Interact CardioVasc Thorac Surg 2005;4:143-146. doi:10.1510/icvts.2004.102673
© 2005 European Association of Cardio-Thoracic Surgery
Best evidence topic - Coronary |
Does pleurotomy during internal mammary artery harvest increase post-operative pulmonary complications?
Mark Wheatcrofta,
Vivek Shrivastavab,
Brian Nyawob,
Anthony Rostronc and
Joel Dunningd,*
a Cardiovascular Research Unit, Sheffield University, UK
b Department of Cardiothoracic Surgery, James Cook University Hospital, Middlesbrough, UK
c Department of Cardiothoracic Surgery, Freeman Hospital, Newcastle, UK
d Department of Cardiothoracic Surgery, Freeman Hospital, Freeman Road, Newcastle upon Tyne NE7 7AZ, UK
Received 18 November 2004;
accepted 21 January 2005
*Corresponding author. Tel.: +44 07801548122.
E-mail address: joeldunning{at}doctors.org.uk (J. Dunning).
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Abstract
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A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether pleurotomy during internal mammary artery (IMA) harvest increases post-operative pulmonary complications. Altogether, 154 papers were found using the reported search, of which 8 presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these papers are tabulated. We conclude that all patients undergoing cardiac surgery suffer a significant deterioration in pulmonary function and chest radiograph appearance post-operatively. Pleurotomy seems to compound this with increased rates of atelectasis and pleural effusions, although no impact on clinical outcome or length of hospital stay has been demonstrated.
Key Words: Evidence-based medicine; IMA harvest; Post-operative complications; Pleura; Cardiovascular procedures; Review
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1. Introduction
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A best evidence topic was constructed according to a structured protocol. This protocol is fully described in the ICVTS [1].
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2. Clinical scenario
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You are a first year cardiothoracic registrar who is starting to work for a consultant surgeon who always prefers the pleura to remain intact whilst harvesting the internal mammary artery (IMA). The surgeon avoids pleurotomy to reduce pulmonary complications after cardiac surgery, but you wonder whether there is any evidence in the literature to support this practice.
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3. Three-part question
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Does [pleurotomy] during [IMA harvest] increase the incidence of [post-operative pulmonary complications]?
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4. Search strategy
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Medline 1966-Oct 2004 using the OVID interface.
[cardiac surgery.mp OR CABG.mp OR coronary art$ bypass graft$.mp OR cardiopulmonary bypass.mp OR exp cardiovascular surgical procedures/ OR heart surgery.mp OR LIMA.mp] AND [exp Pleura/ OR Pleura$.mp OR extrapleur$.mp OR pleurotomy.mp]
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5. Search outcome
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One hundred and fifty-four papers were found of which 19 were relevant. Eleven papers were discounted as they did not compare IMA harvest with intact pleura versus IMA harvest with open pleura, and thus did not directly address the question. There were no meta-analyses on this topic. Three RCTs were identified and the remainder were all cohort studies with small sample/population sizes. These are presented in Table 1.
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6. Comments
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The majority of relevant studies assessed the effect of pleurotomy on post-operative lung function, ventilatory requirements and radiographic changes. Only three studies considered the effect of pleurotomy on clinical outcome [2–4]. In addition, the lengths of post-operative follow-up varied extensively from 30 min to 3 months. We identified three PRCTs that compared IMA plus pleurotomy to IMA without pleurotomy.
The largest PRCT was conducted by Noera et al. [2], the only significant outcome being greater transfusion requirements in the pleurotomy group, although they did find that the rate of pleural effusion and raised left hemidiaphragm was greater albeit not significant in the same group. This study is further supported by Ali et al. [4] and Wimmer-Greinecker et al. [5]. In the study undertaken by Ali et al., they found that the pleurotomy group had significantly more pleural effusions but that this did not result in more thoracocenteses. Pleurotomy also safe-guarded against the development of cardiac tamponade, with 5 in the closed group but none in the open pleura group. Another clinically relevant outcome was that hospital stay was not different between the two groups.
Lim et al. [3] assessed post operative chest radiology and length of stay in a heterogeneous group that comprised 138 CABG, 39 valve replacements and 29 CABG + valve replacement. Patients were divided into those with pleurotomy(n=164) and those without (n=42). The pleurotomy group had significantly more atelectasis (67.7% vs. 45.2%, P<0.007) but there was no difference in rates of consolidation, effusion or length of stay.
