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Eur J Cardiothorac Surg 2005;28:781
© 2005 Elsevier Science NL
Letter to the Editor |
a Department of Cardiac Surgery, University of Florence, Cattedra e Scuola di Specializzazione in Cardiochirurgia, Viale Morgagni, 85, 50134 Careggi, Firenze, Italy
b Brigham and Women's Hospital, Harvard University, Boston, MA, USA
Received 8 August 2005; accepted 10 August 2005.
* Corresponding author. Tel.: +39 338 9855782; fax: +39 55 4277458. (Email: mbonacchi{at}unifi.it).
Key Words: Coronary arteries • Free flow • Internal mammary arteries
We appreciate the comments of Dr Shahzad G. Raja about our paper concerning the use of skeletonized bilateral internal mammary arteries (BIMA) for urgent/emergent surgical revascularization in unstable angina (UA) [1]. Skeletonization of internal thoracic arteries for myocardial revascularization offers several proven advantages such as decreased incidence of sternal wound infection, greater length, and multiple arterial anastomoses [2,3].
In our paper, we have demonstrated that this technique can be safely used also for urgent/emergent surgical revascularization in unstable angina (UA) since does not increase operative mortality but improves late outcomes.
Global ischemic time plays a very important role in operative mortality in patients with UA therefore, it is important to obtain early and adequate reperfusion following the onset of symptoms as quickly as possible. Our results at immediate and late follow-up with improved freedom from cardiac death, from coronary reintervention and from myocardial infarction may relate to the increased conduit diameter and blood flow reported in skeletonized compared with pedicled mammary grafts. In fact the free blood flow from the skeletonized LIMA is, almost twice as high as that from the non-skeletonized one and comparable to the vein graft [3,4]. Thus, greater immediate spontaneous blood flow to the ischemic heart may reduce the incidence of low cardiac output syndrome and operative mortality.
Despite these advantages there is reluctance to use skeletonized internal mammary arteries because the potential risk of damage during the harvesting [5]. In emergent/urgent surgery, moreover, the main objection is the longer harvesting time. Technically skeletonization may be more demanding than pedicled IMA harvesting and certainly there is a learning curve like anything else in surgery. For this reason, first we have started to employ bilateral skeletonized IMA for grafting the left coronary system in elective surgery and, later on, we have expanded that use also in urgent/emergent situation. We found a significant 15-min increase in operating times for one AMI skeletonization compared to pedicled (42 ± 21 vs. 25 ± 9.5 min, p
0.001). Moreover, we have divided the skeletonized group in two additional groups according to the harvesting time (correlated to two groups of surgeons: those more experienced than the others): the FAST group, with a mean harvesting time of 21 ± 5 min (range 19–29 min) and the SLOW with a mean harvesting time of 36 ± 8 min (range 26–45 min). The difference in mean harvesting time between the two groups was statistically significant (p<0.05). The mammary harvesting time variable, however, when entered in the logistic model, was not a risk factor for operative mortality or perioperative complications.
In conclusion, in emergent/urgent myocardial revascularization with careful patients management it is possible to spend some few minutes more for both IMAs' harvesting as skeletonized technique, knowing the important early and long-term advantages of this conduit such as early improved flow/reperfusion and freedom from late atherosclerotic disease also in UA patients [3].
We concur with Dr Raja and encourage for a paradigm shift in the use of arterial conduit in UA.
References
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