A prospective study on clinical outcome following pleurotomy during cardiac surgery

Open Versus Closed Pleura Internal Mammary Artery Harvesting and Early Pulmonary Function After Coronary Artery Bypass Grafting

BACKGROUND

The internal mammary artery is the vessel of choice for myocardial revascularisation during coronary artery bypass grafting (CABG). Although it is possible to harvest the left internal mammary artery (LIMA) without opening the left pleura, pleurotomy is usually performed to provide adequate exposure and allow the placement of the LIMA medial to the upper lobe, preventing any undue tension on the mammary pedicle. However, the intact pleura technique may have a lower risk of postoperative pulmonary complications. We aimed to study the effects of both procedures on pulmonary function and the incidence of complications.

METHOD

One hundred patients with ischaemic heart disease indicated for CABG were included and divided into two groups. The closed pleural technique group included 50 patients with preservation of the pleural integrity during mammary harvesting. The open pleural procedure group included 50 patients without preservation of pleural integrity. Spirometry was done pre- and postoperatively in both groups and postoperative pulmonary complications in both groups were recorded and analysed.

RESULTS

Internal mammary harvesting with preservation of pleural integrity during CABG in patients in the closed pleural procedure group showed significant improvement in forced expiratory volume in the first second (FEV1%), forced vital capacity (FVC%), and FEV1/FVC compared with the corresponding values in patients in the open pleural procedure group, on day 5 postoperatively, at discharge, and at day 30. There were fewer complications in preservation of pleural integrity with regard to lung atelectasis and pleural effusion, which were significantly lower in patients in the open pleural procedure group.

CONCLUSIONS

Preservation of pleural integrity has beneficial effects on pulmonary function and has fewer associated pulmonary complications.

Effect of LIMA Harvesting Technique on Postoperative Drainage in Off-Pump CABG

OBJECTIVE

We investigated the effects of pedicled and semiskeletonized left internal mammary artery (LIMA) harvesting techniques on postoperative drainage in patients subjected to off-pump CABG, ignoring other advantages or disadvantages of those techniques.

METHODS

The present study comprises a total of 160 subjects that underwent coronary artery bypass surgery in our clinic. Data were collected consecutively and retrospectively. An attempt was made to have similar groups in terms of demographic characteristics. Patients that underwent off-pump coronary artery bypass surgery by two surgical teams which differed only in LIMA harvesting technique were dichotomized and compared according to these techniques. The first group (Group 1) consisted of patients in whom LIMA was harvested with surrounding tissues using the pedicled technique. The second group (Group 2) consisted of patients in whom LIMA was harvested using the semiskeletonized technique, with the veins separated from surrounding connective tissues.

RESULTS

The mean amount of drainage in the first 24 hours was 706.1±234.2 ml vs. 591±258.8 ml (Group 1 vs. Group 2; P=0.005), the mean amount of drainage in the second 24 hours was 270±133.6 ml vs. 189.4±140.4 ml (Group 1 vs. Group 2; P<0.001), and the mean amount of total drainage was determined to be 976.1±306.9 ml vs. 781.2±335.5 ml (Group 1 vs. Group 2; P<0.001).

CONCLUSION

It was observed that semiskeletonized LIMA presents reduced amount of postoperative drainage in the first and second 24-hour periods and total amount of drainage than pedicled LIMA, independent of pleural integrity.

Pulmonary Complications After Cardiac Surgery

Over the past two decades there has been a steady evolution in the practice of adult cardiac surgery with the introduction of “off-pump” surgery. However, respiratory complications remain a leading cause of postcardiac surgical morbidity and can prolong hospital stays and increase costs. The high incidence of pulmonary complications is in part due to the disruption of normal ventilatory function that is inherent to surgery in the thoracic region. Furthermore, patients undergoing such surgery often have underlying illnesses such as intrinsic lung disease (e.g., chronic obstructive pulmonary disease) and pulmonary dysfunction secondary to cardiac disease (e.g., congestive heart failure) that increase their susceptibility to postoperative respiratory problems. Given that many patients undergoing cardiac surgery are thus susceptiple to pulmonary complications, it is remarkable that more patients do not suffer from them during and after cardiac surgery. This is to a large degree because of advances in anesthetic, surgical and critical care that, for example, have reduced the physiological insults of surgery (e.g., better myocardial preservation techniques) and streamlined care in the immediate postoperative period (e.g., early extubation). Moreover, the development of minimally invasive surgery and nonbypass techniques are further evidence of the attempts at reducing the homeostatic disruptions of cardiac surgery. This review examines the available information on the incidences, consequences, and treatments of postcardiac surgery respiratory complications.

Effect of using pump on postoperative pleural effusion in the patients that underwent CABG

OBJECTIVE

The present study investigated effect of using pump on postoperative pleural effusion in patients who underwent coronary artery bypass grafting.

METHODS

A total of 256 patients who underwent isolated coronary artery bypass grafting surgery in the Cardiovascular Surgery clinic were enrolled in the study. Jostra-Cobe (Model 043213 105, VLC 865, Sweden) heart-lung machine was used in on-pump coronary artery bypass grafting. Off-pump coronary artery bypass grafting was performed using Octopus and Starfish. Proximal anastomoses to the aorta in both on-pump and off-pump techniques were performed by side clamps. The patients were discharged from the hospital between postoperative day 6 and day 11.

