Combined PCI and minimally invasive heart valve surgery for high-risk patients

Abstract

Combined coronary artery valvular heart disease is a major cause of morbidity and mortality in the adult patient population. The standard treatment for such disease has been open heart surgery in which coronary artery bypass grafting (CABG) is performed concurrently with valve surgery using a median sternotomy and cardiopulmonary bypass. With the increasing complexity of patients referred to surgery, some patients may prove to be poor surgical candidates for combined valve and CABG surgery. In certain selected patients who fall into this category, valve surgery and percutaneous coronary intervention (PCI) have been considered a feasible alternative. Conventionally, valve surgery is performed in the cardiac surgical operating room, whereas PCI is carried out in the cardiac catheterization laboratory. Separation of these two procedural suites has presented a logistic limitation because it impedes the concomitant performance of both procedures in one setting. Hence, PCI and valve surgery usually have been performed as a "two-stage" procedure in two different operative suites, with the procedures being separated by hours, days, or weeks. Technologic advancements have made possible the construction of a "hybrid" procedural suite that combines the facilities of a cardiac surgical operating room with those of a cardiac catheterization laboratory. This design has enabled the concept of "one-stage" or "one-stop" PCI and valve surgery, allowing both procedures to be performed in a hybrid suite in one setting, separated by minutes. The advantages of such a method could prove to be multifold by enabling a less invasive surgical approach and improving logistics, patient satisfaction, and outcomes in selected patients.

Hybrid approach of percutaneous coronary intervention followed by minimally invasive mitral valve surgery: a 5-year single-center experience

“…In the setting of coronary artery and valvular disease, the less invasive approach of PCI plus minimally invasive valve surgery has demonstrated excellent early and mid-term outcomes (9)(10)(11)(12)(13)(14)(15)(16)(17). However, the data evaluating the use of PCI for coronary artery disease prior to isolated MV surgery (PCI + MIMVS) are limited.…”

Surgical Update

“…14,24 Traditional treatment involves combined valve and CABG surgery using a median sternotomy. However, this combined surgical approach may prove to have a prohibitively high risk in some patients.…”

“…Patients requiring valve re-replacement or native valve surgery after prior CABG surgery also can benefit from this approach because it can prevent the requirement for and dangers associated with a redo sternotomy, dissection of pericardial adhesions, and injury to patent bypass grafts. 24,25 Furthermore, mitral valve exposure after previous aortic valve surgery can be challenging using the standard approach, whereas minimally invasive right thoracotomy offers superior exposure.…”

“…We have adopted this technique and previously reported our encouraging experience in 32 patients who underwent combined PCI and mitral valve replacement. 24 We have continued the use of this technique and now have updated data on 39 high-risk patients who underwent PCI and minimally invasive mitral valve surgery through a small (5-cm) anterolateral right thoracotomy between March 2006 and June 2009 (unpublished data). Of the 39 patients, 5 (13%) presented with acute coronary syndrome, 19 (49%) were in congestive heart failure, 16 (41%) underwent urgent or emergent surgery, and 16 (41%) had prior heart surgery.…”

Outcomes of a hybrid approach of percutaneous coronary intervention followed by minimally invasive aortic valve replacement

“…The goal of utilizing an approach of PCI + MIVS is the avoidance of a standard median sternotomy required to perform coronary artery bypass (CABG) and valve surgery, which potentially reduces the operative risk of the patient. This concept of reducing the total risk of a single major operation to the less invasive procedures of PCI+MIVS has been applied in clinical practice and reported by various groups (9)(10)(11)(12)(13)(14)(15)(16).…”