Coronary perforation during percutaneous coronary intervention

Percutaneous Coronary Intervention-Related Iatrogenic Fistula in Acute Coronary Syndrome

Iatrogenic coronary artery fistula (CAF) can occur following acute myocardial infarction, percutaneous coronary intervention (PCI) procedures, and heart surgery. Iatrogenic CAF linked to PCI has a low incidence rate. Early diagnosis and treatment are crucial when an iatrogenic fistula develops, as it may lead to cardiac tamponade, myocardial infarction, or death. In this report, we present a case of iatrogenic CAF secondary to coronary perforation caused by guidewire-induced trauma, followed by stent implantation and balloon inflation in the context of acute coronary syndrome (ACS). It was successfully managed through prolonged balloon inflation within the previously implanted stent just prior to the rupture zone.

Ellis type 4 coronary artery perforation during percutaneous coronary intervention: Case series and review

Ellis type 4 coronary artery perforation (CAP4), also referred to as Ellis type 3 cavity-spilling perforation, is a rare but life-threatening complication of percutaneous coronary intervention characterized by extravasation of blood into a cardiac chamber, anatomic cavity, or coronary sinus or vessel. CAP4 is uncommon, accounting for 1.9% to 3.0% of all CAP. Only 11 cases of CAP4 have been reported in detail; we report an additional two cases and review prior reports of this rare complication. Our first case highlights a patient with chronic anginal symptoms due to a 75% concentric stenotic lesion in the mid-LAD. Revascularization was complicated by perforation during pre-dilation with robust contrast extravasation into the left ventricle. Successful postperforation hemostasis was achieved with heparin reversal and covered stent placement. The second case demonstrates another major mechanism of CAP4: wire perforation. During intervention, the absence of blood flow distal to the lesion in the setting of an ST segment elevation myocardial infarction obscured the course of the nonhydrophilic floppy wire leading to perforation that was managed conservatively. In our scoping review, we found that the majority of CAP4 occurred in the LAD. The most frequently involved cavity was the left ventricle-other cavities involved were the right ventricle and coronary veins. Common etiologies of CAP4 included guidewire perforation (62%) and balloon dilation (31%). Perforation was managed with reversal of anticoagulation in 46% of cases, prolonged balloon inflation in 54% of cases, and covered stent deployment in 15% of cases. No patients required surgical repair or pericardiocentesis and perforations were successfully sealed in all cases. In-hospital mortality was 0%.

Intra-pericardial thrombin injection as bailout strategy in iatrogenic pericardial tamponade

BACKGROUND

Cardiac tamponade is a rare but life-threatening complication of cardiac interventions. Despite prompt pericardiocentesis, clinical management can be challenging and sometimes haemodynamic stabilisation is difficult to achieve. Intra-pericardial thrombin injection after pericardiocentesis promotes haemostasis and acts as a sealing agent, as previously described for left ventricular free-wall rupture. We aimed to evaluate intra-pericardial thrombin injection as a bailout strategy for pericardial tamponade following percutaneous cardiac interventions.

METHODS

In a 5-year single-centre retrospective analysis we identified 31 patients with cardiac tamponade due to percutaneous intracardiac procedures. Intra-pericardial thrombin injection as a bailout strategy was administered in 5 of 31 patients (16.1%).

RESULTS

Patients receiving intra-pericardial thrombin were in a more critical state when thrombin was applied, as demonstrated by a higher rate of resuscitation (40% versus 26.9%) and a trend toward a prolonged stay in the intensive care unit (177.6 ± 84.0 vs 98.0 ± 31.4 h). None of the patients with pericardial tamponades treated with intra-pericardial thrombin needed cardiothoracic surgery. Mortality after 30 days was lower with intra-pericardial thrombin injection than with standard treatment (0% vs 15.4%). We observed no complications using intra-pericardial thrombin.

CONCLUSION

Intra-pericardial thrombin injection could be considered as a bailout strategy for patients with iatrogenic pericardial tamponade due to percutaneous procedures. We recommend further evaluation of this technique in the clinical management of refractory pericardial tamponade.

