Simultaneous Hybrid COronary Revascularization Using Totally Endoscopic Left Internal Mammary Artery Bypass Grafting and Placement of RapamycIN Eluting Stents in the SAme IntervenTIONal Session

Hybrid revascularization vs. coronary bypass for coronary artery disease: a systematic review and meta-analysis

INTRODUCTION

Coronary artery bypass graft is the mainstay of treatment for multivessel coronary artery disease and is superior to percutaneous coronary intervention. Combined approaches such as hybrid coronary revascularization integrate coronary artery bypass grafting with percutaneous coronary intervention during the same procedure or weeks apart. These attempt to improve surgical morbidity and long-term outcomes.

EVIDENCE ACQUISITION

Per PRISMA criteria, a systematic review of keywords "Hybrid Revascularization," "Hybrid Coronary Revascularization," "Surgical," "Surgery," "Treatment," "CABG," "HCR" and "PCI" was conducted in PubMed, EMBASE and SCOPUS. Studies comparing this technique's performance on either single or two-stage approach against traditional multiple vessel coronary artery bypass grafting were screened and analyzed for our review.

EVIDENCE SYNTHESIS

Twenty-two studies totaling 6981 participants were ultimately included for analysis. Mean differences in operative time, bleeding, ventilator time and length of stay were significantly lower in the hybrid coronary revascularization group. Odds ratios in transfusions and in-hospital myocardial infarction were also lower in the hybrid coronary revascularization group. Results for in-hospital and all-cause mortality, major adverse cardiac events (MACE), stroke, reintervention, and complete revascularization were not significantly different.

CONCLUSIONS

Our analysis shows hybrid coronary revascularization is a feasible alternative to traditional coronary artery bypass grafting. Short-and long-term outcomes including mortality, MACE, and postoperative morbidity are similar between both groups, while hybrid approaches are associated with decreased perioperative morbidity.

One-year cost-effectiveness and safety of simultaneous hybrid coronary revascularization versus conventional coronary artery bypass grafting

OBJECTIVES

To evaluate the cost-effectiveness and safety of simultaneous hybrid coronary revascularization (sHCR) compared to conventional coronary artery bypass grafting (CABG) in elective patients with multivessel coronary artery disease.

METHODS

Cost-utility analysis of a prospective cohort follow-up study comparing per protocol 50 sHCR patients to 50 contemporaneous matched patients undergoing CABG. Resource utilization data and health-related quality of life were collected prospectively, and the cumulative 1-year costs were assessed from the Danish health sector perspective. Effectiveness was measured by quality-adjusted life years using EuroQol-5D. Probabilistic sensitivity analyses using bootstrapping were conducted. Secondary safety measures including early clinical outcomes and freedom from major adverse cardiac or cerebrovascular events at 1 year were assessed.

RESULTS

The clinical trial was discontinued prematurely due to safety reasons after inclusion of 50 patients (24 sHCR; 26 CABG), as the chest tube output and the risk of postoperative pleural effusions requiring thoracocentesis were significantly increased following sHCR compared with CABG. Based on 48 patients available for 1-year follow-up, both treatment strategies were similarly effective (quality-adjusted life year difference between the groups -0.019), with a net cost difference in favour of conventional CABG estimated to be €2173 per patient. Exclusion of 1 outlier patient with chronic renal failure and deep sternal wound infection in the sHCR group resulted in an equalization of the total 1-year costs.

CONCLUSIONS

At 1 year, sHCR was less cost-effective than conventional CABG and associated with higher chest tube output and a higher risk of postoperative pleural effusions requiring thoracocentesis.

CLINICAL TRIAL REGISTRATION

NCT01496664.

Practice Patterns and Clinical Outcomes After Hybrid Coronary Revascularization in the United States

Background—

Hybrid coronary revascularization (HCR) involves a combination of surgical and percutaneous techniques, which in selected patients may present an alternative to conventional coronary artery bypass grafting (CABG).

