Hybrid coronary revascularization: which patients? when? how?

Hybrid coronary revascularization (HCR) versus coronary artery bypass grafting (CABG) in multivessel coronary artery disease (MVCAD): A meta-analysis of 14 studies comprising 4226 patients

OBJECTIVES

To compare the outcomes of hybrid coronary revascularization (HCR) with traditional coronary artery bypass grafting (CABG) in multivessel coronary artery disease (MVCAD).

BACKGROUND

HCR has emerged as an alternative to CABG in patients with MVCAD. Through minimally invasive surgical techniques, HCR carries the potential for faster recovery postoperatively, fewer complications, and lower utilization of resources.

METHODS

Systematic search of electronic databases was conducted up to December 2021 and studies comparing HCR with CABG in the treatment of MVCAD were included in this meta-analysis. Primary outcomes of interest were incidence of 5-year mortality and major adverse cardiac and cerebral event (MACCE).

RESULTS

Fourteen studies (12 observational studies and 2 randomized controlled trials) comprising 4226 patients were included. The rates of 5-year mortality (odds ratios [OR]: 1.55; 95% confidence interval [CI]: 0.92-2.62; I²  = 83.0%) and long-term MACCE (OR: 0.97; 95% CI: 0.47-2.01; I²  = 74.7%) were comparable between HCR and CABG groups. HCR was associated with a significantly lower likelihood of perioperative blood transfusion (OR: 0.36; 95% CI: 0.25-0.51; I²  = 55.9%), shorter mean hospital stay (weighted mean difference: -2.04; 95% CI: -2.60 to -1.47; I²  = 54%), and risk of postoperative acute kidney injury (OR: 0.45; 95% CI: 0.23-0.88; p = 0.02). CABG demonstrated a lower likelihood of requiring long-term repeat revascularization (OR: 1.51; 95% CI: 1.03-2.20; I²  = 18%) over a follow-up duration of 29.14 ± 21.75 months.

CONCLUSION

This meta-analysis suggests that HCR is feasible and safe for the treatment of MVCAD. However, benefits of HCR should be carefully weighed against the increased long-term risk of repeat-revascularization when selecting patients, and further studies evaluating differences in long-term mortality between HCR and CABG are required.

One-stage hybrid coronary revascularization for the treatment of multivessel coronary artery disease— Periprocedural and long-term results from the “HYBRID-COR” feasibility study

Background

The constant growth of interest in hybrid coronary artery revascularization (HCR) is apparent. Yet, few studies report outcomes of the one-stage HCR. Consequently, the status of such procedures is not adequately supported in clinical guidelines. The aim of this study was to report the safety, feasibility, and long term-outcomes of the one-stage HCR.

Methods and results

Patients were enrolled in the prospective one-stage hybrid coronary revascularization program (HYBRID-COR). They underwent a one-stage hybrid revascularization procedure while on double antiplatelet therapy (DAPT) with Ticagrelor: endoscopic atraumatic coronary artery bypass grafting (EACAB) for revascularization of the left anterior descending (LAD) artery and percutaneous intervention in non-LAD arteries with contemporary drug-eluting stents. The composite primary endpoint included MACCE (major adverse cardiac and cerebrovascular events: death, myocardial infarction, stroke, and repeated revascularization) in long-term observation. The study cohort consisted of 30 patients (68% male) with stable coronary artery disease (26.7%) and unstable angina (73.3%). Procedural success was 100%. No death, myocardial infarction (MI), or stroke were observed in the perioperative period. One patient (3.3%) required chest revision and blood transfusion due to surgical bleeding. Kidney injury was noted in two patients (6.6%). In a long-term follow-up (median; IQR: 4.25; 2.62–4.69 years), two patients (6.6%) underwent repeated revascularization and one patient (3.3%) died due to MI. The overall primary endpoint rate was 9.9%.

Conclusion

One-stage hybrid revascularization, on DAPT, is a feasible, safe, and efficient way of achieving complete revascularization in selected patients. The complication rate is low and acceptable. Further randomized trials are required.

Hybrid coronary revascularization in multivessel coronary artery disease: a systematic review

Aim: Hybrid coronary revascularization (HCR) for multivessel coronary artery disease (CAD) integrates coronary artery bypass grafting (CABG) and percutaneous intervention in a planned revascularization strategy. This systematic review summarizes the state of this art of this technique. Methods: Major databases searched until October 2021. Results: The available literature on HCR includes three randomized trials, ten meta-analysis and 27 retrospective studies. The greatest benefits are observed in patients with low-to-intermediate risk and less complex coronary anatomy; highly complex disease and the presence of risk factors favored conventional CABG in terms of adverse events and survival. Conclusion: HCR is an interesting approach for multivessel CAD but should not be considered a 'one-size-fits-all' procedure. Further studies will specify the subset of patients likely to benefit most from this hybrid approach.

