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Eur J Cardiothorac Surg 2007;32:555-556. doi:10.1016/j.ejcts.2007.06.004
Copyright © 2007, European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved

Letters to the Editor

Fractional flow reserve of pedicled left and right internal thoracic arteries

Michael Poullis*, Richard Warwick

Department of Cardiothoracic Surgery, Thomas Drive, Liverpool L13 3PE, England, United Kingdom

Received 25 April 2007; accepted 4 June 2007.

* Corresponding author. Address: The Cardiothoracic Centre, Thomas Drive, Liverpool L14 3PE, United Kingdom. Tel.: +44 151 293 2456/2398; fax: +44 151 293 2254. (Email: mike.poullis{at}ctc.nhs.uk).

Key Words: Internal mammary artery • Fractional flow reserve

Glineur et al. [1] provide important functional data on fractional flow reserve in bypass grafts. Debate about single or bilateral mammary artery (BIMA) utilisation continues, and is usually centred around sternal wound complications.

However, Glineur et al. reveal an important point in their data which I feel is not adequately explained in their manuscript, or the accompanying editorial [2]. Why should the right internal mammary artery (RIMA) grafts have a lower resistance to flow than the left internal mammary artery (LIMA) grafts? In their manuscript, the authors speculate that LIMA has better long-term results secondary to interactions between flow and LIMA wall, frictional forces, release of endothelial factors, and superior endothelial cell function.

Superior endothelial cell function has to be questioned due to the same endothelium being present in the LIMA and the RIMA. Endothelium is known to secrete nitric oxide (NO), an important vasodilator. Statin therapy, which was not commented on in the paper, needs to be consistent across the patient group as statins both upregulate endothelial nitric oxide synthase (eNOS) and inhibit inducible nitric oxide synthase (iNOS) [3].

Technique of harvest also remains an important factor, which was not mentioned in the manuscript. Skeletonisation removes surrounding periadventitial connective tissue, however this is known to affect vascular reactivity [4]. Patients having RIMAs are more likely to be skeletonised secondary to the perceived risk of reduced sternal ischaemia and dehiscence.

An additional point not mentioned by Glineur or Pijls in the editorial comment is that the RIMA tends to be a larger diameter vessel, particularly in right-handed manual workers, compared with the LIMA. This point probably explains the lower resistance of the RIMA compared to that of LIMA.

References

  1. Glineur D, Poncelet A, Khoury GE, D’hoore W, Astarci P, Zech F, Noirhomme P, Hanet C. Fractional flow reserve of pedicled internal thoracic artery and saphenous vein grafts 6 months after bypass surgery. Eur J Cardiothorac Surg 2007;31(3):376-381.[Abstract/Free Full Text]
  2. Pijls NH, Botman KJ. Editorial comment: Functional assessment of bypass grafts by fractional flow reserve. Eur J Cardiothorac Surg 2007;31(3):381-382.[Free Full Text]
  3. Vaughan CJ, Delanty N. Neuroprotective properties of statins in cerebral ischemia and stroke. Stroke 1999;30(9):1969-1973.[Abstract/Free Full Text]
  4. Dashwood MR, Dooley A, Shi-Wen X, Abraham DJ, Souza DS. Does periadventitial fat-derived nitric oxide play a role in improved saphenous vein graft patency in patients undergoing coronary artery bypass surgery?. J Vasc Res 2007;44(3):175-181.[CrossRef][Medline]



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Home page
 Eur. J. Cardiothorac. Surg.Home page
D. Glineur and C. Hanet
Reply to Poullis and Warwick
Eur. J. Cardiothorac. Surg., September 1, 2007; 32(3): 556 - 556.
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