Hybrid coronary revascularization

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Hybrid coronary revascularization
Other namesHybrid coronary bypass
Specialty cardiology

Hybrid coronary revascularization (HCR) or hybrid coronary bypass is a relatively new type of heart surgery that provides an alternative to traditional coronary artery bypass surgery (CABG) or percutaneous coronary intervention (PCI or PTCA) by combining the two into one operation. It is this combining aspect that "hybrid" refers to. HCR is one of several types of hybrid cardiac surgery; it is not to be confused with a MIDCAB (minimally invasive direct coronary artery bypass) procedure, which uses the smaller thoracotomy incision but does not involve coronary stenting. [1]

Contents

Benefits

Hybrid bypass offers all the benefits of a MIDCAB, although there are some disadvantages.

  1. A much smaller incision (made through the rib cage as opposed to cutting the sternum and opening the rib cage) than with traditional bypass surgery.
  2. Less pain for the patient and quicker recovery time. Particularly in high risk patients, morbidity and mortality decreases in comparison to conventional surgery. [2] [3] A study from FuWai Hospital in Beijing [4] reports on 104 patients with multivessel coronary artery disease who were compared with the same sized group of patients undergoing off pump surgery using propensity score matching. The patients treated with the hybrid approach had a significantly lower ICU stay and intubation time and experienced less complications in terms of bleeding and transfusions needs. At a median follow up of 18 months, patients undergoing the hybrid procedure also had a significantly higher freedom from major adverse cardiac or cerebrovascular events (99% vs. 90.4%; p = 0.03).[ citation needed ] HCR is also associated with a significant decrease in the need for blood transfusion and a significant reduction in the duration of intubation. [5]
  3. Less risk of complications, infections etc. and also decreases the necessity for two separate cardiac procedures (bypass and stenting). [1] However, it requires the implementation of suitable X-ray equipment in the OR, i.e. a hybrid operating room. Helpful in this regard is the regular use of completion angiography. In a study designed and published by the Vanderbilt Heart and Vascular Institute, [6] routine intraoperative completion angiography performed in a fully functional hybrid operation room detected important defects in 97 of 796 (12% of the grafts) venous coronary artery bypass grafts in 366 adult patients (14% of the patients) with complex coronary artery disease. Their findings in completion angiography at the end of the operation included suboptimal anastomoses, poor lie of the venous bypass graft, and bypasses to not diseased vessels. The angiography findings led to a change in the management, including minor adjustments of the graft, traditional surgical revision or percutaneous coronary interventions, resulting in optimal bypass outcomes. However, early perioperative angiography is not recommended nor it is a standard practice; therefore, in the case of suspected early postoperative myocardial ischemia, immediate angiography should be performed to verify patency of the grafts. [7]
  4. In the study from FuWai, the hybrid procedure was also less costly than an exclusively percutaneous strategy. [4]

A 2018 Meta Analysis with over 4000 patient cases found HCR to have significant advantages compared with conventional CABG. Reduced incidence of Blood Transfusion, reduced hospital stay duration and reduced intubation duration were all reported. In contrast, HCR was found to be significantly more expensive compared to CABG. [8] However, 2018 guidelines recommend (Level 2B recommendation) that hybrid coronary revascularization may be considered in specific patient subsets at experienced centres. [9]

See also

Related Research Articles

<span class="mw-page-title-main">Angioplasty</span> Procedure to widen narrow arteries or veins

Angioplasty, also known as balloon angioplasty and percutaneous transluminal angioplasty (PTA), is a minimally invasive endovascular procedure used to widen narrowed or obstructed arteries or veins, typically to treat arterial atherosclerosis. A deflated balloon attached to a catheter is passed over a guide-wire into the narrowed vessel and then inflated to a fixed size. The balloon forces expansion of the blood vessel and the surrounding muscular wall, allowing an improved blood flow. A stent may be inserted at the time of ballooning to ensure the vessel remains open, and the balloon is then deflated and withdrawn. Angioplasty has come to include all manner of vascular interventions that are typically performed percutaneously.

<span class="mw-page-title-main">Coronary artery bypass surgery</span> Surgical procedure to restore normal blood flow to an obstructed coronary artery

Coronary artery bypass surgery, also known as coronary artery bypass graft, is a surgical procedure to treat coronary artery disease (CAD), the buildup of plaques in the arteries of the heart. It can relieve chest pain caused by CAD, slow the progression of CAD, and increase life expectancy. It aims to bypass narrowings in heart arteries by using arteries or veins harvested from other parts of the body, thus restoring adequate blood supply to the previously ischemic heart.