Emergent coordination and situated learning in a Hybrid OR: The mixed blessing of using radiation

Mobilising knowledge and coordinating actions in order to make use of new innovations and technologies is a major challenge in the health care sector. Drawing upon a longitudinal, qualitative study of a Hybrid Operating Room in Sweden, we illustrate how the staff from a variety of medical specialties need to coordinate their tasks and competencies, and learn how to use the technology in a safe way. This study shows that learning across highly-professionalized communities is a recursive process of emergent coordination and situated learning, which includes the acknowledgement of others' expertise, task interdependence, and the pragmatic accommodation of latitude and control. Moreover, there was continuous negotiations between the different communities about what should constitute approved practice based on the task being performed. This obstructed the development of a dominant community with the authority to independently exclude other communities. We thus conclude that emergent coordination of tasks and expertise is an important aspect of learning how to use technologies that break with conventions of established and previously separated practices.

Intraoperative transit-time flowmetry in patients undergoing coronary surgery to determine relationships between graft flow and patency and prior coronary interventions and flow demand: a retrospective study

Background

The aim of this study was to delineate impacts of percutaneous coronary intervention (PCI), flow demand, and status of myocardium on graft flow.

Methods

We retrospectively assessed 736 individual coronary artery bypass grafts that had been created as the sole bypass graft for a vascular region in 405 patients. The grafts comprised 334 internal thoracic artery (ITA) to left anterior descending (LAD), 129 ITA and 65 saphenous vein grafts (SVG) to left circumflex (LCX), and 142 gastroepiploic artery (GEA) and 66 SVG to right coronary artery (RCA). Minimal luminal diameter, size of revascularized area, history of myocardial infarction, and PCI in the relevant area were examined to determine whether these factors are associated with flow insufficiency (FI), which was defined as ≤ 20 mL/min.

Results

FI developed in 123/736 grafts (16.7%) and correlated significantly with stenosis in the distal portion (23.0% vs. 12.8%, p = 0.0003). Prior myocardial infarction significantly correlated with FI in GEA–RCA (p = 0.002) and ITA–LCX grafts (p = 0.04). There was a history of PCI to the LAD (PCI group) in 54 ITA to LAD bypass grafts (16.2%), whereas the remaining 280 had no history of PCI to the LAD (no-PCI group). Graft flow was significantly greater in the no-PCI than in the PCI group (53 ± 29 vs. 42 ± 27; p = 0.006). The incidences of FI and graft failure were significantly higher in the PCI than the no-PCI group (22.2%, vs. 8.2%; p = 0.003; 9.2% vs. 1.8%; p = 0.003, respectively).

Conclusions

Prior PCI has a negative impact on graft flow. The influences of small revascularized area, myocardial infarction, and PCI are greater, necessitating consideration of factors associated with flow demand or microvasculature when planning revascularization.

Robot-assisted cardiac surgery

Recognition of the significant advantages of minimizing surgical trauma has resulted in the development of minimally invasive surgical procedures. Endoscopic surgery offers patients the benefits of minimally invasive surgery, and surgical robots have enhanced the ability and precision of surgeons. Consequently, technological advances have facilitated totally endoscopic robotic cardiac surgery, which has allowed surgeons to operate endoscopically rather than through a median sternotomy during cardiac surgery. Thus, repairs for structural heart conditions, including mitral valve plasty, atrial septal defect closure, multivessel minimally invasive direct coronary artery bypass grafting (MIDCAB), and totally endoscopic coronary artery bypass graft surgery (CABG), can be totally endoscopic. Robot-assisted cardiac surgery as minimally invasive cardiac surgery is reviewed.

Robotically assisted hybrid coronary revascularization: does sequence of intervention matter?

OBJECTIVE

Hybrid coronary revascularization (HCR) is a treatment strategy for the revascularization of multivessel coronary disease that combines the advantages of both minimally invasive surgical techniques and percutaneous coronary intervention (PCI). The optimal sequence by which revascularization should be accomplished has not been determined. We investigated clinical outcomes in a series of patients planned for HCR via robotically assisted totally endoscopic coronary artery bypass (TECAB) and standard PCI based on revascularization sequence.

METHODS

A total of 238 patients planned for HCR between 2001 and 2011 were divided into three groups based on treatment sequence: (a) TECAB before PCI, (b) PCI before TECAB, and (c) same-session procedure. Multiple procedural and clinical end points before discharge and up to 2 years after the procedure were compared between the three groups in an intention-to-treat analysis. Demographic features were reviewed to determine baseline differences between each group.

