propensity-matching analysis [0/58 (0%) vs 6/58 (10.3%), P = 0.031]. The mean preoperative glucose levels were similar between the two groups (157.5 ± 54.6 vs 176.1 ± ±70 mg/dl, P = 0.063), whereas the mean glucose values were significantly lower on the first and second operative days in the CIT group than in the IST group (132.9 ± 44.1 vs 197.8 ± 78.6 mg/dl, P < 0.0001; 153.5 ± 58.8 vs 199.6 ± 89.1 mg/dl, P < 0.0001, respectively). The glucose variability levels within 24 h postoperatively were significantly higher in the IST group (46.1 ± 19.4 vs 66.4 ± 26.8 mg/dl, P < 0.0001). The 30-day and 1-year survival rates were similar between the two groups (100 vs 99.2%, P = 0.384; 96.6 vs 94.4%, P = 0.454). No results were changed in the propensity-matching models. The CIT approach reduced the variability in glucose concentration and resulted in fewer instances of DSWI after CABG with BIMA grafts.

Total Arterial Revascularization with Composite Y/T Grafts: Comparison of Early and Long-Term Outcomes of Bilateral Internal Mammary Arteries with Left Internal Mammary-Radial Artery Composite Grafts

Objectives: Coronary artery bypass graft surgery (CABG) utilizing total arterial revascularization (TAR) can be performed by constructing a composite Y/T-graft using either bilateral internal mammary arteries (BIMA) or the left internal mammary and radial arteries (LIMA-rad). The aim of our study was to compare the early and long-term clinical outcomes in patients, who received BIMAs with those who received LIMA-rad, both groups of patients being exclusively revascularized with the Y/T composite graft. Methods: A total of 504 patients underwent TAR solely with Y/T composite grafts at our institution from January 2001 through June 2010. Of these, BIMAs were used in 210 patients and LIMA-rad in 294 patients. Comparison of the 2 groups with regard to cumulative long-term mortality and major adverse cardiac and cerebrovascular events (MACCE) was performed using the competing risks method after matching for age, gender, number of diseased coronary arteries and presence of left main disease. The matched groups contained 186 patients each. Multivariate logistic regression analysis identified the significant predictors and the independent effect of the type of TAR (BIMA or LIMA-rad) on 30-day MACCE. Hazard ratios for late mortality and MACCE were estimated by Cox regression analysis. Results: The overall 30-day mortality amongst the matched groups was 1.6%, being 2.2% and 1.1% in the BIMA and LIMA-rad groups (p = 0.7), respectively. All-cause mortality (11·9% in BIMA group vs 12·4% in LIMA-rad group; p = 0·7) and acute myocardial infarction (1.1% vs 0.8%; p = 0·09) at 6 years were not significantly different between the matched groups. However, stroke rate was significantly higher in the BIMA group (5.8%) than in the LIMA-rad group (0.5%) (p = 0.007). Conversely, the rate of repeat revascularization was higher in patients with LIMA-rad (7.4%) than those with BIMA (4%), although it did not reach statistical significance (p = 0.16). Conclusions: TAR using BIMA or LIMA-rad in a Y/T configuration is associated with excellent early and long-term outcomes. Patients, who received BIMA, had a higher propensity of developing a stroke, but a lower repeat revascularization rate than those receiving LIMA-rad at follow-up.

Major Bleeding Events in Patients with Vacuum-Assisted Therapy of Post-Sternotomy Mediastinits

