Respiratory dysfunction after coronary artery bypass grafting employing bilateral internal mammary arteries: the influence of intact pleura.
OBJECTIVE
To evaluate the role of intact pleurae regarding the postoperative respiratory functional status in patients undergoing coronary revascularization employing both internal mammary arteries (IMAs), according to the pedunculated or skeletonized technique (SKT) with opened or intact pleurae.


METHODS
Using both IMAs, 299 patients underwent elective coronary revascularization. They were randomized and divided into group I (n=82, undergoing IMA harvesting according to the SKT without opening the pleurae); group II (n=186, undergoing IMA harvesting according the pedunculated technique with open pleurae); and group III (n=31, undergoing IMA harvesting according the SKT with incidentally opened pleurae). There were no differences regarding the preoperative patient characteristics and the anaesthetic and surgical management.


RESULTS
There were two deaths in group I versus seven in group II and one in group III (P=ns). The number of total arterial myocardial revascularization and arterial composite grafts was significantly higher in groups I and III than in group II, (P<0.001 and P<0.005, respectively). The incidence of postoperative complications was similar between groups. Blood loss of >1000 ml was significantly higher in group II than group I (P<0.028); but the incidence of re-thoracotomy and blood transfusion was similar between groups. The mechanical ventilation time was significantly higher in groups II and III versus group I (P<0.018 and P<0.02, respectively). The incidence of prolonged ventilation (>24 h), pleural effusion, thoracocentesis and atelectasis, resulted in being significantly higher in group II than group I. The incidence of thoracocentesis was significantly higher in group III than group I. The pain score and analgesic requirements at 1-12 h after awakening were significantly higher in groups II and III versus group I, becoming similar after the chest tubes were removed. PaO(2) was significantly higher, and PaCO(2) and FiO(2) were significantly lower in group I than groups II and III at 1 and 4 h before extubation and at 1 and 4 h after extubation. PaO(2) and PaCO(2) became similar between groups at the 5th postoperative day.


CONCLUSIONS
According to our results, we may conclude that pleural integrity has beneficial effects on the respiratory functional status after coronary revascularization using both IMAs. A meticulous and more careful IMA harvesting approach significantly reduces the postoperative morbidity regarding the pulmonary functional status, and as a consequence, reduces the hospital costs.
Bonacchi
M
M
Cattedra of Cardiac Surgery, University of Florence, Florence, Italy. mbonacchi@hotmail.com
Prifti
E
E
Giunti
G
G
Salica
A
A
Frati
G
G
Sani
G
G
D016063:Blood Loss, Surgical; D001803:Blood Transfusion; D002315:Cardiopulmonary Bypass; D001026:Coronary Artery Bypass / Q000379:methods*; D005260:Female; D006801:Humans; D008297:Male; D008323:Mammary Arteries / Q000637:transplantation*; D008875:Middle Aged; D010994:Pleura / Q000502:physiology*; D011183:Postoperative Complications; D012086:Reoperation; D012121:Respiration, Artificial; D012131:Respiratory Insufficiency / Q000209:etiology*; D014182:Transplantation, Autologous