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Leviner DB, Torregrossa G, Puskas JD. Incomplete revascularization: what the surgeon needs to know. Ann Cardiothorac Surg 2018; 7:463-469. [PMID: 30094210 DOI: 10.21037/acs.2018.06.07] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
For many years, the concept of "complete revascularization" (CR) was considered an absolute truth in coronary surgery with improved long-term survival and a lower rate of reintervention. This was derived from early publications which showed a survival benefit for patients undergoing coronary artery bypass grafting (CABG) who received CR. Many advances in the field of coronary revascularization have been made in the years that passed since those publications, including more frequent use of percutaneous coronary intervention (PCI) in patients with multivessel disease (MVD). This has led some to question the importance of CR and raise the option of "reasonable incomplete revascularization" (IR) for selected patients. The definition of CR is variable in the literature with the two most common definitions being an anatomical (revascularization of all coronary segments with stenosis and larger than a predefined size) and a functional definition (where revascularization is considered complete if all ischemic and viable territories are reperfused). No randomized control trials have been conducted to compare complete versus IR, and a significant proportion of data is based on post hoc analysis of data from randomized control trials and registries. Multiple studies have proven that CR is achieved more frequently with CABG then with PCI. A review of the available data from the past three to four decades shows a trend toward improved results with CR, regardless of the reperfusion strategy chosen. This should impact the heart team discussion when choosing a revascularization strategy and impact the surgical decision making while preforming CABG. IR can be part of a hybrid revascularization strategy or be reserved for rare cases where the cost of achieving CR much outweighs the benefit.
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Affiliation(s)
- Dror B Leviner
- Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Gianluca Torregrossa
- Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - John D Puskas
- Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Modrau IS, Nielsen PH, Bøtker HE, Christiansen EH, Krusell LR, Kaltoft AK, Mæng M, Terkelsen CJ, Kristensen SD, Lassen JF, Thuesen L. Feasibility and early safety of hybrid coronary revascularisation combining off-pump coronary surgery through J-hemisternotomy with percutaneous coronary intervention. EUROINTERVENTION 2015; 10:e1-6. [PMID: 24103704 DOI: 10.4244/eijv10i10a195] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS To assess the procedural feasibility and early safety of hybrid coronary revascularisation, combining off-pump left internal mammary artery grafting to the left descending coronary artery (LAD) through an inferior J-hemisternotomy (JOPCAB) with percutaneous coronary intervention (PCI) of non-LAD lesions. METHODS AND RESULTS A total of 100 patients with multivessel coronary artery disease involving LAD were included in this prospective registry. Hybrid revascularisation was performed by JOPCAB, either prior to PCI (89%) or following PCI (11%). In 96% of the cases, the procedure was carried out according to the preoperative strategy and without perioperative (24 hours) major adverse cardiac or cerebral events. At one month, we observed no deaths, one stroke and two procedure-related myocardial infarctions. Five patients underwent reoperation for graft dysfunction, four of whom were identified by angiography without prior signs of ischaemia. Reoperation due to bleeding was necessary in six patients, and nine patients received red blood cell transfusion. CONCLUSIONS Our prospective registry documented promising procedural feasibility and early safety of coronary hybrid revascularisation combining JOPCAB with PCI. ClinicalTrials.gov identifier: NCT01496664.
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Affiliation(s)
- Ivy S Modrau
- Department of Cardiothoracic Surgery, Aarhus University Hospital, Skejby, Aarhus, Denmark
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Jaik NP, Umakanthan R, Leacche M, Solenkova N, Balaguer JM, Hoff SJ, Ball SK, Zhao DX, Byrne JG. Current status of hybrid coronary revascularization. Expert Rev Cardiovasc Ther 2014; 9:1331-7. [DOI: 10.1586/erc.11.124] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Harskamp RE, Zheng Z, Alexander JH, Williams JB, Xian Y, Halkos ME, Brennan JM, de Winter RJ, Smith PK, Lopes RD. Status quo of hybrid coronary revascularization for multi-vessel coronary artery disease. Ann Thorac Surg 2013; 96:2268-77. [PMID: 24446561 PMCID: PMC4339110 DOI: 10.1016/j.athoracsur.2013.07.093] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
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.
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Thuesen L, Modrau IS, Nielsen PH, Boetker HE. Hybrid coronary revascularization: a mainstream revascularization strategy in the future? Interv Cardiol 2013. [DOI: 10.2217/ica.13.42] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Abstract
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.