Objective: In the last decade vacuum assisted therapy for surgical treatment of post-sternotomy mediastinitis became standard therapy. Severe complications like acute major bleeding are rare, but can be lethal. Methods: Between January 2011 and July 2014 68 (1.4%) of 4865 patients (pts.) with sternotomy received a vacuum assisted closure (VAC) due to post-sternotomy mediastinitis in our department. We analyzed patient characteristics and clinical outcome retrospectively. Results: The mean age of patients with mediastinitis was 67.6 ± 11.7 years. 38% (26 pts.) were female. 53% (36 pts.) underwent coronary artery bypass grafting with use of bilateral internal mammary arteries in 38% (26 pts.). 15% (10 pts.) had isolated aortic valve replacement, 29% (20 pts.) other combined procedures and 2% (2 pt.) ventricular assist devices. Body-mass-index was 28.5 ± 5.1 kg/m2. Diagnosis of deep sternal infection occurred 21.8 ± 18.3 days after primary operation. Infection related mean hospital stay was 22 ± 11.7 days with 8 ± 4.2 VAC-operations and mean weight loss of 4.8 ± 5.3 kg. Total in-hospital mortality was 17.6% (12 pts.). 10 pts. died due to sepsis and multiple organ failure (7 pts.), heart failure (2 pats.) or endocarditis. Major bleeding complication occurred in 4 pts. (6.9%) due to injury of right ventricle in 3 pts. and massive erosion of the right lung in one patient. Emergency extracorporal circulation (ECC) via femoral vessels was established in all cases, nevertheless one patient died within the operation. Sternum restabilization was performed in three patients during emergency operation. One patient died subsequently at day 18 due to sepsis. Two of these patients are still alive. One patient was re-admitted with recurrent sternum instability after 15 days. Conclusion: Major bleeding events due to injury of the right ventricle are a rare, but potentially lethal complication of post-sternotomy mediastinitis. However, VAC therapy is an effective method, but surgical debridement and refixation of the sternum should performed as early as possible.

Potential Risk Factors for Surgical Site Infection after Isolated Coronary Artery Bypass Grafting in a Bahrain Cardiac Centre: A Retrospective, Case-Controlled Study.

Objective:The purposes of this study were to determine the incidence of surgical site infections (SSI) and associated risk factors in patients undergoing isolated coronary artery bypass grafting (CABG) in our cardiac center during a 2-year period.Materials and Methods:Retrospective case-control analysis for 80 patients who underwent isolated cardiac surgery CABG. These patients were divided into the SSI study group (n = 40) and the noninfected control group (n = 40). Eight potential perioperative risk variables were compared between the two groups using univariate logistic regression analysis.Results:Univariate analysis was carried out for eight potential risk factors. The risk factors found to be significant were: Impaired estimated glomerular filtration rate (P = 0.011) and impaired left ventricular ejection fraction (P = 0.015). However, Factors found to have no significant influence on the incidence of SSIs were: Perioperative length of hospital stay (days), urgency of surgery, use of bilateral internal mammary artery (BIMA) grafting, prolonged cardiopulmonary bypass duration, elevated body mass index.Conclusions:Patients with comorbidities of impaired renal function and/or impaired left ventricular systolic function are at high risk of developing SSI. There appears to be a relationship between SSIs in CABG patients and impaired renal or LV function (low ejection fraction). CABG with BIMA grafting could be performed safely even in diabetics. Future studies should consider further scrutiny of these and other factors in relation to SSIs in a larger surgical population.

Bilateral internal mammary artery T-grafts: Long-term survival and results of serial angiography

episode of endocarditis requiring surgery. During the second decade in-hospital mortality tended to be lower (6.9 vs 21%, p=0.057) and 5 years cumulative survival was higher (89 vs 64%, p=0.008). Age, reoperation for bleeding, and severe perioperative complication were independent predictors for mortality. Conclusions:Aortic prosthetic valve endocarditis is associated with a high early complication rate and a substantial early mortality. Patients that survive the immediate postoperative period have a satisfactory long term survival and the risk for recurrent endocarditis requiring surgery is low. The results have markedly improved during the last decade.

Impact of pump status and conduit choice in coronary artery bypass: A 15-year follow-up study in 1412 propensity-matched patients