Iatrogenic Causes of Cardiac Tamponade Resulting From Surgical Procedures: An Overview

Cardiac tamponade is one of the most severely life-threatening emergencies encountered, mainly because of its significant impact on the pumping capacity of the heart by compressing the cardiac chambers due to the rapid accumulation of blood, fluid, pus, or clots in the pericardial sac. These accumulations may be collected following traumas, malignancies, uremia, and many other medical conditions as well as surgical procedures. Numerous errors and medicolegal aspects have been identified in diagnosing and treating cardiac tamponade associated with cardiac-related procedures such as valve replacement surgeries, cardiac pacemaker implantation, pericardiocentesis, and other non-cardiac related procedures such as peri-hiatal surgeries. Patients taking anticoagulants or anticancer medications are especially susceptible to developing cardiac tamponade when undergoing surgical procedures, raising the question of preoperative screening to avoid errors. Misdiagnosis, treatment delay or failure to deliver the utmost quality of treatment, lack of complication screening and follow-ups for those at risk, surgeons rushing to complete cases, burnout, and other human factors are predispositions to the development of cardiac tamponade. Fortunately, most of these errors occurring within healthcare settings are avoidable and must be prevented for eliminating any risks to reduce the incidence and mortality of cardiac tamponade cases resulting from iatrogenic etiology. It is an intricate condition where precision and caution are crucial.

Management of Coronary Complications

Coronary complications are increasingly rare but remain fatal if not managed promptly and effectively. We review the incidence, management, and prevention of the most serious coronary complications including acute vessel closure from dissection, no-reflow, thrombosis, and air embolism as well as mechanical complications including perforation, stent dislodgment, and atherectomy burr entrapment.

Coronary perforation incidence, outcomes and temporal trends (COPIT): a systematic review and meta-analysis

Coronary perforation is a potentially life-threatening complication of percutaneous coronary intervention (PCI). We studied incidence, outcomes and temporal trends following PCI-related coronary artery perforation (CAP).

METHODS

Prospective systematic review and meta-analysis including meta-regression using MEDLINE and EMBASE to November 2020. We included 'all-comer' PCI cohorts including large PCI registries and randomised controlled trials and excluding registries or trials limited to PCI in high-risk populations such as chronic total occlusion PCI or cohorts treated only with atheroablative devices. Regression analysis and corresponding correlation coefficients were performed comparing perforation incidence, mortality rate, tamponade rate and the rate of Ellis III perforations against the midpoint (year) of data collection to determine if a significant temporal relationship was present.

RESULTS

3997 studies were screened for inclusion. 67 studies met eligibility criteria with a total of 5 568 191 PCIs included over a 38-year period (1982-2020). The overall pooled incidence of perforation was 0.39% (95% CI 0.34% to 0.45%) and remained similar throughout the study period. Around 1 in 5 coronary perforations led to tamponade (21.1%). Ellis III perforations are increasing in frequency and account for 43% of all perforations. Perforation mortality has trended lower over the years (7.5%; 95% CI 6.7% to 8.4%). Perforation risk factors derived using meta-regression were female sex, hypertension, chronic kidney disease and previous coronary bypass grafting. Coronary perforation was most frequently caused by distal wire exit (37%) followed by balloon dilation catheters (28%). Covered stents were used to treat 25% of perforations, with emergency cardiac surgery needed in 17%.

CONCLUSION

Coronary perforation complicates approximately 1 in 250 PCIs. Ellis III perforations are increasing in incidence although it is unclear whether this is due to reporting bias. Despite this, the overall perforation mortality rate (7.5%) has trended lower in recent years. Limitations of our findings include bias that may be introduced through analysis of multidesign studies and registries without pre-specified standardised perforation reporting CMore research into coronary perforation management including the optimal use of covered stents seems warranted.

PROSPERO REGISTRATION NUMBER

CRD42020207881.

Clinical and procedure characteristics in patients treated with polytetrafluoroethylene-covered stents after coronary perforation: a CIRC-8U multicenter registry and literature review