<span class="mw-page-title-main">Interventional cardiology</span>

Interventional cardiology is a branch of cardiology that deals specifically with the catheter based treatment of structural heart diseases. Andreas Gruentzig is considered the father of interventional cardiology after the development of angioplasty by interventional radiologist Charles Dotter.

<span class="mw-page-title-main">Percutaneous coronary intervention</span> Medical techniques used to manage coronary occlusion

Percutaneous coronary intervention (PCI) is a minimally invasive non-surgical procedure used to treat narrowing of the coronary arteries of the heart found in coronary artery disease. The procedure is used to place and deploy coronary stents, a permanent wire-meshed tube, to open narrowed coronary arteries. PCI is considered 'non-surgical' as it uses a small hole in a peripheral artery (leg/arm) to gain access to the arterial system, an equivalent surgical procedure would involve the opening of the chest wall to gain access to the heart area. The term 'coronary angioplasty with stent' is synonymous with PCI. The procedure visualises the blood vessels via fluoroscopic imaging and contrast dyes. PCI is performed by an interventional cardiologists in a catheterization laboratory setting.

<span class="mw-page-title-main">Drug-eluting stent</span> Medical stent that releases drug

A drug-eluting stent (DES) is a thin tube that is used to treat narrowed arteries in medical procedures. It releases drugs to prevent the growth of scar tissue and reduce the risk of stent restenosis, which is the narrowing of the stented area of an artery after treatment. A drug-eluting stent is different from other types of stents because it has a coating that delivers medication directly to the arterial wall. A DES is often made of metal alloys and can be inserted into blocked or narrowed arteries through a catheter placed in a peripheral artery, such as in the arm or leg. DES is fully integrated with a catheter delivery system and is viewed as one integrated medical device.

Minimally invasive direct coronary artery bypass (MIDCAB) is a surgical treatment for coronary heart disease that is a less invasive method of coronary artery bypass surgery (CABG). MIDCAB gains surgical access to the heart with a smaller incision than other types of CABG. MIDCAB is sometimes referred to as "keyhole" heart surgery because the operation is analogous to operating through a keyhole.

Postperfusion syndrome, also known as "pumphead", is a constellation of neurocognitive impairments attributed to cardiopulmonary bypass (CPB) during cardiac surgery. Symptoms of postperfusion syndrome are subtle and include defects associated with attention, concentration, short-term memory, fine motor function, and speed of mental and motor responses. Studies have shown a high incidence of neurocognitive deficit soon after surgery, but the deficits are often transient with no permanent neurological impairment.

The history of invasive and interventional cardiology is complex, with multiple groups working independently on similar technologies. Invasive and interventional cardiology is currently closely associated with cardiologists, though the development and most of its early research and procedures were performed by diagnostic and interventional radiologists.

<span class="mw-page-title-main">Endovascular aneurysm repair</span> Surgery used to treat abdominal aortic aneurysm

Endovascular aneurysm repair (EVAR) is a type of minimally-invasive endovascular surgery used to treat pathology of the aorta, most commonly an abdominal aortic aneurysm (AAA). When used to treat thoracic aortic disease, the procedure is then specifically termed TEVAR for "thoracic endovascular aortic/aneurysm repair." EVAR involves the placement of an expandable stent graft within the aorta to treat aortic disease without operating directly on the aorta. In 2003, EVAR surpassed open aortic surgery as the most common technique for repair of AAA, and in 2010, EVAR accounted for 78% of all intact AAA repair in the United States.

<span class="mw-page-title-main">Off-pump coronary artery bypass</span>

Off-pump coronary artery bypass or "beating heart" surgery is a form of coronary artery bypass graft (CABG) surgery performed without cardiopulmonary bypass as a treatment for coronary heart disease. It was primarily developed in the early 1990s by Dr. Amano Atsushi. Historically, during bypass surgeries, the heart is stopped and a heart-lung machine takes over the work of the heart and lungs. When a cardiac surgeon chooses to perform the CABG procedure off-pump, also known as OPCAB, the heart is still beating while the graft attachments are made to bypass a blockage.

<span class="mw-page-title-main">Coronary stent</span> Medical stent implanted into coronary arteries

A coronary stent is a tube-shaped device placed in the coronary arteries that supply blood to the heart, to keep the arteries open in patients suffering from coronary heart disease. The vast majority of stents used in modern interventional cardiology are drug-eluting stents (DES) It is used in a medical procedure called percutaneous coronary intervention (PCI). Coronary stents are divided into two broad types - drug-eluting and bare metal stents, as of 2023 drug-eluting stents were used in more than 90% of all PCI procedures. Stents reduce angina and have been shown to improve survival and decrease adverse events after a patient has suffered a heart attack - medically termed an acute myocardial infarction.