Previous studies have demonstrated that bilateral internal mammary artery (BIMA) grafts lead to superior outcomes compared with single internal mammary artery grafts. This study examines whether cardiopulmonary bypass affects conduit-dependent outcomes of coronary artery bypass grafting (CABG) surgery. From 1994 to 2013, a total of 6666 patients underwent isolated CABG surgery at our institution. Of these procedures, 3548 (53.2%) were performed off pump. A BIMA-saphenous vein graft (SVG) was used in 1544, and 5122 had left internal mammary artery-SVGs. These 2 conduit groups differed significantly in baseline characteristics. Propensity matching based on 22 preoperative variables and using a nearest-neighbor matching algorithm was used to make balanced cohorts, resulting in 2 groups of 1006. To account for the influence of pump status on conduit selection, a second propensity score was developed for pump use. These cases were matched to create 4 patient cohorts of 353 patients each (a total of 1412), balanced for both conduit use and pump status. Late mortality was determined using the Social Security Death Index. No difference was found in survival between patients receiving BIMA-SVGs on or off pump (78.9% vs 79.1%). BIMA-SVGs outperformed the left internal mammary artery-SVGs regardless of whether the procedure was performed off pump (73.9%) or on pump (69.9%). This study demonstrates that the use of cardiopulmonary bypass does not significantly affect the long-term outcomes in these patients as long as full revascularization is achieved. In addition, these results are consistent with prior research showing that the use of BIMAs produces better outcomes than use of a single internal mammary artery when performing CABG.

Complications after sternal reconstruction: a 16-y experience

BackgroundUnlike risk factors associated with sternotomy complications, those associated with sternal reconstruction have not been well elucidated. We sought to examine complication rates after sternal wound reconstruction and to identify perioperative risk factors associated with these complications. MethodsWe evaluated the records of 230 consecutive patients who underwent sternal reconstruction with muscle flaps after cardiac surgery. Patient demographics, clinical comorbidities, and operative procedure types were evaluated against two outcome variables—major complications and reconstructive failure. ResultsThe mean age of our cohort was 62 y. Major complications (readmission, reoperation, or death) occurred in 76 patients (33%), including mortality rate of 3.5%. Obesity, chronic obstructive pulmonary disease, and type of reconstructive procedure correlated with an increased risk of major complications. Reconstructive failure occurred in 39 patients (17%) and was associated with female gender, obesity, previous coronary artery bypass graft procedure, and prior left internal mammary artery usage. Regression analyses demonstrated that obesity is independently associated with an increased risk of major complications and that women are at an increased risk of reconstructive failure. Reconstructions involving the rectus abdominis were correlated with an increased risk of major complications, but this difference was not significant in multiple regression analysis. ConclusionsUsual risk factors for sternal wound development after cardiac surgery include diabetes, age, obesity, tobacco use, history of stroke, bilateral left internal mammary artery harvest, and significant blood transfusion. In distinction, this study found that the risks independently associated with major complications and reconstructive failures after reconstruction of sternal wounds are limited to obesity and female gender.

Best practices in coronary revascularization procedures: are we where we should be?

To address the most recent evidence bases for coronary artery bypass grafting (CABG) and stenting in patients with multivessel and left main coronary artery disease (CAD) and for optimizing the performance of CABG with particular reference to multiple arterial grafts, off-pump and less invasive CABG, graft flow measurements and external stenting of vein grafts. Current evidence confirms that CABG results in markedly superior survival to stenting for most patients with multivessel and/or left main stem CAD, as well as a significant reduction in subsequent myocardial infarction and repeat revascularization. Whereas there is strong circumstantial evidence of important survival benefits with bilateral internal mammary arteries, there is no evidence for clinical benefits of off-pump CABG, except perhaps in higher-risk patients. There appears to be increasing justification for routine graft flow measurements, while minimally invasive and robotic CABG remains as a niche specialty. CABG remains the most effective revascularization strategy in terms of survival and freedom from myocardial infarction and repeat revascularization in most patients with multivessel and/or left main stem CAD. There is a strong case for much wider use of bilateral internal mammary arteries during CABG, and off-pump CABG may be beneficial in higher-risk patients with particular reference to reducing neurologic injury. There is a strong rationale for the routine use of graft flow measurement, and particularly when using composite arterial grafts. There is a potential role for the development of an external stent to reduce the development of intimal hyperplasia in vein grafts.

Effects of on-pump and off-pump surgery in the Arterial Revascularization Trial.

