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Department of Cardiac Surgery, Heart Center Leipzig, Leipzig, Germany
Accepted for publication August 13, 2008.
* Address correspondence to Dr Holzhey, Herzzentrum Leipzig, Strümpellstrabe 39, Leipzig, 04289, Germany (Email: dholzhey{at}web.de).
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Abstract |
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Methods: From 1996 to 2007, revascularization of the left anterior descending artery was performed in 1,696 patients by minimally invasive direct coronary artery bypass grafting (MIDCAB), in 89 patients by beating-heart totally endoscopic coronary artery bypass grafting (TECAB) and in 30 patients by arrested-heart TECAB. Of these patients, 117 were scheduled for a hybrid procedure. Revascularization of the left anterior descending artery was performed by either MIDCAB (107 patients), beating-heart TECAB (8 patients) or arrested-heart TECAB (2 patients). Percutaneous coronary intervention of vessels other than the left anterior descending artery was performed 4 to 6 weeks preoperatively (53 cases), intraoperatively (5 cases), or 2 to 45 days postoperatively (59 cases). Demographic data, perioperative outcome, and annual follow-up were obtained from all patients.
Results: Minimally invasive bypass and stenting could be completed in all patients. Two high-risk patients (1.9%) died postoperatively. Follow-up of all patients adds up to 208 patient-years. Eight patients died during follow-up. Kaplan-Meier survival was 92.5% (95% confidence interval [CI]: 86.5% to 98.4%) at 1 year and 84.8% (95% CI: 73.5% to 94.9%) at 5 years. Follow-up angiogram of symptomatic patients showed 1 bypass occlusion and 5 in-stent restenosis with need for reintervention. Freedom from major adverse cardiac and cerebral events (including reintervention) and angina was 85.5% (95% CI: 76.9% to 94.1%) at 1 year and 75.5% (95% CI: 62.7% to 87.3%) at 5 years.
Conclusions: Minimally invasive hybrid coronary revascularization is a safe approach with good long-term results. It should be performed in selected patients at centers with considerable experience in minimally invasive bypass surgery and requires close cooperation between cardiologists and surgeons.
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Introduction |
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In a recent summary, Friedrich and Bonatti [3] reviewed the results of 18 previously published studies of hybrid procedures with a total number of 367 patients. They also summarized the potential advantages and strategic considerations of preoperative, intraoperative, and postoperative percutaneous coronary intervention (PCI). Several smaller and larger series of different hybrid approaches have proven the feasibility and safety of this collaborative approach [4–9]. Here we report the short- and long-term results of a minimally invasive hybrid approach as first described by Angelini and colleagues [10] in 1996.
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Patients and Methods |
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TopAbstractIntroductionPatients and MethodsResultsCommentReferences |
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Demographic and perioperative data of all patients were collected retrospectively until 2002 and prospectively from then on. All bypass grafts were checked for patency in patients undergoing intraoperative or postoperative PCI. Follow-up data (major adverse cardiac and cerebral events and freedom from angina) were collected annually by postal or telephone contact. Follow-up angiograms were not routinely obtained except for 23 symptomatic patients.
Indication for the Hybrid Approach
Current recommendations for coronary artery revascularization do not include hybrid procedures, owing to limited availability of outcome data and a lack of randomized trials. Thus, choosing a hybrid approach is usually based on an individual decision. In all cases, the patients with multivessel disease including the LAD were informed that the best evidence-based treatment was a standard CABG procedure. Patients who then reconsidered were excluded from this analysis. The different reasons for using a hybrid approach can be summarized as follows.
Rescue PCI of circumflex artery/right coronary artery
A number of patients with unstable angina due to a culprit lesion in the circumflex artery or right coronary artery and additional stenosis of the LAD underwent primary PCI of the culprit lesion by the referring cardiologist. Accordingly, a MIDCAB procedure was then scheduled 4 to 6weeks later. In these patients, the result of the stent was controlled before surgery. In the presence of in-stent restenosis, the patient was rescheduled for a standard bypass procedure and excluded from further analysis.
Patient preference
Some well-informed patients wanted to avoid sternotomy and opted for a hybrid approach. Patients were informed that they might require future reinterventions, including repeat target vessel revascularization or bypass surgery. This group includes a number of patients with left main stenosis, and the MIDCAB procedure served to protect PCI of the left main stem. This is, in general, not our policy but was performed upon request of the patient and the referring cardiologist.
Multimorbid or high-risk patients
These are probably the best accepted indications and include patients with a high risk for sternotomy-associated problems such as mediastinitis or with reduced life expectancy. This group was the largest in this series and included patients with malignancies, redo patients with a history of deep sternal wound infections, patients dependent on crutches or wheel chair with additional risk factors such as diabetes mellitus, severe obesity, chronic obstructive pulmonary disease, end-stage peripheral occlusive disease, and history of stroke with paraplegia.
Operative Technique
All patients were operated on while taking acetyl salicylic acid (100 mg per day). Clopidogrel was discontinued 3 days preoperatively unless patients had received a drug-eluting stent or bare-metal stent preceding the MIDCAB by less than 4 weeks.
The MIDCAB procedure was performed through a 5- to 6-cm anterolateral muscle-sparing minithoracotomy. Take-down of the left internal thoracic artery and sewing of the anastomoses were performed under direct vision. A standard reusable pressure stabilizer was used. Proximal LAD occlusion was performed using a 4-0 felt-pledgeted suture. Preconditioning was not applied. Distal occlusion was avoided whenever possible. No intracoronary shunts were used.
