Bilateral Internal Mammary Artery Use for Coronary Artery Bypass Grafting Remains Underutilized: A Propensity-Matched Multi-Institution Analysis

BITA is a fantastic operation, you can even differentiate at out-patients whose had received BITA from SITA without reading the operative report. I was very touched by under-using BITA in STS data base. If we surgeons would have performed at least 70% of cases using BITA, then, there were be no room to compare PCI to CABG, In fact, CABG is under-powered in many trials to PCI, as we remains on a steady technical steep, while PCI continues to expands its wings. It is a false prevailing idea that BITA increases the risk of mediastinitis, the majority of deep sternal infections I had seen occurred on using SITA. Therefore, by using adequate skelotenization technique with preservation of internal thoracic veins, postponding operation until reaching adequate HbA1c, and tight glycemic control, the infectious risk do not overtake comparing to SITA. By the time of my residency in orthopedics 4 rules flayed daily in our minds: respecting the periostium, gentle handling of tissues to minimize the risk of further collection and to be able to restore covering, adequate drainage, and perfect bone stability and sheaths suturing without creating ischemia. The rules that are mainly overlooked in cardiac surgery for many diverse reasons that deserves to be scoped meticulously in an Editorial. Some technical shortcomings do also explain the low progression rate of BITA that needs to be fixed by expert consensus (inadequate length, small diameter, competition flow, restrictive anastomoses or so-called ITA-spasm ect). Some technical aspects may also having played some decisive role by diverting cardiologists and surgeons intentions towards off-pump, MIDCAB, hybrid, robotic surgery as part of an unfair competitive cold-war. But, the main practical limits are not surgeon-driven, but rather team-driven. The first is the indifference of our cardiologists who do not mandate the referral surgeon to perform BITA. The second is the financial aspect for occupying OR-time , surgeons and anesthesiologist incomes that may depend on number of cases. And the third one is the surgeon reputation, as the best surgeon considered by the team is as the faster one. Therefore, this article sounds timely towards worldwide collective efforts to widespread BITA bypassing, because the best chance of a given patient is his first CABG.