The Arterial Revascularization Trial (ART) is a randomized comparison of bilateral internal mammary artery (BIMA) versus single internal mammary artery (SIMA) grafting in coronary artery bypass graft (CABG) surgery and is one of the largest randomized trials of surgery ever conducted. ART is also one of the largest studies of contemporary CABG with a high proportion of off-pump surgeries (41%). The objective of this post hoc analysis was to evaluate the surgical process and 1-year outcomes for surgery performed on-pump compared with off-pump. ART randomized 3102 patients with multivessel coronary artery disease (CAD) to SIMA or BIMA grafts to determine if BIMA grafts have an additional survival advantage at 10 years. The 1-year interim analysis showed an overall very low mortality and major morbidity rate irrespective of whether the procedure was with an SIMA or BIMA. The surgical process and 1-year outcomes were analysed according to whether surgery was performed on-pump or off-pump. Baseline variables were not statistically significantly different between on- and off-pump surgery within each treatment group after taking account of the effects of clustering by individual surgeons. At both 30 days and 1 year, there was a low incidence of death (1.2%, 2.3%), stroke (1.1%, 1.7%), myocardial infarction (MI) (1.4%, 1.9%), repeat revascularization (0.5%, 1.5%) and wound reconstruction (1.2%). A similar average number of grafts were performed with on- and off-pump surgery (median = 3), but the duration of surgery was 20-30 min and ventilation time ∼ 2 h shorter with off-pump surgery. Blood loss and platelet transfusions were lower in the off-pump group, with no difference in the need for balloon pump or renal support. Sternal wound reconstruction was similar with off-pump surgery in the SIMA group (0.5 vs 0.6%) and lower with off-pump surgery in the BIMA group (1.4 vs 2.2%). Repeat revascularization was marginally higher in off-pump patients at 30 days (0.8 vs 0.3%) and at 1 year (1.7 vs 1.3%). The outcomes of contemporary CABG are excellent with low mortality, stroke, myocardial infarction and need for wound reconstruction and repeat revascularization whether performed on-pump or off-pump. Controlled-trials.com (ISRCTN46552265).

The imaging study of internal mammary artery and its branches

To investigate the distribution of the internal mammary artery and its branches by the multi-slice spiral CT angiography, and to explore the feasibility of transferring pedicled transverse rectus abdomials myocataneous (TRAM) flap for breast reconstruction through resection of inferior costicartilages. 30 female patients received abdominal CT angiography. (1) The distance between internal mammary artery and the sternum midline were recorded; (2) The position and the numbers of branches from bilateral internal mammary arteries at the level of 5th, 6th, 7th rib was observed; (3) The points where the superior epigastric artery gets through the rectus abdominis muscle were located. ( The average distance between left internal mammary artery to the sternum midline is from 1. 66 cm (0. 62-2. 39 cm ) to 2.34 cm (0.69-3.36 cm) at the level from 4th to 6th intercostal space. The average distance between right internal mammary artery to the sternum midline is from 1.55 cm(0. 66-2. 29 cm) to 2.29 cm(0. 73-3. 67 cm) at the level from 4th to 6th intercostal space; ) The number of branches is the most at the level of 6th intercostal space; (3) There are 235 branches in the superior epigastric artery. This imaging study of internal mammary artery explores the feasibility of transferring pedicled transverse rectus abdominals myocataneous flap for breast reconstruction. It has important significance in the breast reconstruction using TRAM flap with lengthened pedicle.

Right internal mammary artery versus radial artery as second arterial conduit in coronary artery bypass grafting: A case-control study of 1526 patients

Objective: Additional arterial grafts such as the right internal mammary artery (RIMA) or the radial artery (RA) have been proposed to improve long term outcomes in coronary artery bypass grafting (CABG). RA is largely preferred over RIMA as it is less technically demanding and there is a perception that bilateral IMA usage increases the risk of sternal wound complications. However, there is a paucity of direct comparison of the two conduits to guide surgeons to choose the best second arterial conduit for CABG. Methods: A propensity score adjusted analysis of patients undergoing multiple arterial grafting with RIMA (n = 747) and RA (n = 779) during the study period (2001–2013) was conducted to investigate the impact of the two strategies on early and late outcomes. Results: RIMA did not increase the incidence of postoperative complications including deep sternal wound infection (P = 0.8). Compared to the RIMA, the RA was associated with an increased risk for late mortality (Hazard Ratio [HR] 1.9; 95% confidence interval (CI) 1.2–3.1; P = 0.008) and repeat revascularization (HR 1.5; 95% CI 1.0–2.2; P = 0.044). A trend towards an extra risk for late mortality from RA over RIMA was observed among diabetic (HR 3.3; 95% CI 1.1–9.7) and obese patients (HR 2.1; 95% CI 0.8–5.46). Conclusions: RIMA as a second conduit did not increase the operative risk including sternal wound complications and improved long term outcomes including overall survival when compared to RA. This advantage was stronger among diabetic and obese patients. These findings strongly support RIMA as the first choice second arterial conduit in CABG. Further randomized studies with angiographic control and long-term follow-up are needed to address this issue.