Methods and Results—

Patients were included who underwent HCR (staged/concurrent) or isolated CABG in the Society of Thoracic Surgeons Adult Cardiac Surgery Database (July 2011 to March 2013). HCR represented 0.48% (n=950; staged=809, concurrent=141) of the total CABG volume (n=198 622) during the study period, and was performed in one-third of participating centers (n=361). Patients who underwent HCR had higher cardiovascular risk profiles in comparison with patients undergoing CABG. In comparison with CABG, median sternotomy (98.5% for CABG, 61.1% for staged HCR, and 52.5% for concurrent HCR), direct vision harvesting (98.9%, 66.0%, and 68.1%) and cardiopulmonary bypass (83.4%, 45%, and 36.9%) were less frequently used for staged and concurrent HCR, whereas robotic assistance (0.7%, 33.0%, and 30.5%) was more common. After adjustment, no differences were observed for the composite of in-hospital mortality and major morbidity (odds ratio, 0.93; 95% confidence interval, 0.75–1.16; P =0.53 for staged HCR, and odds ratio, 0.94; 95% confidence interval, 0.56–1.56; P =0.80 for concurrent HCR in comparison with CABG). There was no statistically significant association between operative mortality and either treatment group (odds ratio, 0.74; 95% confidence interval, 0.42–1.30; P =0.29 for staged HCR, and odds ratio, 2.26; 95% confidence interval, 0.99–5.17; P =0.053 for concurrent HCR in comparison with CABG).

Conclusion—

HCR, either as a staged or concurrent procedure, is performed in one-third of US hospitals and is reserved for a highly selected patient population. Although HCR may appear to be an equally safe alternative for CABG surgery, further randomized study is warranted.

Status quo of hybrid coronary revascularization for multi-vessel coronary artery disease

Hybrid coronary revascularization (HCR) combines bypass grafting of the left anterior descending (LAD) coronary artery with percutaneous coronary intervention (PCI) of non-LAD vessels. HCR has been performed as an alternative to CABG or multi-vessel PCI in thousands of patients since the late 1990s. In this review article, we provide an overview on patient selection, procedural sequence and timing, use of surgical techniques and anti-platelet agents. Additionally, patient recovery, satisfaction, costs and clinical outcomes of individual studies after HCR are evaluated. Future directions are also discussed, including the need for adequately powered randomized trials.

Clinical and angiographic results after hybrid coronary revascularization

BACKGROUND

With hybrid coronary revascularization (HCR), minimally invasive left internal mammary artery (LIMA) to left anterior descending coronary artery (LAD) grafting is combined with percutaneous coronary intervention (PCI) of non-LAD vessels. The purpose of this study was to examine the short-term clinical and angiographic results in one of the largest HCR series to date.

METHODS

From 2003 to 2012, 300 consecutive patients (aged 64±12 years, female 31.7%, predicted risk of mortality 1.6%±2.1%) underwent HCR on an intent-to-treat basis at a single institution. After robotic or thoracoscopic LIMA harvest, off-pump LIMA to LAD grafting was performed through a 3- to 4-cm sternal-sparing, non-rib-spreading thoracotomy. PCI was utilized to treat non-LAD lesions either before, after, or concomitant with the surgical procedure.

RESULTS

Of the 300 patients undergoing HCR on an intent-to-treat basis, HCR was performed with surgery first in 192 patients (64.0%), PCI first in 56 (18.7%), and as a concomitant procedure in 21 (7.0%). Of the 31 patients (10.1%) who did not undergo HCR, 24 patients (8.0%) did not have PCI and thus were incompletely revascularized. For all patients, 30-day mortality, stroke, and nonfatal myocardial infarction occurred in 4 (1.3%), 3 (1.0%), and 4 (1.3%), respectively. Angiographic LIMA evaluation was performed in 248 patients and revealed a FitzGibbon A LIMA patency rate of 97.6% (242 of 248 patients). Repeat revascularization was required in 13 of 300 patients (4.3%).

