Abstract:

Aim: was to establish methods of coronary artery bypass graft (CABG) with use of internal thoracic artery (ITA), that influenced high risk of continued diaphragmatic dysfunction in early post-operative period, on the base of analysis of dynamics of diaphragmatic dysfunction after operation.

Materials and methods: the retrospective study included 880 patients in the early period after CABG with use of ITA. The mobility of diaphragm domes was estimated on 2,8±0,88 day after the surgery, when transferred from the intensive care unit to the in-patient department and again on 7,7±1,9 day when transferred to the rehabilitation department. Patients were divided into 3 groups. The first group with normal diaphragm mobility with an initial study of 529(60,1%) patients. The second group with diaphragmatic dysfunction in the initial study and the restored mobility of the diaphragm in a re-examination of 249(28,3%) patients. The third group with diaphragmatic dysfunction, which persists in the re-examination of 102(11,6%) patients. The criterion for diaphragmatic dysfunction was the amplitude of the diaphragm's movement ess than 10 mm. Using the model of logistic regression, the influence of the CABG methods on the probability of maintaining diaphragmatic dysfunction at the end of the early postoperative period was determined. Two CABG methods were included in the model: «in situ» and autograft.

Results: in the primary study, 39,9% of patients had diaphragmatic dysfunction, 21,1% left-sided, 8,0% right-sided, and 10,8% bilateral. The prevalence of diaphragmatic dysfunction during the early postoperative period decreases threefold, from 39,9% to 11,5%, and was persisted more often as a unilateral lesion: left-sided in 7,2% of patients or right-sided in 3,4%, Less often, bilateral dysfunction persists in 0,9% of patients. Restoration of the function of the diaphragm during repeated examination was observed in 71,2% of cases of initial dysfunction. A different effect was established on the persistence of unilateral and bilateral diaphragmatic dysfunction by the end of the early postoperative period, depending on methods of CABG with use of ITA and their combination. High likelihood conservation diaphragmatic dysfunction by the right harvest of ITA was observed after bypass «in situ» (OR 4.4; CI 2,2-8,9) and by the harvest of ITA left after bypass graft (OR 4.1; CI 1,6-10,6). Other methods of grafting either did not have an effect on the preservation of dysfunction on the part of the ITA harvest, or the effect was traced, but was statistically insignificant.

Conclusion: dysfunction of the diaphragm acquired after CABG with use of ITA is reversible. During the early postoperative period, 71,2% of patients undergo full restoration of diaphragm mobility, the prevalence of diaphragmatic dysfunction decreases three-fold, the frequency of bilateral diaphragm dysfunction decreases by 10 times. Methods of CABG with use of ITA, «insitu» and autograft, affect the likelihood of the dysfunction of the diaphragm retained during the early postoperative period by surgical manipulation. Results of the study indicate that chances of maintaining diaphragmatic dysfunction were 4,4 times higher by grafting the right ITA «in .situ» and 4,1 times by grafting the left ITA with a graft. While the likelihood of maintaining diaphragmatic dysfunction was low by grafting the right ITA with a graft and was absent from the grafting of the left ITA «in situ».

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