We recently documented the outcomes of our centers" concomitant off-pump coronary artery bypass grafting (CABG) and pulmonary operations. As we mentioned in our manuscript, each of these patients was discussed at multiple councils with cardiac and thoracic surgery teams. These patients were also followed by their primary cardiology and pulmonology attending physicians during pre- and postoperative period, most of the these patients were followed by Oncology Department on long-term follow-up.

The mean ± standard deviation body mass index (BMI) was 26.9±4.1 kg/m², and the median was 27.1 (range, 22.5 to 32.9) kg/m². The reason why we did not account left ventricular diastolic dysfunction (LVDD) in our retrospective analysis, as we reviewed the recent literature about concomitant off-pump CABG and lung surgery, none of the manuscripts mentioned the preoperative LVDD effects on the outcomes of off-pump CABG and pulmonary operations and its impact on the long-term outcomes of the surgery.

Braksatar et al.[1] mentioned the impact of the left ventricle diastolic dsyfunction on respiratory adverse events in cardiac surgery patients which was a single-center, observational, prospective study with overall 56 patients, excluding the pulmonary disease with severe or moderate restrictive or obstructive order, and also excluding postoperative bleeding surgical revision patients. This group operated their patients on pump with cardiopulmonary bypass which was totally different physiology then off-pump technique. During postoperative period they supported nine of 56 patients with norepinephrine as a inotropic support. They mentioned their limitation as relatively small sample size and novel coronavirus disease 2019 (COVID-19) pandemic influenced their results and, therefore, their patients required quite long artificial ventilation. In this manuscript, these data were not comparable to our data on the basis of an observational prospective analysis; instead, our data were based on surgical techniques and long-term outcomes.

In our center, we have done off-pump CABG since late 1990s and we are experienced as a team on the long-term outcomes and management of off-pump CABG patients. Our Thoracic Surgery Team is experienced about video-assisted thoracoscopic surgery since early 2000s with excellent outcomes.

We prefer simultaneous procedures, due to corroborated advantages such as shorter hospital stay, lower perioperative morbidity and potential to avoid cancer growth and dissemination.

Due to our postoperative results, none of the patients had pulmonary complications, postoperative period went uneventful for all our patients. Ten of 23 patients were extubated in the operating room due to Enhanced Recovery After Surgery (ERAS) protocol,[2] and the rest of patients were extubated in cardiovascular intensive care unit less than 10-h postoperative period.

In this manuscript, we attempted to emphasize the importance of the excellence centers for offpump CABG and concomitant lung operations as a reference center. We strongly believe the importance of being on excellence center would be able to implant off-pump CABG, minimally invasive, boost total arterial revascularization adopt quickly to new techniques with proven advantages and manage patients with coronary artery disease and lung disease as a high quality reference center with skilled anesthesiologist teams.

Acknowledgements: The authors would like to express their gratitude to Haldun Y. Karagöz MD and Şükrü Dilege MD for sharing their personal experiences, and mentorship.

Data Sharing Statement: The data that support the findings of this study are available from the corresponding author upon reasonable request.

Conflict of Interest: The authors declared no conflicts of interest with respect to the authorship and/or publication of this article.

Funding: The authors received no financial support for the research and/or authorship of this article.

References

1) Braksator M, Jachymek M, Witkiewicz K, Witkiewicz W, Pogorzelska MP, Kotfis K, et al. The impact of left ventricular diastolic dysfunction on respiratory adverse events in cardiac surgery patients -observational prospective single center study. J Clinic Med 2023;12:4960.doi 10.3390/ jcm 12154960.

2) Engelman DT, Ben Ali W, Williams JB, Perrault LP, Reddy VS, Arora RC, et al. Guidelines for perioperative care in cardiac surgery: Enhanced recovery after surgery society recommendations. JAMA Surg 2019;154:755-66. doi: 10.1001/jamasurg.2019.1153.