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Eur J Cardiothorac Surg 2001;20:1069-1070
© 2001 Elsevier Science NL
Letter to the Editor |
a Cattedra of Cardiac Surgery, University of Florence, Florence, Italy
b IRCCS NEUROMED, Via Atinense N. 18, 86077 Isérnia, Pozzilli, Italy
Received 6 August 2001; accepted 7 August 2001.
Corresponding author. Cardiochirurgia, University Hospital of Florence "Careggi", Viale Morgagni 85, 50134 Firenze, Italy. Tel.: +39-338-9855782; fax: +39-55-4277458
e-mail: mbonacchi{at}hotmail.com
We appreciate the interest and comments expressed by Dr Totaro and colleagues regarding our paper [1], which emphasize the importance of preserved pleural integrity for a minor respiratory dysfunction and a better postoperative respiratory outcome in patients undergoing coronary artery bypass grafting (CABG) by employing double internal mammary arteries (IMAs).
We agree with the authors’ opinion that the mechanical ventilation time alone would be of less significance for the respiratory function evaluation during the postoperative course, due to various associated factors. However, in our study, we analyzed a series of other postoperative concomitant variables, such as prolonged ventilation incidence, and FiO2 (%), gas analysis, pressure assistance, etc., in various stages of the patients’ extubation process. Besides, postoperative complications, such as unilateral or bilateral pleural effusion, pneumothorax, number of thoracentesis, diaphragm impairment and reintubation incidence, and intensive care unit stay were analyzed. We believe that the analysis of all these variables gives a clear view of the postoperative respiratory functional status in this pool of patients. However, for a better understanding of the respiratory dysfunction, preoperative and postoperative mechanical respiratory tests are required. This was the main limitation of our study, which was clearly defined in our manuscript.
We congratulate with Dr Totaro for reported data, undertaken by him and his surgical group in the postoperative evaluation of the respiratory dysfunction in patients undergoing CABG. However, it seems that the groups underwent single IMA harvesting with open or closed pleura, and only one of the three reported groups had bilateral pleural opening. In our report, we included only patients with bilateral IMA harvesting, which were divided into closed and bilateral open pleurae. It has been well demonstrated that bilateral IMA harvesting and the opening of both pleurae increases significantly the postoperative atelectasis incidence [2], extubation time [3], and other respiratory complications in comparison with harvesting of only one IMA and non- or only one open pleura [4,5]. We demonstrate that, in patients undergoing CABG using bilateral IMAs, the postoperative respiratory dysfunction is improved with intact pleurae [1]. Contrarily, Dr Totaro reports a higher incidence of pleural effusion requiring thoracentesis and records a higher incidence of pneumothorax in patients with closed pleurae. Perhaps, their high incidence of postoperative pleural effusion and pneumothorax may be correlated with surgical–technical inaccuracy (pulmonary lesions, unseen pleural holes, etc.) or mechanical barotraumas.
Despite the small number of patients included so far in the preliminary data reported by Totaro and colleagues, we believe that a comparison of the postoperative outcome between the two studies would make no sense, due to important differences in the study protocol inclusion criteria.
Regarding the IMA harvesting technique, better postoperative functional status has been demonstrated in patients undergoing IMA harvesting according to the semiskeletonized technique versus the pedunculated one [6]. However, there are very few studies on this subject, and most of them deal with single IMA harvesting, and further reported experiences are required. We agree with the author that a comparative study in regard to the postoperative respiratory function, between patients undergoing the skeletonized technique and the pedunculated technique for double IMA harvesting would increase the information on this delicate topic. Regarding this issue, we have initiated a prospective trial, the results of which will be published as soon as possible.
We thank Dr Totaro and colleagues for their comments and contributions to explaining this challenging and arguable topic regarding the influence of the pleura's integrity in CABG patients’ pulmonary outcome.
References
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