This study aimed at identifying the clinical characteristics and in-hospital outcomes of patients treated with polytetrafluorethylene (PTFE)-covered stents after coronary interventions in a multicenter registry. Subjects with coronary artery perforation were selected from 31,262 consecutive patients who underwent coronary interventions in the hospital registries. Subjects were divided into two groups: those with a PTFE-covered stent implantation and those without a PTFE-covered stent implantation. Clinical characteristics and in-hospital outcomes were compared between the two groups. Data for 82 consecutive coronary perforations (15 PTFE-covered stents and 67 non-PTFE-covered stents) were extracted from each hospital registry. The PTFE-covered stent group had a higher prevalence of perforations due to pre-dilatation before stenting or post-dilatation after stenting (80% vs. 10.4%; p < 0.001), more Ellis classification III perforations (66.6% vs. 28.4%; p = 0.019), longer perforation to hemostasis time (74 min vs. 10 min; p < 0.001), lower hemostatic success rates (73.3% vs. 94.0%; p = 0.015), and higher in-hospital mortality (26.7% vs. 6.0%; p = 0.015) than the non-PTFE-covered stent group. Although the prevalence of intravascular ultrasound (IVUS) usage was high during coronary interventions (86.7%), IVUS was performed in less than half the cases just before coronary perforations (47%) in the PTFE-covered stent group. Patients requiring PTFE-covered stents are more likely to be observed after balloon dilatation before or after stenting and have a poor prognosis. Careful coronary intervention is needed when IVUS image acquisition is not achieved in addition to proper evaluation of IVUS. Furthermore, if coronary artery perforation occurs, it is important to determine the need for a prompt PTFE-covered stent.

Left ventricular free-wall rupture, a potentially lethal mechanical complication of coronaric angioplasty : an unusual case report

The incidence of complications of coronary perforation varied significantly among studies probably due to population heterogeneity and interventional techniques applied in each centre. Free wall rupture, cardiac tamponade and miocardial infarction are the most  feared. The treatment of perforation remains a challenge of every cath- lab team. The management strategies range from observation to urgent operation depending on patient's hemodynamic status, severity and location of the perforation, coronary anatomy, interventional practice and equipment in each centre and operators' skills on-site. In this case an extracorporeal circulation and cardioplegic arrest with anterograde hot blood cardioplegia was done. A composite Dacron with autologous pericardium patch was used for left ventricular free wall rupture repair and the geometry of the left ventricle was restored. Subsequently aorta was declamped; the patient was weaned from CEC and a good spontaneous hemodynamic was recovered.

A Practical Approach to the Management of Complications During Percutaneous Coronary Intervention

Percutaneous coronary intervention relieves symptoms in patients with chronic ischemic heart disease resistant to optimal medical therapy and alters the natural history of acute coronary syndromes. However, adverse procedural outcomes may occur during the intervention. Knowledge of possible complications and their timely management are essential for the practicing cardiologist and can be life-saving for the patient. In this review, the authors summarize potential complications of percutaneous coronary intervention focusing on their practical management.

Incidence, predictors, management and outcomes of coronary perforations

OBJECTIVES

We examined the contemporary incidence, types, predictors, angiographic characteristics, management and outcomes of coronary perforation.

BACKGROUND

Coronary perforation is a rare, but important, complication of percutaneous coronary intervention (PCI). There is lack of data on perforations stratified as large and distal vessel perforations.

METHODS

Retrospective, observational cohort study of all patients who underwent PCI at a high volume, tertiary hospital between the years 2009 and 2016. Angiograms of all coronary perforation cases were reviewed to determine the mechanism, type, and management of perforation. Risk-adjusted periprocedural complication rates were compared between patients with and without coronary perforation. One-year mortality outcomes of patients with large vessel vs. distal vessel perforation were also examined.

RESULTS

Coronary perforation occurred in 68 of 13,339 PCIs (0.51%) performed during the study period: 51 (75%) were large vessel perforations and 17 (25%) distal vessel perforations. Most (67%) large vessel perforations were due to balloon/stent inflation, whereas most (94%) distal vessel perforations were due to guidewire exit. Patients with coronary perforations had significantly higher risk for periprocedural complications (adjusted odds ratio 7.57; 95% CI: 4.22-13.50; P < 0.001). Only one patient with large vessel perforation required emergency cardiac surgery, yet in-hospital mortality was high with both large vessel (7.8%) and distal vessel (11.8%) perforations.

CONCLUSIONS

Coronary perforation is an infrequent, but potentially severe PCI complication. Most coronary perforations are large vessel perforations. Although coronary perforations rarely lead to emergency cardiac surgery, both distal vessel and large vessel perforations are associated with high in-hospital mortality, highlighting the importance of prevention.

Huge coronary perforation during percutaneous intervention sealed by injection of polyvinyl alcohol microspheres

During percutaneous coronary intervention, coronary perforation is one of the most feared life-threatening complications, as it may cause cardiac tamponade or acute myocardial infarction. The incidence of this serious complication in recent years has increased from 0.2 to 0.6%, most likely due to the increase of complex procedures. However, the management of coronary perforation has not been established yet. We report the first case of coronary perforation successfully managed with intracoronary injection of hydrogel microspheres.