<span class="mw-page-title-main">Coronary ischemia</span> Medical condition

Coronary ischemia, myocardial ischemia, or cardiac ischemia, is a medical term for a reduced blood flow in the coronary circulation through the coronary arteries. Coronary ischemia is linked to heart disease, and heart attacks. Coronary arteries deliver oxygen-rich blood to the heart muscle. Reduced blood flow to the heart associated with coronary ischemia can result in inadequate oxygen supply to the heart muscle. When oxygen supply to the heart is unable to keep up with oxygen demand from the muscle, the result is the characteristic symptoms of coronary ischemia, the most common of which is chest pain. Chest pain due to coronary ischemia commonly radiates to the arm or neck. Certain individuals such as women, diabetics, and the elderly may present with more varied symptoms. If blood flow through the coronary arteries is stopped completely, cardiac muscle cells may die, known as a myocardial infarction, or heart attack.

Minimally invasive cardiac surgery, also known as MICS CABG or the McGinn technique is heart surgery performed through several small incisions instead of the traditional open-heart surgery that requires a median sternotomy approach. MICS CABG is a beating-heart multi-vessel procedure performed under direct vision through an anterolateral mini-thoracotomy.

Vessel harvesting is a surgical technique that may be used in conjunction with a coronary artery bypass graft (CABG). For patients with coronary artery disease, a physician may recommend a bypass to reroute blood around blocked arteries to restore and improve blood flow and oxygen to the heart. To create the bypass graft, a surgeon will remove or "harvest" healthy blood vessels from another part of the body, often from the patient's leg or arm. This vessel becomes a graft, with one end attaching to a blood source above and the other end below the blocked area, creating a "conduit" channel or new blood flow connection across the heart.

<span class="mw-page-title-main">Reperfusion therapy</span> Restoring blood flow post-heart attack

Reperfusion therapy is a medical treatment to restore blood flow, either through or around, blocked arteries, typically after a heart attack. Reperfusion therapy includes drugs and surgery. The drugs are thrombolytics and fibrinolytics used in a process called thrombolysis. Surgeries performed may be minimally-invasive endovascular procedures such as a percutaneous coronary intervention (PCI), which involves coronary angioplasty. The angioplasty uses the insertion of a balloon and/or stents to open up the artery. Other surgeries performed are the more invasive bypass surgeries that graft arteries around blockages.

<span class="mw-page-title-main">Hybrid cardiac surgery</span>

A hybrid cardiac surgical procedure in a narrow sense is defined as a procedure that combines a conventional, more invasive surgical part with an interventional part, using some sort of catheter-based procedure guided by fluoroscopy imaging in a hybrid operating room (OR) without interruption. The hybrid technique has a reduced risk of surgical complications and has shown decreased recovery time. It can be used to treat numerous heart diseases and conditions and with the increasing complexity of each case, the hybrid surgical technique is becoming more common.

In medicine, vein graft failure (VGF) is a condition in which vein grafts, which are used as alternative conduits in bypass surgeries, get occluded.

John D. Puskas is an American researcher, author, inventor and cardiovascular surgeon. As of 2022, he is Professor, Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, and chairman, Department of Cardiovascular Surgery at Mount Sinai Morningside, Mount Sinai Beth Israel and Mount Sinai West. He holds 11 U.S. patents and co-founded the International Coronary Congress and the International Society for Coronary Artery Surgery. He is credited by ResearchGate with 330 publications and 15,234 citations and as of 2022 Scopus reports an h-index of 62. Puskas is known for advancing coronary artery bypass (CABG) surgery by refining surgical techniques for all-arterial, off-pump CABG and inventing finer instruments to be used for advanced coronary bypass surgical procedures. He is credited with performing the first totally thoracoscopic bilateral pulmonary vein isolation procedure. He is the co-editor of State of the Art Surgical Coronary Revascularization, the first textbook solely devoted to coronary artery surgery.

Mario F.L. Gaudino, MD, PhD, MSCE, FEBCTS, FACC, FAHA is an Italian cardiothoracic surgeon who is the Stephen and Suzanne Weiss Professor in Cardiothoracic Surgery (II) and Professor of Clinical Epidemiology and Health Services Research at Weill Cornell Medicine and an attending cardiac surgeon at NewYork-Presbyterian Hospital and Weill Cornell Medical Center. He is an expert in coronary revascularization and clinical trialist. He is known for conducting the PALACS trial, which demonstrated that posterior pericardiotomy at the time of cardiac surgery reduced the incidence of post-operative atrial fibrillation and pericardial effusion.

