The Use of Bilateral Internal Mammary Arteries for Coronary Revascularization in Patients with COPD: Is It a Good Idea?


  • Yasser Yehia Hegazy Cardiac Surgery Department, MediClin Heart Institute Lahr/Baden, Lahr
  • Ralf Sodian Cardiac Surgery Department, MediClin Heart Institute Lahr/Baden, Lahr, Germany
  • Wael Hassanein Cardiothoracic Surgery Department, Alexandria University, Alexandria
  • Amr Rayan Cardiac Surgery Department, MediClin Heart Institute Lahr/Baden, Lahr
  • Juergen Ennker Cardiac Surgery Department, MediClin Heart Institute Lahr/Baden, Lahr



Background: The use of bilateral internal mammary arteries (BIMA) is limited worldwide, especially in patients with chronic obstructive pulmonary disease (COPD). Thus, we assessed the safety of the use of BIMA in COPD patients.
Methods: From cohorts of 8846 patients operated on at our center for primary isolated multi-vessel coronary bypass operations between 2002 and 2012, we studied two propensity-matched groups of patients with COPD who received either single internal mammary artery and saphenous vein grafts (SIMA group: 137 patients) or exclusively BIMA (BIMA group: 137 patients). Preoperative data were similar regarding age (63.59 ± 10.62 versus 65.55 ± 9.61 years;
P = .10), body mass index (BMI) (28.6 ± 4.71 versus 28.42 ± 3.86 kg/m2; P = .72), diabetes mellitus (32% versus 27%; P = .08), EuroSCORE (4.34 ± 2.23 versus 4.8 ± 2.52; P = .09) and ejection fraction (58.7 ± 13.08% versus 60.29 ± 14.13%; P = .32).
Results: No significant differences were noticed between the two groups regarding the number of peripheral anastomoses (3.07 ± 0.77 versus 3.06 ± 0.85; P = .90), total operation time (192.17 ± 43.06 versus 200.63 ± 39.24 min; P = .08), postoperative stroke (0.7% versus 0%; P = .29), myocardial infarction (2.92% versus 3.6%; P = .81), reintubation (2.9% versus 4.4%; P = .66), reexploration (0.7% versus 2.2%;
P = .32), deep sternal wound infection (2.9% versus 3.6%;
P = .81) and 30-day mortality (2.2% versus 2.9%; P = .77). However, postoperative blood loss (726.1 ± 468.35  versus 907 ± 890.58 mL; P = .03) was higher in the BIMA group.
Conclusion: COPD patients can benefit from coronary artery revascularization with BIMA; however, postoperative blood loss can be higher using this technique.


Albert A, Sergeant P, Florath I, Ismael M, Rosendahl U, Ennker J. 2011. Process review of a departmental change from conventional coronary artery bypass grafting to totally arterial coronary artery bypass and its effects on the incidence and severity of postoperative stroke. Heart Surg Forum 14:E73-80.

Barbut D, Yao FF, Lo Y, et al. 1997. Determination of size of aortic emboli and embolic load during coronary artery bypass grafting. Ann Thorac Surg 63:1262-7.

Boschetto P, Beghe B, Fabbri LM, Ceconi C. 2012. Link between chronic obstructive pulmonary disease and coronary artery disease: implication for clinical practice. Respirology 17:422-31.

Bridgewater B, Keogh B. 2008. On behalf of the Society for Cardiothoracic Surgery in Great Britain & Ireland. Sixth National Adult Cardiac Surgical Database Report.

Clark RE. 1994. Definitions of terms of The Society of Thoracic Surgeons National Cardiac Surgery Database. Ann Thorac Surg 58:271-3.

Daganou M, Dimopoulou I, Michalopoulos N, et al. 1998. Respiratory complications after coronary artery bypass surgery with unilateral or bilateral internal mammary artery grafting. Chest 113:1285-9.

De Paulis R, de Notaris S, Scaffa R et al. 2005. The effect of bilateral internal thoracic artery harvesting on superficial and deep sternal infection: The role of skeletonization. J Thorac Cardiovasc Surg 129:36-43.