CONCLUSIONS

Hybrid coronary revascularization represents an alternative approach for patients with multivessel coronary disease with excellent short-term outcomes. It provides a minimally invasive alternative to traditional coronary artery bypass graft surgery and may prove more durable than multivessel PCI.

Combining PCI and CABG: the role of hybrid revascularization

Hybrid coronary revascularization combines the benefits of both percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) in the treatment of multivessel coronary artery disease (CAD) by combining the benefits of the LIMA-to-LAD graft and drug eluting stent (DES) to non-LAD regions. Through this approach, a patient receives the long-term benefit of the LIMA graft and avoids the morbidity of a full sternotomy and saphenous vein grafts. Available data related to outcomes following hybrid revascularization is limited to small studies. In this review we seek to provide an overview of hybrid revascularization in the era of modern drug eluting stent technology, discuss appropriate patient selection, and comment on future trial design. Additionally, we review the recent literature pertaining to the hybrid approach.

Hybrid coronary revascularization as a safe, feasible, and viable alternative to conventional coronary artery bypass grafting: what is the current evidence?

The “hybrid” approach to multivessel coronary artery disease combines surgical left internal thoracic artery (LITA) to left anterior descending coronary artery (LAD) bypass grafting and percutaneous coronary intervention of the remaining lesions. Ideally, the LITA to LAD bypass graft is performed in a minimally invasive fashion. This review aims to clarify the place of hybrid coronary revascularization (HCR) in the current therapeutic armamentarium against multivessel coronary artery disease. Eighteen studies including 970 patients were included for analysis. The postoperative LITA patency varied between 93.0% and 100.0%. The mean overall survival rate in hybrid treated patients was 98.1%. Hybrid treated patients showed statistically significant shorter hospital length of stay (LOS), intensive care unit (ICU) LOS, and intubation time, less packed red blood cell (PRBC) transfusion requirements, and lower in-hospital major adverse cardiac and cerebrovascular event (MACCE) rates compared with patients treated by on-pump and off-pump coronary artery bypass grafting (CABG). This resulted in a significant reduction in costs for hybrid treated patients in the postoperative period. In studies completed to date, HCR appears to be a promising and cost-effective alternative for CABG in the treatment of multivessel coronary artery disease in a selected patient population.

Robotic cardiac surgery: advanced minimally invasive technology hindered by barriers to adoption

Robotic cardiac surgery utilizes the most advanced surgical technology to offer patients a minimally invasive alternative to open surgery in the treatment of a broad range of cardiac pathologies. Although robotics may offer substantial benefits to physicians, patients and healthcare institutions, there are important barriers to its adoption that includes inadequate funding, competition from alternate therapies and challenges in training. There is a growing body of evidence to demonstrate the efficacy of robotic cardiac surgery. Technological innovations are improving patient safety and expanding the indications for robotic cardiac surgery beyond the treatment of mitral valve and coronary artery disease. Robotic cardiac surgery is rapidly becoming a feasible, safe and effective option for the definitive treatment of cardiac disease in the context of 21st century challenges to healthcare provision such as diabetes, obesity and an aging population.

Hybrid coronary revascularization versus off-pump coronary artery bypass grafting for the treatment of multivessel coronary artery disease

BACKGROUND

Hybrid coronary revascularization (HCR) combines a minimally invasive (3-cm anterolateral thoracotomy), sternal-sparing, off-pump left internal mammary artery-left anterior descending (LIMA-LAD) coronary artery anastomosis with percutaneous coronary intervention (PCI) to non-LAD coronary arteries. We compared outcomes of HCR versus traditional off-pump coronary artery bypass grafting (OPCAB) for the treatment of multivessel coronary artery disease (CAD).