Alfredo E. Rodríguez is an Argentine interventional cardiologist, clinical researcher, and author. He is the Chief of Interventional Cardiology Service at Otamendi Hospital and Director and Founder of the Cardiovascular Research Center (CECI) a non -profit Research Organization in Buenos Aires Argentina.

References

  1. 1 2 Murphy, Gavin J; Bryan, Alan J; Angelini, Gianni D (2004). "Hybrid Coronary Revascularization in the Era of Drug-Eluting Stents". The Annals of Thoracic Surgery. 78 (5): 1861–7. doi:10.1016/j.athoracsur.2004.07.024. PMID   15511503.
  2. ↑ Kon, Zachary N; Brown, Emile N; Tran, Richard; Joshi, Ashish; Reicher, Barry; Grant, Michael C; Kallam, Seeta; Burris, Nicholas; Connerney, Ingrid; Zimrin, David; Poston, Robert S (2008). "Simultaneous hybrid coronary revascularization reduces postoperative morbidity compared with results from conventional off-pump coronary artery bypass". The Journal of Thoracic and Cardiovascular Surgery. 135 (2): 367–75. doi:10.1016/j.jtcvs.2007.09.025. PMC   2962576 . PMID   18242270.
  3. ↑ Bonatti, J; Schachner, T; Bonaros, N; Jonetzko, P; Ohlinger, A; Ruetzler, E; Kolbitsch, C; Feuchtner, G; Laufer, G; Pachinger, O; Friedrich, G (2008). "Simultaneous hybrid coronary revascularization using totally endoscopic left internal mammary artery bypass grafting and placement of rapamycin eluting stents in the same interventional session. The COMBINATION pilot study". Cardiology. 110 (2): 92–5. doi:10.1159/000110486. PMID   17971657. S2CID   32152844.
  4. 1 2 Hu, Shengshou; Li, Qi; Gao, Peixian; Xiong, Hui; Zheng, Zhe; Li, Lihuan; Xu, Bo; Gao, Runlin (2011). "Simultaneous Hybrid Revascularization Versus Off-Pump Coronary Artery Bypass for Multivessel Coronary Artery Disease". The Annals of Thoracic Surgery. 91 (2): 432–8. doi:10.1016/j.athoracsur.2010.10.020. PMID   21256284.
  5. ↑ Reynolds, AC; King, N (August 2018). "Hybrid coronary revascularization versus conventional coronary artery bypass grafting: Systematic review and meta-analysis". Medicine (Baltimore). 97 (33): e11941. doi:10.1097/MD.0000000000011941. PMC   6112891 . PMID   30113498.
  6. ↑ Zhao, David X; Leacche, Marzia; Balaguer, Jorge M; Boudoulas, Konstantinos D; Damp, Julie A; Greelish, James P; Byrne, John G (2009). "Routine Intraoperative Completion Angiography After Coronary Artery Bypass Grafting and 1-Stop Hybrid Revascularization". Journal of the American College of Cardiology. 53 (3): 232–41. doi:10.1016/j.jacc.2008.10.011. PMID   19147039. S2CID   39700219.
  7. ↑ Robinson, NB; Sef, D; Gaudino, M; Taggart, DP (February 2023). "Postcardiac surgery myocardial ischemia: Why, when, and how to intervene". The Journal of Thoracic and Cardiovascular Surgery. 165 (2): 687–695. doi: 10.1016/j.jtcvs.2021.05.052 . PMID   34556355.
  8. ↑ Reynolds AC, King N. (2018) Hybrid coronary revascularization versus conventional coronary artery bypass grafting: Systematic review and meta-analysis. Medicine (Baltimore). 2018 Aug;97(33):e11941
  9. ↑ Sousa-Uva, M; Neumann, FJ; Ahlsson, A; Alfonso, F; Banning, AP; Benedetto, U; Byrne, RA; Collet, JP; Falk, V; Head, SJ; Jüni, P; Kastrati, A; Koller, A; Kristensen, SD; Niebauer, J; Richter, DJ; Seferovic, PM; Sibbing, D; Stefanini, GG; Windecker, S; Yadav, R; Zembala, MO; ESC Scientific Document, Group (1 January 2019). "2018 ESC/EACTS Guidelines on myocardial revascularization". European Journal of Cardio-thoracic Surgery : Official Journal of the European Association for Cardio-thoracic Surgery. 55 (1): 4–90. doi: 10.1093/ejcts/ezy289 . PMID   30165632.
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