The influence of bilateral internal mammary arteries on short- and long-term outcomes: A propensity score matching in accordance with current recommendations

We undertook a single-center, 12 years outcomes analysis of the influence of bilateral internal mammary arteries (BIMA) over single internal mammary artery (SIMA) on short-term outcomes and long-term outcomes by means of propensity score matching technique in accordance to current recommendations. A propensity score was generated for each patient from a multivariable logistic regression model based on 20 pretreatment covariates. The study population consisted of 4195 patients undergoing coronary artery bypass graft procedure using SIMA (n = 3445; 78.3%) or BIMA (n = 750; 21.7%). A total of 750 matching sets were derived. The BIMA group was associated with an increased rate of superficial sternal wound infection (5.6% vs 1.7%; P = .0001) but the incidence of deep sternal wound infection was comparable between the 2 groups, at 2.1% and 1.5% in BIMA and SIMA groups, respectively (P = .43). With regard to other postoperative complications the 2 groups were comparable. Operative mortality rate did not significantly differ between the 2 groups, at 0.7% and 1.2% in the BIMA and SIMA groups, respectively (P = .28). After a mean follow-up time of 4.8 ± 3.2 years, BIMA use was associated with a significantly lower risk for late mortality (hazard ratio, 0.61; 95% confidence interval 0.38-0.97; P = .03) and need for repeat revascularization (hazard ratio, 0.75; 95% confidence interval, 0.53-0.96; P = .03). When compared with SIMA grafting, BIMA use did not increase operative morbidity and mortality and was associated with a better long-term survival.

Effect of bilateral internal mammary artery grafts on long-term survival: a meta-analysis approach.

Although the potential survival benefit of bilateral internal mammary artery (BIMA) grafting in comparison with single internal mammary artery (SIMA) grafting has been emphasized by many investigators, the use of BIMA is still low in clinical practice in the absence of randomized trials and long-term results. In the current study, we aimed to assess if there is a long-term survival benefit of BIMA up to 10 years after coronary bypass surgery. We selected published articles comparing survival between SIMA and BIMA patients with follow-up duration of more than a mean of 9 years. We evaluated the log hazard ratio with 95% confidence interval for included studies by using a random-effects meta-analysis. Nine eligible observational studies provided 15 583 patients (8270 SIMA and 7313 BIMA) for meta-analysis. Five studies used propensity score methods for statistical adjustment, 2 with a propensity score-based patient-matching method and 3 with quintile-based stratification. A significant reduction in mortality by using BIMA was observed (hazard ratio, 0.79; 95% confidence interval, 0.75-0.84); no study showed any significantly harmful effect of BIMA on survival. Subgroups of studies using different statistical approaches-unmatched, quintile-based propensity score analysis, and propensity score-based exact patient matching-all showed the survival benefit of BIMA grafting. BIMA grafting appears to have better survival with up to 10 years follow-up in comparison with SIMA grafting. Long-term survival benefit of BIMA seems to continue in the second decade after surgery. An ongoing randomized trial comparing SIMA and BIMA groups will add evidence on this issue.

Circulation : Clinical Summaries

<i>Circulation</i> : Clinical Summaries

Intraaortic balloon pump boon for off-pump coronary artery bypass grafting.