In a relatively small study, Rolla et al. [8] recruited 57 patients all of whom had an IMA conduit, therefore blinding chest radiograph reporting. The two groups were of similar size, 32 with pleurotomy, 25 without. There was no difference in post-op chest radiograph on day 2 or 6 and all patients were found to have significantly worse PFTs persisting at 2 months post operation.
Tomita et al. [9] divided 99 elective CABG cases into 45 BIMA + pleurotomy, 45 IMA + pleurotomy and 9 IMA/SVG only with no pleurotomy and studied PFTs and post-operative chest radiograph changes. There were no differences between groups with all patients suffering significant reductions in PFTs.
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7. Clinical bottom line
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All patients undergoing cardiac surgery suffer a significant deterioration in Pulmonary Function tests and chest radiograph appearance post-operatively. Pleurotomy seems to compound this with increased rates of atelectasis and pleural effusions, although no impact on clinical outcome or length of hospital stay has been demonstrated.
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Appendix A. ICVTS on-line discussion
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Author: Madhu R. Illa (Almafraq Hospital, AbuDhabi, UAE)
eComment: There are various techniques for harvesting the IMA, each surgeon has got his/her choice. I always open the pleura and expose the entire length of the IMA before starting the dissection. Though some surgeons say that opening the pleuara increases the morbidity, I do not agree with them, and in my experience over the last ten years, I have hardly experienced any complications directly related to pleurotomy. In fact, pleurotomy is helpful in the immediate PO period when a left pleural drain is put in, any excess bleeding is immediately apparent and it also prevents any tomponade effect if there is any excess drain from the IMA dissection. It also avoids the occasional complication of pnemothorax. If an extrapleural IMA harvesting is done, there is always a risk of injuring the pleura which may not be apparent at the time, but in the PO period on the ventilatory support, it will present as a full blown pnemothorax, compromising the patient safety. Personally, I think pleurotomy will act as a safety valve rather than producing any complications and morbidity, and it holds good in other situations especially in pediatric cardiac surgery, where the pleura is very delicate, and however much care one takes, there is a chance of injuring the pleura. Thus, I feel in both pleura should be kept open to avoid PO problems.
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References
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- Dunning J, Prendergast B, Mackway-Jones K. Towards evidence based medicine in cardiothoracic surgery: best BETS. Interactive CardioVasc Thorac Surg 2003;2:405–409.[Abstract/Free Full Text]
- 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;52:1292–1294.[Abstract]
- Lim E, Callaghan C, Motalleb-Zadeh R, Wallard M, Misra N, Ali A, Halstead JC, Tsui S. A prospective study on clinical outcome following pleurotomy during cardiac surgery. Thorac Cardiovasc Surg 2002;50:287–291.[CrossRef][Medline]
- Ali IM, Lau P, Kinley CE, Sanalla A. Opening the pleura during internal mammary artery harvesting: advantages and disadvantages. Can J Surg 1996;39:42–45.[Medline]
- Wimmer-Greinecker G, Yosseef-Hakimi M, Rinne T, Buhl R, Matheis G, Martens S, Westphal K, Moritz A. Effect of internal thoracic artery preparation on blood loss, lung function and pain. Ann Thorac Surg 1999;67:1078–1082.[Abstract/Free Full Text]
- Landymore RW and Howell F. Pulmonary complications following myocardial revascularization with the internal mammary graft. Eur J Cardiothorac Surg 1990;4:156–161.[Abstract]
- Bonnacchi M, Prifti E, Giunti G, Salica A, Frati G, Sani G. Respiratory dysfunction after coronary artery bypass grafting and employing bilateral internal mammary arteries: the influence of the intact pleura. Eur J Cardiothorac Surg 2001;19:827–833.[Abstract/Free Full Text]
- Rolla G, Fogliati P, Bucca C, Brussino L, Di Rosa E, Di Summa M, Comoglio C, Malara D, Ottino GM. Effect of pleurotomy on pulmonary function after coronary artery bypass grafting with internal mammary artery. Respir Med 1994;88:417–420.[CrossRef][Medline]
- Tomita S, Sakata R, Umebayasi Y, Miyata A, Terai H, Ueyama K, Uezu T. Study of pulmonary function after CABG with pleurotomy. Jpn J Thoracic Surg 1994;47:528–532.
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Abstract
1. Introduction