
==== Front
Indian J Crit Care Med
Indian J Crit Care Med
IJCCM
Indian Journal of Critical Care Medicine : Peer-reviewed, Official Publication of Indian Society of Critical Care Medicine
0972-5229
1998-359X
Jaypee Brothers Medical Publishers

10.5005/jp-journals-10071-24684
Letter to the Editor
Mirror, Mirror on the Wall; He Had a “Bypass” After All!
Magoon Rohan 1https://orcid.org/0000-0003-4633-8851

Jose Jes 2https://orcid.org/0000-0003-1734-9519

Kumar Mukesh 3https://orcid.org/0009-0005-2632-7495

1 Department of Anaesthesia and Cardiac Anaesthesia, Atal Bihari Vajpayee Institute of Medical Sciences (ABVIMS) and Dr. Ram Manohar Lohia Hospital, New Delhi, India
2 Department of Cardiac Anesthesiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka, India
3 Department of Cardiac Anaesthesia, Atal Bihari Vajpayee Institute of Medical Sciences (ABVIMS) and Dr. Ram Manohar Lohia Hospital, New Delhi, India
Rohan Magoon, Department of Anaesthesia and Cardiac Anaesthesia, Atal Bihari Vajpayee Institute of Medical Sciences (ABVIMS) and Dr. Ram Manohar Lohia Hospital, New Delhi, India, Phone: +91 9711128628, e-mail: rohanmagoon21@gmail.com
7 2024
29 6 2024
28 7 706707
Copyright © 2024; The Author(s).
2024
https://creativecommons.org/licenses/by-nc/4.0/ © The Author(s). 2024 Open Access. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (https://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted use, distribution, and non-commercial reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
How to cite this article: Magoon R, Jose J, Kumar M. Mirror, Mirror on the Wall; He Had a “Bypass” After All! Indian J Crit Care Med 2024;28(7):706–707.

Keywords

Coronary artery bypass grafting
Internal mammary grafts
Left internal thoracic artery
Pleurotomy
Postoperative pulmonary function
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pmcAs practicing cardiac anesthesiologists, we totally comprehend the merit nested in the recent research report by Mavkar and Shukla which has to offer novel promises of preserving the post-cardiac surgery pulmonary function by integrating the Buteyko breathing technique with conventional physiotherapy.1 Despite having resorted to the inclusion of a homogenous cohort undergoing off-pump coronary artery “bypass” grafting (CABG), the authors' randomized controlled trial (RCT) quite likely “bypassed” other relevant surgical details, which need to be brought to the attention of the readership.1–4

Given that Mavkar and Shukla hint toward and we concur as to the intricacies of CABG surgery, there ought to be a more focused discussion considering a research frame investigating postoperative breathing technique in a cardiothoracic surgical setting where procedural nuances can only be far from innocent.1–4 Regardless of the use of cardiopulmonary bypass, left internal thoracic artery (LITA) harvest is a routine step and in fact, the graft of choice during a CABG.5 Of note, independent researchers, namely, Guizilini et al. outline the counterproductive effects of pleurotomy during LITA harvest on the postoperative pulmonary mechanics, that is, the forced vital capacity (FVC) and the forced expiratory volume in 1 second (FEV1) following off-pump CABG.2 It is thereby believed that while studying a similar study population and outcome measures, the index RCT could have shed some light on whether an intact pleura or an open pleura technique was employed for LITA harvest in their participants.1 Even for the practicalities surrounding incidental opening of pleura during an otherwise intended intact pleura LITA harvest, the chest drain practices could have been clarified to enhance the contextual lucidity.1–3 The authors indeed describe the challenges presented by the drain-site discomfort while performing the postoperative day-2 (POD-2) pulmonary function test (PFT) in their study subjects.1

Moreover, driven by the lower reported attrition rates for the arterial grafts when compared to the saphenous venous (SV) grafts, the coronary surgeons might choose to harvest the bilateral internal thoracic artery or what is frequently called the internal mammary artery (IMA).5 In an interesting study by Ferdinande et al., it was found that the decline in the post-CABG pulmonary mechanics is accentuated depending upon one or two pleural cavity/cavities being violated.4 The researchers outlined a much more markedly reduced POD-2 FVC in the bilateral IMA (BIMA) group as opposed to the single IMA (SIMA) and, the SV groups (31 ± 9% vs 35 ± 8%, and 45 ± 10% of the respective preoperative PFT values, p < 0.05). For that matter, the POD-2 FEV1 pretty much demonstrated a similar course of decline in the three corresponding groups (32 ± 10% vs 34 ± 8%, and 46 ± 9% of the respective preoperative PFT values, p < 0.05).4

Hence, we again reiterate that these details can be difficult to “bypass” while evaluating a rather complex study subset undergoing “bypass.”1–4

Orcid

Rohan Magoon https://orcid.org/0000-0003-4633-8851

Jes Jose https://orcid.org/0000-0003-1734-9519

Mukesh Kumar https://orcid.org/0009-0005-2632-7495

Source of support: Nil

Conflict of interest: None
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References

1. Mavkar SS Shukla MP Effect of Buteyko breathing technique as an adjunct to routine physiotherapy on pulmonary functions in patients undergoing off-pump coronary artery bypass surgery: A randomized controlled trial Indian J Crit Care Med 2024 28 3 280 285 10.5005/jp-journals-10071-24655 38477002
2. Guizilini S Gomes WJ Faresin SM Bolzan DW Buffolo E Carvalho AC et al. Influence of pleurotomy on pulmonary function after off-pump coronary artery bypass grafting Ann Thorac Surg 2007 84 3 817 822 10.1016/j.athoracsur.2007.04.062 17720381
3. Montes FR Maldonado JD Paez S Ariza F Off-pump versus on-pump coronary artery bypass surgery and postoperative pulmonary dysfunction J Cardiothorac Vasc Anesth 2004 18 6 698 703 10.1053/j.jvca.2004.08.004 15650976
4. Ferdinande PG Beets G Michels A Lesaffre E Lauwers P Pulmonary function tests after different techniques for coronary artery bypass surgery. Saphenous vein versus single versus double internal mammary artery grafts Intensive Care Med 1988 14 6 623 627 10.1007/BF00256766 3263404
5. Cao C Ang SC Wolak K Peeceeyen S Bannon P Yan TD A meta-analysis of randomized controlled trials on mid-term angiographic outcomes for radial artery versus saphenous vein in coronary artery bypass graft surgery Ann Cardiothorac Surg 2013 2 4 401 407 10.3978/j.issn.2225-319X.2013.07.03 23977615