[Coronary pseudoaneurysm after percutaneous treatment of a coronary perforation]

Coronary pseudoaneurysms are rare and usually occur after percutaneous procedures, spontaneous dissections, aortocoronary bypass, or chest trauma. Although most of the cases are casual, other patients present as acute myocardial infarction, fistula formation or cardiac tamponade. We report the case of a coronary pseudoaneurysm after percutaneous treatment of a coronary perforation.

Pericardial effusion following drain removal after percutaneous epicardial access for an electrophysiology procedure

OBJECTIVES

To determine the frequency and predictors of pericardial effusion following epicardial sheath removal.

BACKGROUND

Pericardial effusion can occur following cardiac surgical or interventional procedures including percutaneous epicardial access (EpiAcc), which is increasingly used as part of electrophysiology ablation procedures.

METHODS

A retrospective analysis of the Mayo Clinic comprehensive electronic medical record was performed from all patients who underwent planned EpiAcc as part of an electrophysiology ablation procedure between January 1, 2004 and June 30, 2013.

RESULTS

Of 144 patients (mean age 51.3 ± 15.5 years, 68% male) who underwent planned EpiAcc as part of an electrophysiology ablation (95.8% pericardial access success rate), seven (4.9%) developed a postoperative pericardial effusion requiring repeat EpiAcc. Inferior access was utilized in 74 (51.4%) patients. Patients with pericardial effusion tended to be younger (41.1 years vs 51.8 years, P = 0.08) and were more likely to have undergone inferior approach access (85.7% vs 49.6%, P = 0.06) than those who did not develop postoperative pericardial effusion. Seventy-one percent of patients with postoperative pericardial effusion versus 32.1% of patients without postoperative pericardial effusion had a preprocedure ejection fraction ≥55% (P = 0.03). There were no procedural-related deaths, and no difference in mortality between groups.

CONCLUSIONS

Postoperative pericardial effusion requiring repeat access/drainage was relatively infrequent, occurring in 4.9% of patients shortly after epicardial procedures. While the majority occur early and therefore require close observation, some patients may present in a delayed manner.

Management and outcomes of coronary artery perforations during percutaneous treatment of acute coronary syndromes

BACKGROUND

Coronary artery perforation (CAP) is an infrequent and life-threatening complication of percutaneous coronary intervention (PCI), requiring prompt intervention. There is insufficient data about the prognosis and management of CAP in patients with acute coronary syndrome (ACS). The aim of this study was to investigate the management of CAP in patients with ACS.

METHODS

The results of 25 patients with CAP were retrospectively analyzed.

RESULTS

Of the 25 patients, 14 patients (56%) had ACS. According to the Ellis classification, the grade of perforation was type-I in 8 (32%) patients, type-II in 6 (24%) patients and type-III in 11 (44%) patients. Prolonged balloon inflation was performed to 20 (80%) cases of CAP. It successfully sealed the perforation in three cases of type-I, five cases of type-II CAP and in seven cases of type-III CAP. Seven patients underwent covered stent implantation. Emergent CABG was required in two patients with type-III CAP. In-hospital mortality was not observed in the patients.

CONCLUSION

The outcomes of CAP in patients with ACS were similar to patients with stable coronary disease. The continuation of anti-platelet agents after the successful management of CAP may be encouraged in these patients.

Successful management of Ellis type III left anterior descending artery perforation following percutaneous coronary intervention by a covered stent: Successfully resolved the dramatic complication

Coronary artery perforation is a rare but catastrophic complication of percutaneous coronary intervention (PCI). Grade III coronary perforation and rupture invariably results in pericardial effusion and tamponade requiring urgent pericardiocentesis. Advances in coronary intervention have increased the opportunity to treat coronary artery perforation. We are reporting a case of 55 years old hypertensive female who presented with effort angina. Coronary angiogram revealed significant stenosis in the left anterior descending coronary artery. Post PCI, she had Ellis type III coronary perforation and pericardial tamponade and cardiogenic shock. The patient was resuscitated, pericardiocentesis done, autologous blood transfusion given and covered stent deployed.

Outcome of prolonged balloon inflation for the management of coronary perforation

BACKGROUND

Coronary perforation (CP) is a rare, sometimes lethal complication of percutaneous coronary intervention (PCI).