Off-pump coronary artery bypass techniques have evolved in the past decade, but there are some concerns about hemodynamic decompensation requiring conversion to cardiopulmonary bypass. These conversions are associated with higher morbidity and mortality. We use an intraaortic balloon pump to treat ischemia-induced hemodynamic instability and arrhythmias during off-pump coronary artery bypass. The objective of this study was to assess the impact of intraaortic balloon pump use in off-pump coronary artery bypass to prevent emergency conversion to cardiopulmonary bypass. Data of 529 consecutive unselected patients who underwent isolated coronary artery bypass were included in this retrospective study of prospectively collected data and operation notes. Complete revascularization was performed using an off-pump technique. All arterial grafts using bilateral internal mammary arteries, and aortic no-touch technique were preferred. If the clinical situation demanded, vein grafts were used. During the procedure, any hemodynamic compromise not responding to conventional inotropic therapy was treated with intraaortic balloon pump insertion. Complete revascularization was possible in all 529 patients. An intraaortic balloon pump was inserted in 33 (6.2%) patients to treat hemodynamic instability; in all cases, conversion to cardiopulmonary bypass was avoided and complete revascularization was achieved. For treating hemodynamic instability during off-pump coronary artery bypass, we recommend intraaortic balloon pump insertion as the preferred bail-out method rather than conversion to cardiopulmonary bypass.

Bilateral internal mammary artery for multi-territory myocardial revascularization: long-term follow-up of pedicled versus skeletonized conduits.

The aim of this study was to evaluate 17-year actual clinical outcomes of patients undergoing coronary artery bypass graft (CABG) using skeletonized versus pedicled bilateral internal mammary arteries (BIMAs). From September 1991 to June 1996, 548 consecutive patients underwent CABG for multivessel disease using BIMA. After propensity matching, 350 patients were enrolled: 175 patients with skeletonized BIMA (Group S) and 175 with pedicled BIMA (Group P). The two groups were adequately comparable. Composite end-point: deaths, new revascularization and new myocardial infarctions were defined as 'events'. Group S provided a higher rate of total arterial myocardial revascularization (94.3 vs 82.9%, P 0.001) with a higher average number of arterial anastomoses (3.1 ± 0.8 vs 2.7 ± 0.8, P < 0.001) and BIMA anastomoses (2.5 ± 0.3 vs 2.1 ± 0.3, P < 0.001). In Group S, the incidence of sequential grafts was higher (37.7 vs 17.7%, P < 0.001). The rate of sternal wound healing problems was lower (1.7 vs 7.4%, P = 0.010). Thirty-day mortality and morbidity were similar. The median survival time of survivors was 17.8 years (min-max = 17.0-21.5); 17.3 (17.0-18.0) in Group S vs 19.1 (18.1-21.5) in Group P, P < 0.001. Seventeen-year actual outcomes were better in Group S: deaths (8.7 vs 27.9%, P < 0.001), cardiac deaths (4.7 vs 13.4%, P = 0.005), cardiac events (10.5 vs 22.1%, P = 0.003), new revascularization (2.9 vs 8.7%, P = 0.021) and events (15.1 vs 36.1%, P < 0.001). Skeletonization of BIMA allows one to achieve a higher rate of arterial grafting and better outcome if compared with pedicled BIMA.

Staphylococcus aureus and repeat bacteremia in febrile patients as early signs of sternal wound infection after cardiac surgery.

BackgroundSternal wound infection is a devastating complication of cardiothoracic surgery that carries high postoperative morbidity and mortality rates. We explored whether our current program of extensive bacteriological examination including repeat blood cultures may contribute to the early diagnosis of sternal wound infection.MethodsWe retrospectively analyzed 112 patients who were subjected to our bacteriological examination protocol including within 90 days after cardiothoracic surgery. Univariate and multivariate analyses were made in order to identify risk factors for sternal infection.ResultsThe median patient age was 75 years, and 65 patients were male. In 35 cases (31.2%) the blood cultures showed the presence of bacterial infection with the following frequencies: Staphylococcus aureus, 18 cases; Coagulase-negative Staphylococcus, 7 cases; other organisms, 10 cases. Eleven patients presented repeat bacteremia on at least 2 different occasions. Twenty patients (17.8%) presented sternal wound infections. There was no difference in operative mortality between the patients with and without sternal wound infection. Univariate and multivariate analyses demonstrated that bilateral mammary artery use (OR, 13.68, 95% CI, 1.09-167.36, p = 0.043), positive blood culture for Staphylococcus aureus (OR, 19.51, 95% CI, 4.46-104.33, p < 0.0001), repeat bacteremia (OR, 17.98, 95% CI, 2.51-161.77, p = 0.004) were risk factors that were associated for sternal wound infection.ConclusionRepeat blood cultures in febrile patients appear to be useful for the early detection of Staphylococcus aureus and repeat bacteremia, and these were associated with sternal wound infection. Bilateral internal mammary artery use was another risk factor of sternal wound infection in febrile patients. These factors may identify patients suitable for expeditious radiological examination and aggressive treatments.

