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The authors reported no conflicts of interest., The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline, handling or reviewing manuscripts for which they, may have a conflict of interest. The editors and, reviewers of this article have no conflicts of interest., , “HOW TO BIMA?” IS IN, FACT THE QUESTION, To the Editor:, We read with interest the Commentary by Schwann and colleagues1, written in response to our original, manuscript.2 We do not agree with, the authors, who place the emphasis, entirely on bilateral internal mammary artery (BIMA) use, and state that the configuration, of BIMA grafts has no relevance. Although we are firm believers in the benefits of BIMA grafting, the optimal configuration of BIMA grafts still remains a matter of controversy., It was not our goal to compare BIMA versus single internal, mammary artery grafting (SIMA), and 100% of patients in, both comparator groups were BIMA recipients. Therefore,, it is perfectly normal that our study will not “move the, BIMA utilization needle” and “offers no compelling reasons to consider the BIMA strategy preferentially over the, current left internal mammary artery/saphenous vein graft, approach.” In our opinion, the optimal BIMA configuration, is a key unknown that may explain why no group has been, able to prospectively show the superiority of BIMA versus, SIMA, with some authors showing a greater adjusted mortality with BIMA compared with SIMA.3, Our mediastinitis rate of 2.4% was incriminated by the, authors as unusually high, but this is very similar to recent, trial data4 and many previous retrospective studies. The risk, of sternal complications post-BIMA depends on the patient’s risk profile, patient selection, and how far the surgeon, wants to go to perform BIMA grafting. Mediastinitis was as, high as 5.5% in the CATHolic University EXtensive BIMA, Grafting Study registry,5 or 3.5% in the Arterial Revascularization Trial (ART),4 and is not simply a result of, , The Editor welcomes submissions for possible publication in the Letters to the Editor, section that consist of commentary on an article published in the Journal or other relevant issues. Authors should:  Include no more than 500 words of text, three authors,, and five references.  Type with double-spacing.  See http://jtcs.ctsnetjournals.org/, misc/ifora.shtml for detailed submission instructions.  Submit the letter electronically via jtcvs.editorialmanager.com. Letters commenting on an article published, in the JTCVS will be considered if they are received within 6 weeks of the time, the article was published. Authors of the article being commented on will be given, an opportunity of offer a timely response (2 weeks) to the letter. Authors of letters, will be notified that the letter has been received. Unpublished letters cannot be returned., , “surgeon experience and skeletonization” as Schwann and, colleagues proclaim., In summary, “How to BIMA?” is in fact the question, and, a key question at that, to optimize outcomes post-coronary, artery bypass grafting. To claim that conduit configuration, is of no prognostic importance is to deny the incredibly, nuanced complexity of contemporary coronary surgery,, which depends on many different factors, including degree, of coronary stenosis, the size and quality of target vessels,, and distal run-off, and not only on the type of conduits used., Dimitri Kalavrouziotis, MD, FRCSC, Siamak Mohammadi, MD, FRCSC, Department of Cardiac Surgery, Quebec Heart and Lung Institute, Quebec City, Quebec, Canada, Image from Shutterstock.com., , References, 1. Schwann TA, Gaudino MF. Commentary: to BIMA or not to BIMA, that should be, the question, rather than how to BIMA. J Thorac Cardiovasc Surg. April 1, 2020, [Epub ahead of print]., 2. Marzouk M, Kalavrouziotis D, Grazioli V, Meneas C, Nader J, Simard S, et al., Long-term outcome of the in-situ versus free internal thoracic artery as the second, arterial graft. J Thorac Cardiovasc Surg. March 13, 2020 [Epub ahead of print]., 3. Schwann TA, Habib RH, Wallace A, Shahian DM, O’Brien S, Jacobs JP, et al., Operative outcomes of multiple-arterial versus single-arterial coronary bypass, grafting. Ann Thorac Surg. 2018;105:1109-12., 4. Taggart DP, Benedetto U, Gerry S, Altman DG, Gray AM, Lees B, et al. Bilateral, versus single internal-thoracic-artery grafts at 10 years. N Engl J Med. 2019;380:, 437-46., 5. Gaudino M, Glieca F, Luciani N, Pragliola C, Tsiopoulos V, Bruno P, et al. Systematic bilateral internal mammary artery grafting: lessons learned from the CATHolic University EXtensive BIMA Grafting Study. Eur J Cardiothorac Surg., 2018;54:702-7., , https://doi.org/10.1016/j.jtcvs.2020.06.029, REPLY: BILATERAL, , INTERNAL MAMMARY ARTERY, GRAFTING: SO MANY QUESTIONS. SO, FEW ANSWERS, Reply to the Editor:, Marzouk and colleagues1 recently reported that patients, who underwent bilateral internal mammary artery, (BIMA) grafting with both utilized as in situ grafts had better long-term survival than those in whom the second IMA, was used as a free graft. In a related commentary, Schwann, , The Journal of Thoracic and Cardiovascular Surgery c Volume 161, Number 1, Downloaded for Abhishek Srivastava ([email protected]) at Fortis Escorts Heart Institute and Research Centre from ClinicalKey.com by, Elsevier on January 08, 2022. For personal use only. No other uses without permission. Copyright ©2022. Elsevier Inc. All rights reserved., , e31, , ADULT, , ADULT: CORONARY: LETTERS TO THE EDITOR