OBJECTIVES

The purpose of this study was to review the cases of CP and to investigate the management after CP.

METHODS

A total of 3469 PCIs were performed in our institution from April 1999 to April 2008. All CP cases were identified from our computerized database.

RESULTS

Thirty patients were identified as having CP (0.86%). According to the Ellis classification, we determined the grade of perforation as type I in 17 cases (56%), type II in 2 cases (7%), and type III in 11 cases (37%). Most CPs were caused by wires (53%), while balloons, stents, and atherectomy devices were responsible for 7%, 37%, and 3%, respectively. Wire caused only 1 case of type III CP (6%), while stent caused 9 type III CPs (82%, p<0.01). Four patients (36%) with type III CP required urgent coronary artery bypass graft surgery (CABG), while no patient with type I/II CP required it (p<0.01). Prolonged balloon inflations were effective for 8 cases out of 11 stent CPs, however, the ballooning duration was significantly longer than that in wire and balloon CP (44±37min vs. 21±13min, p<0.05).

CONCLUSIONS

Stent CP often causes type III CP and one third of type III CP required urgent CABG. Although stent CP required longer balloon inflations for the management, prolonged balloon inflation might be useful for the management even in the stent CP.

Coronary perforation and covered stents: an update and review

Coronary perforation is a rare complication of percutaneous coronary intervention. We present two different types of coronary intervention, but both ending with coronary perforation. However, these perforations were tackled successfully by covered stents. This article reviews the incidence, causes, presentation, and management of coronary perforation in the present era of aggressive interventional cardiology. Coronary perforations are classified as type I (extraluminal crater), II (myocardial or pericardial blushing), and III (contrast streaming or cavity spilling). Types I and II coronary perforations are caused by stiff or hydrophilic guidewires. Type I has a benign prognosis, whereas type II coronary perforations have the potential to progress to tamponade. Type III coronary perforations are caused by balloons, stents, or other intracoronary devices and commonly lead to cardiac tamponade necessitating pericardial drainage. However, type III perforations can be managed with covered stents without need for surgical intervention.

Successful surgical management of coronary perforation requiring pulmonary artery separation

A 73-year-old woman with type III coronary perforation caused by failed angioplasty underwent emergency operation. It was impossible to stop the bleeding from the beating heart because the proximal Cx, which was the perforation site, was behind the main pulmonary artery. After establishing cardiopulmonary bypass, we separated the main pulmonary artery to secure hemostasis and performed coronary artery bypass grafting to the distal Cx. The postoperative course was uneventful therefore the patient was discharged on the tenth postoperative day. Surgical strategies are not standardized for coronary perforation and depend mainly on the surgical anatomy. In a situation like the present, which appears not to have been described previously, it is important to save the life of the patient by whatever means.

Postinfarct ventricular septal defect after coronary covered stent implantation

We report a case of a postinfarction ventricular septal defect caused by an acute recurrent occlusion after the implantation of a covered stent, which was performed as a rescue procedure for the ruptured left anterior descending artery during a percutaneous coronary intervention. Although the emergent implantation of a covered stent for the ruptured coronary arteries such as the left main coronary artery or the origins of the left anterior descending artery can be performed during a percutaneous coronary intervention, and a coronary bypass surgery should be considered in order to decrease the risk of complete occlusion, thus providing a superior long term patency.

Surgical treatment for Ellis type 3 coronary perforation during percutaneous catheter intervention

BACKGROUND

Coronary perforation (CP) is a rare, but sometimes lethal, complication of percutaneous catheter intervention (PCI). We reviewed surgically-treated cases of type 3 CP during PCI.

METHODS AND RESULTS

From 2007 to 2010, 5 patients underwent surgical repair for type 3 CP (3 men, 2 women; mean age, 74 years). The mean number of diseased coronary branches was 2.6 and the mean SYNTAX score was 45. The target lesions were the left anterior descending artery in 4 cases and the right coronary artery in 1 case. Types of American Heart Association/American College of Cardiology classification were type B2 in only one case and type C in 4 cases. The causes of perforation were balloon inflation in 4 patients and rotational atherectomy in 1 patient. The in-hospital mortality rate was 20%. In the cases of CP associated with balloon inflation, coronary lacerations were so severe that re-bleeding occurred even if the covered stent could temporarily achieve hemostasis, and percutaneous cardiopulmonary support and emergency surgery were required.