RESULTS

Of the 238 patients, 175 (73.5%) underwent TECAB before PCI, 38 patients (16.0%) underwent PCI before TECAB, and 25 (10.5%) underwent a simultaneous revascularization procedure. At baseline, the patients undergoing TECAB before PCI were significantly older. There was a significantly higher incidence of previous myocardial infarction in the PCI-first group (P < 0.001). There was a significant difference in intensive care unit (ICU) length of stay (LOS), with shorter ICU stays in the simultaneous revascularization group (P = 0.031) and shorter hospital LOS in the PCI before TECAB group (P = 0.021).

CONCLUSIONS

In conclusion, revascularization sequence did not dramatically impact clinical outcomes in our observational study. The patients undergoing PCI-first and same-session interventions had shorter hospital and ICU LOS compared with the patients undergoing surgery first. Our findings suggest that no revascularization approach is arbitrarily superior and that revascularization sequence should be individualized on the basis of patient presentation and anatomical considerations.

Dual protection therapy with staged coronary artery bypass surgery and stenting in patients with left main coronary artery stenosis: long-term results from a single center

OBJECTIVE

We evaluated the efficacy and safety of dual protection therapy with staged coronary artery bypass grafting (CABG) and bare-metal stenting (BMS) in patients with left main coronary artery (LMCA) disease.

BACKGROUND

CABG is currently the preferred therapy for complex LMCA disease; however, the long-term patency rates of these grafts are unsatisfactory, and stenting alone for LMCA may be associated with the potentially fatal consequences of stent thrombosis or restenosis.

METHODS

Between January 1997 and October 2005, 42 patients underwent staged bypass surgery and BMS, with the latter procedure performed 2 weeks after the initial CABG. Of these patients, 40 received left internal mammary artery (LIMA) grafts, 34 saphenous vein grafts, 6 radial artery grafts, and 3 right IMA (RIMA) grafts. Minimally invasive bypass surgery was performed in 10 patients.

RESULTS

There were no operative complications. Forty-two stents were implanted in 42 lesions without complications. During the follow-up period of 135 ± 55 months, 1 patient died of cancer, 2 of cardiac causes, and 5 patients (12%) experienced target lesion revascularization. The target vessel failure rate was 24%. Forty patients (95%) underwent a 6-month angiographic follow-up. Restenosis was noted in 7 patients (18%). Reocclusion was also noted in 5 LIMA grafts, 5 saphenous vein grafts, 1 radial artery graft, and 1 RIMA graft. Only 1 patient experienced both restenosis of LM stenting and total occlusion of the 2 bypass grafts.

CONCLUSIONS

Dual protection therapy with staged CABG and stenting is not an appropriate therapeutic strategy because of unacceptable graft patency rate. A higher occlusive rate of the bypass grafts may result from decreased blood flow because of competing blood flow between the bypass graft and the native coronary vessel.

Robot-assisted minimally invasive direct coronary artery bypass grafting. ThoraCAB

BACKGROUND

 The aim of this study was to assess the outcome of robot-assisted minimally invasive direct coronary artery bypass grafting (MIDCAB), which is also termed "ThoraCAB".

METHODS AND RESULTS

 From 2005 to 2013, 35 consecutive patients underwent MIDCAB via a small thoracotomy on a beating heart. Before performing MIDCAB, the internal thoracic arteries (ITAs) were endoscopically harvested through 3 ports using the da Vinci Surgical System in a completely skeletonized fashion. Distal anastomosis was hand-sewn using a vacuum stabilizer, and a coronary artery active perfusion system was used to prevent myocardial ischemia during anastomosis. Successful robot-assisted ITA harvesting was achieved in all patients. There was an average of 1.7±0.8 grafts (range, 1-3 grafts) per patient. No patient needed mechanical ventilation for more than 24h. There were no deaths, strokes or myocardial infarctions, and none of the patients required conversion to median sternotomy.

CONCLUSIONS

 Robot-assisted ITA harvesting is safe and feasible. ThoraCAB is a relatively simple procedure and allows multivessel bypass grafting after a small thoracotomy. Therefore, it is expected that ThoraCAB will become the standard procedure for minimally invasive coronary revascularization and will be used in totally endoscopic CABG in the future. 

