Hybrid Coronary Revascularization

Abstract

A dvancement in technique and technology over the past 2 decades has helped improve clinical outcomes in both surgical and interventional percutaneous coronary revascularization. Hybrid coronary revascularization (HCR) procedures introduced in 2011 by the American Heart Association/ American College of Cardiology Foundation updated guidelines for coronary artery bypass grafting (CABG) surgery, 1 combine the superiority of the left internal mammary artery (LIMA) to the left anterior descending artery (LAD) revascularization 2,3 with percutaneous coronary intervention (PCI) by means of drug-eluting stents (DES) for non-LAD vessels. 4Various minimally invasive surgical approaches are used to perform the LIMA to LAD graft. These approaches and techniques include off-pump coronary revascularization, robotically assisted procedures, small left thoracotomy, and partial sternotomy. Article see p 872In the current issue of Circulation, Harskamp and colleagues 5 describe contemporary practice patterns and clinical outcomes after hybrid coronary artery revascularization in the United States. Isolated CABG in patients who underwent HCR in the Society of Thoracic Surgeons Adult Database between July 2011 and March 2013 were the subject of the study. The authors found only 0.48% (n=950) of 198 622 CABG patients had HCR with 809 of 950 patients (85%) having a staged procedure, whereas a small number of patients (141 of 950; 15%) had HCR done concurrently. Only one third of the centers performing CABG procedures participated in the HCR cohort.Patients with HCR had higher cardiovascular risk profiles than CABG patients, whereas CABG patients had more complex coronary anatomy. HCR patients had more off-pump procedures performed and more nonsternotomy approaches. HCR patients also had a higher incidence of robotic assistance. Overall, outcomes were similar between the groups for the composite of in-hospital mortality and major morbidity.The concept of HCR was introduced by Angelini and colleagues 6 in 1996 by performing a minimally invasive thoracotomy LIMA-LAD anastomosis and balloon angioplasty of the non-LAD vessels. Since then, implementation of this procedure has been limited because of the complexity and learning curve of the surgical techniques and suboptimal results of bare-metal stenting compared with surgical revascularization. With the introduction of DES and the decreased rate of stent restenosis, HCR has reemerged as an alternative to conventional surgical revascularization in high-risk patients. In recent years, several institutional series have confirmed that HCR can be accomplished safely with low operative mortality (<2%) and low morbidity. Thus, is HCR the future in coronary revascularization? The results from the practice patterns in the United States described by Harskamp et al 5 warrant caution. The learning curve, the financial and time commitment, and the need for a hybrid operating room create stringent requirements that many programs will not be able to support. In addition, the clinical benefit of HCR ove...

Hybrid Revascularization: A Review

“…PCI using newer everolimus stents in patients with low to intermediate angiographic risk scores is noninferior to CABG with similar rates of death, myocardial infarction (MI), and stroke at 3 years [22]. Although newer-generation DES have decreased risks of thrombosis and restenosis, the need for target vessel revascularization remains a concern for patients undergoing a hybrid procedure [3, 5]. Similarly, repeat revascularization was higher in HCR than standard CABG due to disease in non-LAD locations (3.8% HCR vs. 1.4% CABG after 1 year) [3].…”

“…With PCI already performed, angiographic confirmation is also not readily available should any complications arise from the PCI or surgery [5]. Interruption of DAPT prior to surgery is associated with an increased risk of stent thrombosis [25].…”

“…Interruption of DAPT prior to surgery is associated with an increased risk of stent thrombosis [25]. Regardless of which is performed first, the disadvantages of a staged procedure include having 2 teams, 2 handoffs, and a longer length of stay [5]. …”

“…The hybrid approach takes advantage of the best features of percutaneous and surgical revascularization approaches. The volume of hybrid coronary revascularization in the US comprises only 0.5% of the volume of CABG operations [5]. However, because of the efficacy of newer generation stents, combined with more sophisticated simplified surgical techniques, the volume of hybrid procedures is expected to increase [1, 5, 6].…”

The curative effect of synthetic treatment for refractory acute myocardial infarction

“…Intraoperative or postoperative IABP can improve the therapeutic effect. For AMI patients in whom the culprit vessel is not LAD, when severe stenosis occurs in the LAD after a successful emergency PCI, multi-stop hybrid cardiac surgery with minimally invasive bypass grafting can improve its long-term curative effects (8,9).From a developmental perspective, the authors consider that hybrid cardiac surgery for AMI would likely to be one of the important treatments for AMI in the future. …”