EFFECT OF INTERNAL MAMMARY ARTERY HARVESTING WITH AND WITHOUT PLEUROTOMY ON RESPIRATORY COMPLICATIONS IN PATIENTS UNDERGOING CORONARY ARTERY BYPASS GRAFTING
AbstractBackground: Respiratory problems are one of the major issues faced by cardiovascular surgeons, which increase morbidity and mortality among patients undergoing coronary artery bypass grafting (CABG). It is possible to harvest the left internal mammary artery (LIMA) without opening the left pleura; however this cannot be reliably achieved in all cases due to intimate anatomical relationship. This study was designed to evaluate the effect of internal mammary artery harvesting with and without pleurotomy on respiratory complications in patients undergoing coronary artery bypass grafting. Methods: In this observational study 90 patients who underwent coronary artery bypass surgery were included by review of records. Patients were stratified into two groups according to surgical procedures, i.e., Internal Mammary artery harvesting with pleurotomy; (WP Group) (n=45) and with extra pleural harvesting technique; (EP Group) (n=45). Inclusion criteria were elective coronary artery bypass grafting, age over 18 years, willingness to be randomly assigned, provision of informed consent. Exclusion criteria were chronic obstructive pulmonary disease (COPD) or skeletal abnormalities that caused pulmonary restriction. Only the first 30 days postoperative outcome was studied. Data was analysed using SPSS version 21. Results: The demographic characteristics in terms of age and gender were comparable in study groups. The preoperative clinical presentation and medical history were also found similar. The hospital stay was significantly longer in WP Group than EP Group patients (7.2 vs 6.1 days, p<0.005). Moreover, post-operative morbidity was more prevalent in WP group 10 (22.2%) than EP Group 3 (66%) (p<0.03). In WP Group more respiratory complications were observed; 2 (4.4%) patients had dry cough and atelectasis, 1 (2.2%) patient experienced pleural effusion, 3 (6.6%) had bronchospasm while 1 (2.2%) patient each had sternal dehiscence and bleeding, however, these did not differ significantly among study groups. Conclusion: Respiratory complications were more frequent in patients undergoing Internal Mammary artery harvesting with pleurotomy compared to those managed extra pleural harvesting.Keywords; Coronary Artery Bypass Grafting, Left Internal Mammary Artery, pleurotomy, extra pleural, respiratory complications
Baumgartner FJ, Budoff M. Coronary artery disease. In: Cardiothoracic Surgery, 3`d ed. Texas, U.S.A: Landes Bioscience; 2004:56–8.
Ruel M, Selleke FW. Coronary artery bypass grafting In: Sabiston & Spenser. Eds. Surgery of the Chest, 7th ed. Philadelpia: Elsevier Saunders, 2005:1407.
Iyem H, Islamoglu F, Yagdi T, Sargin M, Berber O, Hamulu A, et al. Effects of pleurotomy on respiratory sequelae after internal mammary artery harvesting. Tex Heart Inst J 2006;33(2):116–21.
Ghavidel AA, Noorizadeh E, Pouraliakbar H, Mirmesdagh Y, Hosseini S, Asgari B, et al. Impact of intact pleura during left internal mammary artery harvesting on clinical outcome. J Tehran Heart Cent 2013;8(1):48–53.
Rahim AMA, Kibria G, Ahmed NU. Effect of pleurotomy during internal mammary artery harvest on pulmonary function. Cardiovasc J 2011;3(2):163–8.
Bonacchi M, Prifti E, Giunti G, Salica A, Frati G, Sani G. Respiratory dysfunction after coronary artery bypass grafting employing bilateral internal mammary arteries: influence of intact pleura. Eur J Cardiothorac Surg 2001;19(6):827–33.
Wheatcroft M, Shrivastava V, Nyawo B, Rostron A, Dunniing J. Does pleurotomy during internal mammary artery harvest increase postoperative pulmonary complications? Interact Cardiovasc Thorac Surg 2005;4(2):143–46.
Oz BS, Iyem H, Akay HT, Yildirim V, Karabacak K, Bolcal C, et al. Preservation of pleural integrity during coronary artery bypass surgery affects respiratory functions and postoperative pain: a prospective study. Can Respir J 2006;13(3):145–9.
Lim E, Callaghan C, Motalleb-Zadeh R, Wallard M, Misra N, Ali A, et al. A prospective study on clinical outcome following pleurotomy during cardiac surgery. Thorac Cardiovasc Surg 2002;50(5):287–91.
Guizilini S, Gomes WJ, Faresin SM, Bolzan DW, Buffolo E, Carvalho AC, et al. Influence of pleurotomy on pulmonary function after off-pump coronary artery bypass grafting. Ann Thorac Surg 2007;84(3):817–22.
Noera G, Pensa PM, Guelfi P, Biagi B, Lodi R, Carbone C. Extrapleural takedown of the internal mammary artery as a pedicle. Ann Thorac Surg 1991;52(6):1292–4.
Peng MJ, Vargas FS, Cukier A, Terra-Filho M, Teixeira LR, Light RW. Postoperative pleural changes after coronary revascularization. Comparison between saphenous vein and internal mammary artery grafting. Chest 1992;101(2):327–30.
Taggart DP, el-Fiky M, Carter R, Bowman A, Wheatley DJ. Respiratory dysfunction after uncomplicated cardiopulmonary bypass. Ann Thorac Surg 1993;56(5):1123–8.
Ferdinande PG, Beets G, Michels A, Lesaffre E, Lauwers P. Pulmonary function tests after different techniques for coronary artery bypass surgery. Saphenous vein versus single versus double internal mammary artery grafts. Intensive Care Med 1988;14(6):623–7.
Totaro P, Fucci C, Minzioni G. Preserved pleura space integrity and respiratory dysfunction after coronary surgery. Eur J Cardiothorac Surg 2001;20(5):1067–70.
Zin WA, Caldeira MP, Cardoso WV, Auler JO Jr, Saldiva PH. Expiratory mechanics before and after uncomplicated heart surgery. Chest 1989;95(1):21–8.
Grossi EA, Esposito R, Harris LJ, Crooke GA, Galloway AC, Colvin SB, et al. Sternal wound infections and use of internal mammary artery grafts. J Thorac Cardiovasc Surg 1991;102(3):342–7.
Loop FD, Lytle BW, Cosgrove DM, Mahfood S, McHenry MC, Goormastic M, et al. J. Maxwell Chamberlain memorial paper. Sternal wound complications after isolated coronary artery bypass grafting: early and late mortality, morbidity, and cost of care. Ann Thorac Surg 1990;49(2):179–87
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