CONCLUSIONS

CP induced by balloon inflation tends to result in a serious condition compared with rotablator-induced CP. Surgery should be immediately performed even after covered stent implantation if there is any possibility of re-bleeding in the case of balloon-induced type 3 CP.

Coronary artery perforation by intracoronary guide wires: risk factors and clinical outcomes

The aims of this study were to determine the incidence of coronary artery perforation by intracoronary guide wires during angioplasty, to identify associated factors, and to assess outcomes. The retrospective analysis covered 4,353 consecutive procedures, corresponding to a total 6,994 lesions treated over a period of 8 years. Coronary artery perforation by guide wires occurred in 15 cases (0.35%). Perforation was associated with the number of hydrophilic wires used (odds ratio=2.33; 95% confidence interval, 1.34-4.05) and treatment of chronic occlusions (odds ratio=3.31; 95% confidence interval, 1.05-10.46). Cardiac tamponade occurred in seven cases (46.7%), six of which were subacute. Three cases were resolved by pericardiocentesis, while four required surgical drainage. Cardiac tamponade was associated with the number of guide wires used (P=.039) and the use of abciximab (P=.016). No death occurred.

Failed pericardiocentesis for acute cardiac tamponade: two cases associated with bivalirudin administration during PCI

Successful management of acute cardiac tamponade secondary to coronary artery perforation during percutaneous coronary intervention (PCI) includes sealing off the site of perforation and pericardiocentesis. We report two cases of acute cardiac tamponade during PCI associated with the administration of bivalirudin, in which attempts at percutaneous pericardiocentesis failed, due to the present of thrombus, rather blood, in the pericardium.

Direct stenting versus predilatation and stenting technique when using paclitaxel-eluting stents

Direct stenting without predilatation is a well-defined, feasible method with bare metal stents. Direct stenting has also been shown to be safe and feasible with drug-eluting stents, however, there is much less evidence with this type of device when compared with bare metal stents. Three hundred and sixty-four coronary lesions in 257 consecutive patients (mean age, 57.4 +/- 9.8 years; 63 women) who had undergone elective stenting either with or without predilatation via a paclitaxel-eluting stent between March 2003 and March 2006 were retrospectively analyzed. Quantitative coronary angiography analysis was compared between the two groups of procedures; stenting with predilatation and direct stenting. All procedures were uneventful. No deaths occurred during the follow-up period. Direct stenting when compared with the predilatation technique, significantly decreased both procedure time (32.1 +/- 17.9 minute versus 41.2 +/- 18.6 minute, P < 0.0001) and fluoroscopy time (10.6 +/- 7.8 minute versus 15.5 +/- 7.6 minute, P < 0.0001). There was no difference in quantitative analysis parameters of coronary angiography during follow-up or the rates of stent thrombosis and restenosis. Direct stenting seems to be as feasible and safe as conventional predilatation and stenting in selected cases. Direct stenting seems to decrease procedural time and radiation exposure without any negative effect on quantitative analysis parameters of coronary angiography with approximately a one-year follow-up period.

Initial Impact of Drug-Eluting Stents on Coronary Artery Bypass Grafting

The impact of drug-eluting stents (DES) on the characteristics and operative results of patients referred for coronary artery bypass grafting (CABG) was studied. We reviewed data from isolated CABG patients 24 months before (group A, n = 134) and 24 months after (group B, n = 98) the introduction of DES for clinical use at Teikyo University Hospital in Tokyo. Group B patients were significantly older than those of group A (66 +/- 9 versus 69 +/- 9 years old). The number of diseased vessels was significantly larger in group B (2.5 +/- 0.6 versus 2.7 +/- 0.5) and left main trunk disease decreased in group B (27% versus 17%). Preoperative IABP support was more frequent in group B (9% versus 17%) and beating heart surgery was significantly more frequent in group B (26% versus 59%). The number of grafts was similar in the 2 groups (3.2 +/- 1.4 versus 3.0 +/- 1.1). The operative mortality rates were 0.7% and 4.1% in group A and B, respectively. Incomplete revascularization followed by postoperative percutaneous coronary intervention (PCI) was performed in 11% and 12%, respectively, and all the patients survived surgery. The operative mortality rates for arrested heart and beating heart surgery were 2% and 2%, respectively. In conclusion, after the introduction of DES, more clinically ill patients were referred to CABG. Combination therapy consisting of CABG and PCI (Hybrid) may be a treatment of choice in critical patients.