RESULTS

The incidence of postoperative right pleural effusion and bilateral pleural effusion was found to be higher as a count in Group 1 (on-pump) as compared to Group 2 (off-pump). But the difference was not statistically significant [P>0.05 for right pleural effusion (P=0.893), P>0.05 for bilateral pleural effusion (P=0.780)]. Left pleural effusion was encountered to be lower in Group 2 (off-pump). The difference was found to be statistically significant (P<0.05, P=0.006).

CONCLUSION

Under the light of these results, it can be said that left pleural effusion is less prevalent in the patients that underwent off-pump coronary artery bypass grafting when compared to the patients that underwent on-pump coronary artery bypass grafting.

Should the integrity of the pleura during internal mammary artery harvesting be preserved?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether preservation of the pleura during internal mammary artery (IMA) harvesting improved clinical outcomes after coronary artery bypass graft surgery. More than 210 papers were found using the reported search, of which 18 presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studies, relevant outcomes, results and study weakness of these papers are tabulated. Most studies dealt with investigating the radiographic changes, pulmonary function tests, ventilation time and also clinical consequences, such as bleeding, the need for blood transfusion, pain scores and the length of hospital stay. There is still no meta-analysis and systematic review regarding this surgical problem. Eighteen articles were found, of which 6 were prospective randomized, controlled trials and 12 were cohort studies. In these studies, some beneficial clinical outcomes were reported including: pleural effusion (15 studies), atelectasis (11 studies), pulmonary function tests (9 studies), arterial blood gases (5 studies), postoperative pain (6 studies), tamponade (2 studies), ventilation time (12 studies with), blood loss (9 studies), transfusion (4 studies), intensive care unit stay (5 studies) and hospital stay (12 studies). Based on our findings, preservation of pleural integrity seems to contribute to decreased pulmonary complications and improved clinical outcomes, such as bleeding, pain and length of hospital stay.

Effect of pleurotomy on blood loss during coronary artery bypass grafting

BACKGROUND

We conducted a retrospective study to compare two different techniques of internal mammarian artery (IMA) preparation concerning pleurotomy upon the effects of blood loss and pulmonary functions.

METHODS

Between January 1998 and November 2006, 1357 consecutive patients undergoing coronary artery bypass grafting (CABG) using the left IMA, either alone or in combination with saphenous vein graft, were included in this study. The patients were divided into two groups according to the pleural opening: Group I (n = 1046) patients underwent IMA harvesting with pleurotomy and Group 2 (n = 311) patients with intact pleura.

RESULTS

During the study, 27 hospital deaths (1.9%) occurred. The amount of postoperative blood loss and blood transfusion requirements were significantly higher in Group 1 than in Group 2 (p = 0.029 and p = 0.0001). The mechanical ventilation stay was significantly higher in Group 1 than in Group 2 (p = 0.0001). The incidence of left pleural effusion and atelectasis was significantly higher in Group 1 than in Group 2 on day 1 and day 3 after operation.

CONCLUSIONS

These results demonstrate that preserving pleural integrity has beneficial effects on the postoperative blood loss. Postoperative blood loss and transfusion requirements were higher in patients with pleurotomy. Left pleural effusion, atelectasis, and mechanical ventilatory stay were significantly reduced in patients with preserved pleural integrity.

Outcomes research in the ICU: an aid in defining the role of physiotherapy

The economic reality of consumers, funders, and regulatory agencies demanding evidence regarding the quality of care patients are receiving in the intensive care unit (ICU) will have an effect on many of the routinely used practices in ICU, including physiotherapy. Outcomes research is a method that has been used to obtain evidence for the medical and respiratory management of patients in ICU. An overview of the literature was conducted to answer the following questions: 1. What is outcomes research? 2. Which outcomes should be measured in the adult critical care environment? 3. Which outcomes are physiotherapists currently including in research reports? Outcomes research is recognized by critical care specialists as a cost-effective method of determining what works in the real world. The value of physiologic measures is questioned, whereas the importance of patient centered, economic, and traditionally accepted outcome measures is increasingly being recognized. Most physiotherapy research reports still include physiologic measurements as the primary outcome of an intervention. Outcomes research provides researchers with the tools to define the role of the physiotherapist in the critical care environment. The outcomes measured must be relevant to patients, families, and funders.

Preservation of pleural integrity during coronary artery bypass surgery affects respiratory functions and postoperative pain: a prospective study

OBJECTIVE

To evaluate the role of preserved pleural integrity in postoperative pain and respiratory functional status in patients undergoing coronary revascularization.

METHODS

Two hundred forty patients undergoing on-pump coronary artery bypass grafting between March 2004 and February 2005 were included in the present study. The patients were prospectively randomized and divided into either an opened pleura (OP) group (n=120, patients with an OP) or a closed pleura (CP) group (n=120, patients whose pleural integrity was preserved). Preoperative patient characteristics were similar. Postoperative respiratory functions were compared between the groups by chest x-rays, respiratory functional tests and arterial blood gas analyses. Postoperative pain was compared by using a multidimensional pain score. All the tests were examined by the same blinded clinician.

RESULTS

The mean age of the patients was 60.4+/-8.8 years. Postoperative bleeding and the duration of hospital stay were markedly higher in the OP group than in the CP group. The incidences of atelectasis and pleural effusion were also significantly higher in the OP group (P<0.01). Respiratory functions and postoperative pain scores were better in the CP group (P<0.01 and P=0.008, respectively).

CONCLUSIONS

Preserving pleural integrity has beneficial effects on the respiratory functions and postoperative pain after coronary revascularization. The preservation of pleural integrity results in better respiratory function, decreased hospital stay and cost, and as a consequence, a better surgical outcome.