METHODS

Between October 8, 2003 and April 23, 2010, 147 patients with multivessel coronary disease were treated with HCR at a US academic center. These were matched 4:1 to 588 contemporaneous patients treated with multivessel OPCAB by sternotomy using an optimal matching algorithm with 8 preoperative variables: age, gender, ejection fraction, presence of diabetes, myocardial infarction (MI), number of diseased vessels, left main coronary artery disease, and Society of Thoracic Surgeons (STS) predicted risk of mortality (PROM) score. In-hospital major adverse events (MACCE) and the need for repeated revascularization during follow-up were compared between groups. All-cause mortality was determined using the Social Security Death Index (SSDI).

RESULTS

Matching produced groups with similar coronary anatomy and statistically similar preoperative risk factors. The incidence of MACCE was similar between groups (3/147 HCR versus 12/588 OPCAB). During a median 3.2 years of follow up, the need for repeated revascularization was higher for HCR than for OPCAB (18/147 [12.2%] versus 22/588 [3.7%]; p < 0.001). The incidence of blood transfusion was higher for the OPCAB group. Estimated 5-year survival was similar between groups (OPCAB, 84.3% versus HCR, 86.8%; p = 0.61).

CONCLUSIONS

Hybrid coronary revascularization is a minimally invasive treatment for multivessel CAD. Although repeated revascularization was greater with HCR, both in-hospital and midterm outcomes were comparable with those of traditional OPCAB. Further investigation into the comparative effectiveness of this alternative strategy is warranted.

Closed chest hybrid coronary revascularization for multivessel disease - current concepts and techniques from a two-center experience

Hybrid coronary revascularization combining minimally invasive coronary surgery and percutaneous coronary intervention (PCI) allows sternal preserving treatment of multivessel coronary disease. The main principle of the technique includes placement of mammary artery graft to the left anterior descending coronary artery (LAD) and performance of PCI in non-LAD target vessels. This principle is based on increasing data showing equivalent results of PCI with coronary revascularization using saphenous vein grafts in selected patients. Providing that perioperative and long-term results are as good as the results of conventional surgical revascularization, this option seems to be quite appealing for patients and referring cardiologists. This concept has been designed to allow rapid rehabilitation and minimize periprocedural pain under concomitant preservation of the patient's body integrity. Robotically assisted endoscopic approaches for hybrid coronary revascularization set the pace for a closed-chest treatment of multivessel coronary disease. The time point of PCI, the use of different anticoagulation protocols as well as the stent selection are some of the variables, which affect outcome. We additionally report on the midterm results of 130 after-closed-chest hybrid-coronary procedures in two institutions. Hybrid procedures using robotic technology and PCI allow closed chest treatment of multivessel coronary artery disease. Single- and double-bypass grafts are feasible and simultaneous interventions can be performed. The overall safety of the procedure seems to be adequate and perioperative clinical results are satisfactory. Intermediate term survival and freedom from angina are excellent.

Early and midterm results of totally endoscopic coronary artery bypass grafting on the beating heart

OBJECTIVE

Despite the early introduction of totally endoscopic coronary artery bypass on the beating heart, only a limited number of cases have been performed. The limiting factor has been the concern about safety and graft patency of the anastomosis. This study describes our experience with totally endoscopic coronary artery bypass on the beating heart with robotic assistance and its early and midterm results.

METHODS

In 365 cases of robotic cardiac operations, 162 patients underwent robotic coronary artery bypass grafting on the beating heart, of whom 60 patients (46 male, 14 female) underwent totally endoscopic coronary artery bypass on the beating heart. The patients' mean age was 56.97 ± 9.7 years (33-77 years). Left internal thoracic artery to left anterior descending anastomosis was performed using the U-Clip device.