The TECAB operation was performed using the da Vinci System (Intuitive Surgical, Sunnyvale, CA). Three left-sided ports were used for inserting a camera and two tools mounted on the patient-side telemanipulator. Endoscopic LIMA harvest was performed. The pericardium was opened, and the LAD identified. For arrested-heart TECAB, cardiopulmonary bypass was started after arterial and venous cannulation of the femoral arteries. A Heartport canula (Heartport, Redwood City, CA) was used to occlude the aorta and give cardioplegia. For beating-heart TECAB, an additional port was inserted subxiphoidally for placement of an endoscopic stabilizer with integrated irrigation of the anastomotic site. The LIMA-to-LAD anastomosis was completed endoscopically on the arrested or stabilized heart.
The 5 patients who received intraoperative stenting were transferred to the angiography laboratory while still under general anesthesia immediately after completing MIDCAB or TECAB (a hybrid suite was then not available). The LIMA-to-LAD bypass graft patency was confirmed, and PCI/stenting successfully completed the hybrid procedure in all these patients.
Patients who were scheduled for postoperative stenting typically received PCI 1 to 3 days after surgery. Longer intervals, as long as 6 weeks, arose for those patients who had been referred by residential cardiologists and usually had PCI after complete recovery from the operation by their referring cardiologist.
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Results |
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Two high-risk patients (logistic EUROScore, 18% and 21%) died postoperatively. One had acute thombosis of the circumflex artery before scheduled stenting and died of low cardiac output. The second patient died 32 days after surgery of pulmonary embolism (seen on autopsy).
One beating-heart TECAB patient needed revision of a partially obstructed anastomosis through a minithoracotomy on the beating heart. One patient had acute stent thrombosis of a right coronary artery stent; repeat PCI was unsuccessful, and the patient was brought back to the operating room under cardiopulmonary resuscitation during which the LIMA was torn off. The patient received two vein grafts, survived, and was discharged 30 days postoperatively. Six patients needed reexploration for bleeding. No further severe complications occurred. Other problems in the postoperative course are summarized in Table 3.
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Comment |
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TopAbstractIntroductionPatients and MethodsResultsCommentReferences |
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The choice of treatment strategy to achieve complete revascularization is still controversially discussed [14]. While some recent registries see an advantage for CABG in multivessel disease involving the LAD [15], the results of more meaningful randomized studies such as the SYNTAX (Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery) trial [16] are still pending.
The hybrid approach seeks to combine the advantages of PCI and minimally invasive CABG, providing the benefits of proven long-term patency of a LIMA-to-LAD graft. Long-term results of stent grafting to the circumflex artery and right coronary artery territories equals vein graft patency, albeit with a higher risk for potential target vessel reintervention.
In accordance with the literature [8], we consider complete arterial revascularization as the optimal revascularization strategy for multivessel coronary artery disease. However, a patent LIMA-to-LAD bypass graft is undoubtfully the single most important factor to improve long-term survival, freedom from angina, and quality of life in patients with coronary artery disease [15]. A hybrid approach offering a LIMA-to-LAD graft avoiding sternotomy may therefore be indicated for selected patients [17].
From our experience, the indications include unstable angina with the immediate need for PCI in a vessel other than the LAD and no prompt possibility for emergency surgical bypass grafting. In these patients, we usually perform MIDCAB/TECAB 4 to 6 weeks after the initial PCI. Before the operation, a routine angiogram should be performed to exclude in-stent restenosis at the time of surgery.
We also see the indication for hybrid procedures in high-risk patients with significant comorbidity, who benefit most from off-pump, no-touch bypass grafting, short operation times, and avoidance of sternotomy. These include, in particular, patients with malignancy, severe calcification of the aorta, prior chest irradiation, obesity plus severe diabetes mellitus, or dependence on crutches or wheel chair.
Some low-risk patients were referred for MIDCAB of a nonstentable LAD lesion and planned for PCI of a second non-LAD lesion afterward. The minimally invasive access and the very short recovery times are very attractive especially for some younger patients requesting hybrid therapy. However, it is mandatory to educate these patients on the potential benefits of total arterial revascularization [18–21].
Limitations
A clear limitation is that the study is retrospective in nature. All patients who received a hybrid procedure were included without specific inclusion or exclusion criteria, yielding a very heterogenic population that is not comparable to much better defined cohorts, such as in the ARTS trial [22]. Also, exclusion of the patients who were initially scheduled for a hybrid procedure, but eventually received multiple bypass grafting because of an in-stent restenosis seen in the angiogram before MIDCAB, may have created a bias. Follow-up angiograms were only performed in symptomatic patients; therefore, no patency data are available. The follow-up periods vary given the long inclusion interval.
Conclusion
From the results presented here, we conclude that minimally invasive hybrid coronary revascularization is a safe approach with acceptable long-term results. It should be offered to patients with a high perioperative risk with sternotomy. Considerable experience in minimally invasive bypass surgery and close cooperation between cardiologists and surgeons are mandatory to ensure the optimal revascularization strategy on an individual basis.
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Related Article
This article has been cited by other articles:
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  W. J. Gomes Hybrid coronary artery revascularization: an evidence-based analysis. Ann. Thorac. Surg., September 1, 2009; 88(3): 1047 - 1047. [Full Text] [PDF]
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D. Holzhey Reply Ann. Thorac. Surg., September 1, 2009; 88(3): 1047 - 1048. [Full Text] [PDF]
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T. Albacker Invited Commentary Ann. Thorac. Surg., December 1, 2008; 86(6): 1860 - 1860. [Full Text] [PDF]
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