Off-pump coronary artery bypass grafting in a patient with neurofibromatosis I

Neurofibromatosis, otherwise known as von Recklinghausen disease, is a congenital hereditary disorder involving tissues of neuroectodermal or mesodermal origin. Involvement of the coronary arteries is, however, extremely rare. To the best of our knowledge, this represents the first report of off-pump coronary artery bypass grafting using the bilateral internal mammary arteries for coronary arterial vasculopathy in a patient with neurofibromatosis and of the longest reported follow-up of such a case after bypass surgery.

Quicker yet safe: skeletonization of 1640 internal mammary arteries with harmonic technology in 965 patients

Skeletonization of the internal mammary artery (IMA) facilitates arterial grafting and has been shown to reduce deep sternal infection but is more time-consuming and tedious than pedicle harvest. We wished to determine if use of harmonic technology (HT) facilitates skeletonization of the IMA and is as safe as the conventional technique of skeletonization. In a consecutive series of 1057 patients with isolated coronary artery bypass graft (CABG) surgery from 2003 to 2013, adverse events and recorded harvest times were compared between harmonic (965 patients) and non-harmonic patients (86 patients). HT was used to harvest 1640 IMAs in 965 (91%) of 1057 consecutive CABG patients and skeletonization with the traditional technique (use of an electrocautery tip as a dissector) was used to harvest 147 IMAs in 86 patients. Six patients had no IMA harvested with this surgery (4 patients had an IMA used from a previous CABG, 1 had no disease of the left anterior descending coronary artery and 1 patient was in cardiogenic shock precluding IMA use). Excluding patients with single-vessel disease, 730/987 (74%) of patients received bilateral IMAs. Demographics of patients with and without harmonic skeletonization, respectively, were the following: mean age: 64.7 vs 67.7 years; diabetes: 33 vs 34%; women: 21 vs 26% and median European System for Cardiac Operative Risk Evaluation: 2.9 vs 3.2. The mean harvest time for 77 non-harmonic skeletonized mammary arteries (49 surgeries) was 32.2 min (95% confidence interval (CI): 30.1, 34.3), for harmonic skeletonized arteries after 450 surgeries was 28.4 min, (95% CI: 27.8, 29.1) and in the last 100 IMAs harvested for the isolated harmonic device use/mammary was 15.4 min (95% CI: 14.0, 16.7). Major adverse events for patients with and without harmonic skeletonization, respectively, were: reoperation for bleeding: 2.7 vs 3.5% (difference = 0.8%, 95% CI: -3.2, 4.8); damaged mammaries: 0.4 vs 0.7% (difference = 0.3%, 95% CI: -1.0, 1.7); deep sternal infection: 1.6 vs 1.2% (difference = -0.4%, 95% CI: -2.8, 2.0) and perioperative infarction: 1.7 vs 2.3% (difference = 0.7%, 95% CI: -2.6, 4.0). In this largest series to date of harmonic IMA skeletonization, this technique results in rare damage, is quicker and with a comparable adverse event rate compared with the non-harmonic method.

Which is the best graft for the right coronary artery?

Bilateral internal mammary arteries directed to the left coronaries are gaining popularity; an increasing level of evidence nowadays supports this surgical strategy. On the other hand, composite right internal mammary artery, radial artery, and gastroepiploic artery targeting high-grade stenotic lesions in the right coronary artery system may confer improved mid- and long-term patency compared to long saphenous veins. This analysis looks into the evidence comparing data of the third best available conduit for grafting the right coronary artery, and by extrapolating this report, compares total arterial revascularization vs. conventional coronary artery bypass grafting.