Dorman MJ, Kurlansky PA, Traad EA, Galbut DL, Zucker M, Ebra G. 2012. Bilateral internal mammary artery grafting enhances survival in diabetic patients: a 30-year follow-up of propensity score-matched cohorts. Circulation. 126:2935-42.

Farinas JM, Carrier M, Hébert Y, et al. 1999. Comparison of long-term clinical results of double versus single internal mammary artery bypass grafting. Ann Thorac Surg 67:466-70.

Fuster RG, Argudo JA, Albarova OG. 2006. Prognostic value of chronic obstructive pulmonary disease in coronary artery bypass grafting. Eur J Cardiothorac Surg 29:202-9.

Gardner SC, Grunwald GK, Rumsfeld JS, et al. 2001. Risk factors for intermediate-term survival after coronary artery bypass grafting. Ann Thorac Surg 72:2033-7.

Geraci JM, Rosen AK, Ash AS, McNiff KJ, Moskowitz MA. 1993. Predicting the occurrence of adverse events after coronary artery bypass surgery. Ann Intern Med 118:18-24.

Grover FL, Johnson RR, Marshall G, Hammermeister KE. 1993. Factors predictive of operative mortality among coronary artery bypass subsets. Ann Thorac Surg 56:1296-307.

Güler M, Kirali K, Toker ME, et al. 2001. Different CABG methods in patients with chronic obstructive pulmonary disease. Ann Thorac Surg 71:52-7.

Hannan EL, Wu C, Bennett EV, et al. 2006. Risk stratification of in-hospital mortality for coronary artery bypass graft surgery. J Am Coll Cardiol 47:661-8.

Higgins TL, Estafanous FG, Loop FD, Beck GJ, Blum JM, Paranandi L. 1992. Stratification of morbidity and mortality outcome by preoperative risk factors in coronary artery bypass patients. A clinical severity score. JAMA 267:234-8.

Itagaki S, Cavallaro P, Adams DH, Chikwe J. 2013. Bilateral internal mammary artery grafts, mortality and morbidity: an analysis of 1526360 coronary bypass operations. Heart 99:849-53

Kurlansky PA, Traad EA, Dorman MJ, Galbut DL, Zucker M, Ebra G. 2010. Thirty-year follow-up defines survival benefit for second internal mammary artery in propensity-matched groups. Ann Thorac Surg 90:101-8.

Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. 1999. Hospital Infection Control Practices Advisory Committee. Guideline for prevention of surgical site infection, 1999. Infect Control Hosp Epidemiol 20:250-78.

Mohammadi S, Dagenais F, Voisine P, et al. 2014. Lessons learned from the use of 1,977 in-situ bilateral internal mammary arteries: a retrospective study. J Cardiothorac Surg 9:1-8.

Nashef SA, Roques F, Michel P, Gauducheau E, Lemeshow S, Salamon R. 1999. European system for cardiac operative risk evaluation (EuroSCORE). Eur J Cardiothorac Surg 16:9-13.

Online STS Risk Calculator. Available at: Accessed October 10, 2015.

Roques F, Nashef SA, Michel P, et al. 1999. Risk factors and outcome in European cardiac surgery: analysis of the EuroSCORE multinational database of 19030 patients. Eur J Cardiothorac Surg 15:816-23.

Shroyer AL, Coombs LP, Peterson ED, et al. 2003. The Society of Thoracic Surgeons: 30-day operative mortality and morbidity risk models. Ann Thorac Surg 75:1856-64.

Tabata M, Grab JD, Khalpey Z, et al. 2009. Prevalence and variability of internal mammary artery graft use in contemporary multivessel coronary artery bypass graft surgery: analysis of the Society of Thoracic Surgeons National Cardiac Database. Circulation 120:935-40.

Tatoulis J. 2013. Total arterial coronary revascularization: patient selection, stenoses, conduits, targets. Ann Cardiothorac Surg 2:499-506.



How to Cite

Hegazy, Y. Y., Sodian, R., Hassanein, W., Rayan, A., & Ennker, J. (2016). The Use of Bilateral Internal Mammary Arteries for Coronary Revascularization in Patients with COPD: Is It a Good Idea?. The Heart Surgery Forum, 19(5), E243-E247.