Robotic totally endoscopic multivessel coronary artery bypass grafting: procedure development, challenges, results

Closed-chest totally endoscopic coronary artery bypass grafting (TECAB) is feasible using robotic technology. During the early phases, TECAB was restricted to single bypass grafts to the left anterior descending artery system. Because most patients referred for coronary artery bypass surgery have multivessel disease, development of endoscopic multiple bypass grafting is mandatory. Experimental work on multivessel TECAB was carried out in the early 2000s, and first clinical cases were already performed. With further technological development of operating robots, double, triple, and quadruple TECAB has become feasible both on the arrested heart and on the beating heart. To date, 161 cases of multivessel TECAB using the da Vinci telemanipulation systems are published in the literature. The main advances enabling multivessel TECAB were the availability of a robotic endostabilizer for beating heart procedures and increased surgeon skills using remote access heart-lung machine perfusion and endo-cardioplegia. Both internal mammary arteries can be harvested and both radial artery and vein graft can be used in multivessel TECAB. Y-grafting and sequential grafting are feasible. Multivessel endoscopic surgical revascularization can be combined with percutaneous coronary interventions in advanced hybrid coronary revascularization. Time requirements for multivessel TECAB are significant, and conversion rates to larger thoracic incisions are higher than those observed for single-vessel TECAB. Clinical short- and long-term outcomes, however, seem to meet the standards of open coronary bypass surgery through sternotomy. The main advantages of multivessel TECAB are a completely preserved sternum, use of double internal mammary artery even in risk groups, and a remarkably short recovery time.

Five hundred cases of robotic totally endoscopic coronary artery bypass grafting: predictors of success and safety

BACKGROUND

Robotic technology has enabled totally endoscopic coronary artery bypass (TECAB) grafting. Little information is available on factors associated with successful and safe performance of TECAB. We report a 10-year multicenter experience with 500 cases, elucidating on predictors of success and safety in TECAB procedures.

METHODS

Between 2001 and 2011, 500 patients (364 [73%] men; 136 [27%] women; median age [minimum-maximum] 60 years [31-90 years], median EuroSCORE 2 [0-13]), underwent TECAB. Single, double, triple, and quadruple TECAB was performed in 334, 150, 15, and 1 patient, respectively. Univariate analysis and binary regression models were used to identify predictors of success and safety. Success was defined as freedom from any adverse event and conversion procedure, safety was defined as freedom from major adverse cardiac and cerebral events, major vascular injury, and long-term ventilation.

RESULTS

Success and safety rates were 80% (400 cases) and 95% (474 cases), respectively. Intraoperative conversions to larger thoracic incisions were required in 49 (10%) patients. The median operative time was 305 minutes (112-1,050 minutes), and the mean lengths of stay in the intensive unit (ICU) and in hospital were 23 hours (11-1,048 hours) and 6 days (2-4 days), respectively. Independent predictors of success were single-vessel TECAB (p = 0.004), arrested-heart (AH)-TECAB (p = 0.027), non-learning curve case (p = 0.049), and transthoracic assistance (p = 0.035). The only independent predictor of safety was EuroSCORE (p = 0.002).

CONCLUSIONS

Single-vessel and multivessel TECAB procedures can be safely performed with good reproducible results. Predictors of success include procedure simplicity and non-learning curve cases, whereas predictors of safety are mainly associated with patient selection.

Hybrid Coronary Revascularization for the Treatment of Left Main Coronary Artery Disease in High-Risk Patients

<p><b>Objective:</b> Hybrid coronary revascularization is an alternative for treatment for high-risk patients with coronary artery disease. We evaluated the efficacy of staged hybrid coronary revascularization for the treatment of unprotected left main coronary artery disease in high-risk patients.</p><p><b>Methods:</b> Patients with left main or proximal left anterior descending coronary artery stenosis who are not good candidates for percutaneous coronary intervention and who had suitable lesions in the right coronary and circumflex arteries were considered for staged hybrid therapy if they had poor left ventricular functions (ejection fraction <0.40) and comorbid illnesses. From January 2008 through December 2010, 11 patients (8 men, 3 women; mean age: 66.1 � 9.1 years) were treated with off-pump coronary artery bypass grafting combined with staged percutaneous coronary intervention. Nine patients had left main coronary artery stenosis together with circumflex or right coronary artery stenosis, and 2 patients had proximal left anterior descending artery stenosis and right coronary artery stenosis.</p><p><b>Results:</b> After off-pump coronary artery bypass grafting, procedure-related complications did not occur, and there was no in-hospital death. Coronary re-angiography after a median of 16 days revealed patent and functioning left internal mammarian artery grafts in all patients. Applying subsequent percutaneous transluminal coronary angioplasty and occasional stenting (n = 14), a total of 14 lesions were treated successfully. Procedure related complications did not occur. All patients remained angina-free, and no stress electrocardiographic changes were recorded.</p><p><b>Conclusion:</b> Our preliminary results indicate that a "staged hybrid" approach to the treatment of left main coronary artery disease in high-risk patients is safe and effective. Hybrid coronary revascularization enables complete revascularization and may be an alternative method of treating left main coronary artery disease in selected high-risk patients.</p>