RESULTS

We completed 58 totally endoscopic coronary artery bypass procedures, in which 16 patients received hybrid procedures. Two patients had conversions to a minithoracotomy. The average left internal thoracic artery harvesting and anastomosis times were 31.3 ± 10.5 (18∼55) minutes and 11.3 ± 4.7 (5∼21) minutes, respectively. The mean operating room and operation times were 336.1 ± 58.5 (210∼580) minutes and 264.8 ± 65.6 (150∼420) minutes, respectively. The drainage was 164.9 ± 83.2 (70∼450) mL. Before discharge, 50 patients underwent angiography and 8 patients underwent computed tomography angiography, and the study showed that graft patency was 100%. Unexpectedly, the left internal thoracic artery graft developed a collateral branch in 2 patients. After discharge, all patients were followed up by computed tomography angiography. The average follow-up time was 12.67 ± 9.43 (1-40) months. One patient had gastric bleeding after surgery.

CONCLUSIONS

Totally endoscopic coronary artery bypass on the beating heart is a safe procedure in selected patients and produces excellent early and midterm patency of anastomosis.

Hybrid options for treating cardiac disease

The options for treating heart disease have greatly expanded during the course of the last 2 1/2 decades with the advent of hybrid technology. The hybrid option for treating cardiac disease implies using the technology of both interventional cardiology and cardiac surgery to treat cardiac disease. This rapidly developing technology has given rise to new and creative techniques to treat cardiac disease involving coronary artery disease, coronary artery disease and cardiac valve disease, and atrial fibrillation. It has also led to the establishment of new procedural suites called hybrid operating rooms that facilitate the integration of technologies of interventional cardiology catheterization laboratories with those of cardiac surgery operating rooms. The development of hybrid options for treating cardiac disease has also greatly augmented teamwork and collaboration between interventional cardiologists and cardiac surgeons.

Robotic coronary artery bypass grafting

Robotically assisted surgery enables coronary surgery to be performed totally or partially endoscopically. Using the Da Vinci robotic technology allows minimally invasive treatments. We report on our experience with coronary artery surgery in our department: patients requiring single or double vessel surgical revascularization were eligible. The procedure was performed without cardiopulmonary bypass on a beating heart. From April 2004 to May 2008, 55 consecutive patients were enrolled in the study, and were operated on by a single surgical team. Operative outcomes included operative time, estimated blood loss, transfusions, ventilation time, intensive care unit (ICU) and hospital length of stay. Average operative time was 270 ± 101 min with an estimated blood loss of 509 ± 328 ml, a postoperative ventilation time of 6 ± 12 h, ICU stay of 52 ± 23 h, and a hospital stay of 7 ± 3 days. Nine patients (16%) were converted to open techniques, and transfusion was required in four patients (7%). Follow-up was complete for all patients up to 1 year. There was one hospital death (1.7%) and two deaths at follow-up. Coronary anastomosis was controlled in 48 patients by either angiogram or computed tomography scan, revealing occlusion or anastomotic stenoses (>50%) in six patients. Overall permeability was 92%. Major adverse events occurred in 12 patients (21%). One-year survival was 96%. Our initial experience with robotically assisted coronary surgery is promising: it avoids sternotomy and with a methodical approach we were able to implement the procedure safely and effectively in our practice, combining minimal mortality with excellent survival.

Robotically-assisted coronary artery bypass grafting

Objectives. Robotic surgery enables to perform coronary surgery totally endoscopically. This report describes our experience using the da Vinci system for coronary artery bypass surgery. Methods. Patients requiring single-or-double vessel revascularization were eligible. The procedure was performed without cardiopulmonary bypass on a beating heart. Results. From April 2004 to May 2008, fifty-six patients were enrolled in the study. Twenty-four patients underwent robotic harvesting of the mammary conduit followed by minimal invasive direct coronary artery bypass (MIDCAB), and twenty-three patients had a totally endoscopic coronary artery bypass (TECAB) grafting. Nine patients (16%) were converted to open techniques. The mean total operating time for TECAB was 372 ± 104 minutes and for MIDCAB was 220 ± 69 minutes. Followup was complete for all patients up to one year. There was one hospital death following MIDCAB and two deaths at follow up. Forty-eight patients had an angiogram or CT scan revealing occlusion or anastomotic stenoses (>50%) in 6 patients. Overall permeability was 92%. Conclusions. Robotic surgery can be performed with promising results.