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Ann Thorac Surg 2000;69:975
© 2000 The Society of Thoracic Surgeons
a Department of Cardiothoracic and Vascular Surgery, Hannover Medical School, Carl Neubury St, 30625 Hannover, Germany
b Department of Cardiac and Vascular Surgery, University of Kiel, Arnold Heller St, D-24105 Kiel, Germany
c Thorax Center, University Hospital Groningen, Hanzeplein, 9713 EZ Groningen, The Netherlands
e-mail: th.wittwer-md{at}t-online.de
To the Editor
Minimally invasive direct coronary artery bypass (MIDCAB) grafting of the left anterior descending coronary artery (LAD) to anterior vessels without cardiopulmonary bypass (CPB) has become a successful treatment in single-vessel disease [1, 2]. However, because of limited access through the anterior minithoracotomy, this approach fails for multivessel revascularization without additional incisions or use of CPB. To expand the benefits of MIDCAB approaches to patients with multivessel disease, a "hybrid" procedure combining surgical LAD revascularization with percutaneous transluminal coronary angioplasty (PTCA) for additional coronary lesions is considered to be an attractive therapeutic option for a subgroup of coronary patients [3, 4]. Assuming that the overall acceptance of this hybrid concept depends primarily on its long-term efficacy, we present our intermediate results after 1 year follow-up.
Between December 1996 and April 1999, 29 men and 6 women (mean age, 56.7 ± 17 years) underwent MIDCAB grafting (left internal mammary artery [LIMA]-LAD) because of LAD culprit lesions not amenable to PTCA, followed by angioplasty of 41 and stenting of 14 additional lesions in the remaining coronary regions. Five patients presented with left ventricular ejection fraction (LV-EF) between 30% and 50%; 3 patients had an LVEF less than 30%. The distribution pattern of one-, two-, and three-vessel disease was 4, 21, and 10, respectively. Previous myocardial infarctions were recorded in 16 patients. Comorbidities included chronic obstructive pulmonary disease (n = 3), diabetes (n = 8), chronic renal failure (dialysis, n = 1), history of stroke (n = 2), hyperthyroidism (n = 2), deep vein thrombosis (n = 1), and malignant melanoma (n = 1).
The degree of revascularization achieved perioperatively was "anatomically complete" in 25 patients (71.4%) and "anatomically incomplete but functionally adequate" in 10 patients (28.6%). Angiography at time of intervention after a median of 7 days postoperatively revealed patent grafts without anastomotic stenosis, kinking, dissection, or competitive bypass flow in all patients. Procedure-related complications did not occur, and immediate relief of symptoms was 100% during the mean hospital stay of 7 ± 4 days.
At a mean interval of 11.4 ± 7.7 months postoperatively, all patients are alive. Follow-up information was obtained at the time of control coronary angiography (n = 15). The remaining patients refused the angiographic examination because of absence of symptoms and were reexamined as outpatients. Two patients with moderate angina required re-PTCA because of new lesions in previously regular coronary arteries. One patient (6.7%) presented asymptomatically with a subtotal restenosis in the right coronary artery after PTCA. All other patients were angina-free without acute ischemia on stress electrocardiographic examination. Angiographically, 100% of the LIMAs and 93.3% of the PTCAs were found to be patent.
The hybrid approach of myocardial revascularization appears to be safe and effective in complete or at least near-complete revascularization of multivessel coronary disease. Subgroups of patients who might experience special benefit include the elderly and reoperative patients with intensive comorbidity and a high risk constellation for CPB with midsternotomy. Also younger patients with aggressive disease in which further coronary revascularization seems likely may benefit from a hybrid procedure. Detailed evaluation in larger randomized multicenter studies is warranted to document the long-term effectiveness of hybrid revascularization compared with conventional CAB grafting or interventional therapy alone.
References
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