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Hybrid coronary revascularization as a safe, feasible, and viable alternative to conventional coronary artery bypass grafting: what is the current evidence? Minim Invasive Surg 2013; 2013:142616. [PMID: 23691303 PMCID: PMC3649801 DOI: 10.1155/2013/142616] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2012] [Accepted: 03/13/2013] [Indexed: 11/30/2022] Open
Abstract
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.
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Hybrid Coronary Revascularization Using Robotic Totally Endoscopic Surgery: Perioperative Outcomes and 5-Year Results. Ann Thorac Surg 2012; 94:1920-6; discussion 1926. [DOI: 10.1016/j.athoracsur.2012.05.041] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2012] [Revised: 05/08/2012] [Accepted: 05/11/2012] [Indexed: 01/09/2023]
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Clinical outcomes after hybrid coronary revascularization versus off-pump coronary artery bypass: a prospective evaluation. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2012; 4:299-306. [PMID: 22437225 DOI: 10.1097/imi.0b013e3181bbfa96] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE : Hybrid coronary revascularization is offered as an alternative strategy for patients with multivessel coronary artery disease (CAD). We present our experience and provide a comparative analysis to off-pump coronary artery bypass grafting (OPCAB). METHODS : Ninety-one patients with multivessel CAD underwent minimally invasive left internal mammary artery to left anterior descending grafting in combination with percutaneous coronary intervention of nonleft anterior descending targets (HYBRID). The primary end point of this study was major adverse cardiac and cerebrovascular events (MACCE), defined as death, stroke, and nonfatal myocardial infarction. MACCE in the HYBRID group were compared with 4175 contemporaneously performed OPCAB operations by logistic (30-day outcomes) and Cox proportional hazards (long-term survival) regression methods. Propensity scoring was used to adjust for potential selection bias. RESULTS : The 30-day MACCE (death/stroke/nonfatal myocardial infarction) rate was 1.1% for the HYBRID group (0%/0%/1.1%) and 3.0% for the OPCAB group (1.8%/1.1%/0.5%) (odds ratio = 0.47, P = 0.48). Angiographic left internal mammary artery evaluation was obtained in 95.6% of patients (87 of 91) revealing FitzGibbon A patency in 98.0% (96 of 98). The reintervention rate at 1 year for the HYBRID group was 5.5% (5 of 91) and was limited to repeat percutaneous coronary intervention. Three-year survival was statistically similar for the two groups (hazard ratio = 0.44, P = 0.18, see Kaplan-Meier figure). CONCLUSIONS : Hybrid coronary revascularization may be noninferior to OPCAB with respect to early MACCE and 3-year survival in the treatment of multivessel CAD.
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Shannon J, Colombo A, Alfieri O. Do hybrid procedures have proven clinical utility and are they the wave of the future? : hybrid procedures have proven clinical utility and are the wave of the future. Circulation 2012; 125:2492-503; discussion 2503. [PMID: 22615420 DOI: 10.1161/circulationaha.111.041186] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Leacche M, Zhao DX, Umakanthan R, Byrne JG. Do hybrid procedures have proven clinical utility and are they the wave of the future? : hybrid procedures have no proven clinical utility and are not the wave of the future. Circulation 2012; 125:2504-10; discussion 2510. [PMID: 22615421 DOI: 10.1161/circulationaha.111.031138] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Marzia Leacche
- Vanderbilt University Medical Center, Department of Cardiac Surgery, 1215 21st Ave S, Nashville, TN 37232-8802
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Hybrid myocardial revascularization - the cardiologist's view. COR ET VASA 2012. [DOI: 10.1016/j.crvasa.2012.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Autologous microsurgical breast reconstruction and coronary artery bypass grafting: an anatomical study and clinical implications. Breast Cancer Res Treat 2012; 134:181-98. [PMID: 22270931 DOI: 10.1007/s10549-011-1948-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2011] [Accepted: 12/26/2011] [Indexed: 10/14/2022]
Abstract
OBJECTIVE To identify possible avenues of sparing the internal mammary artery (IMA) for coronary artery bypass grafting (CABG) in women undergoing autologous breast reconstruction with deep inferior epigastric artery perforator (DIEP) flaps. BACKGROUND Optimal autologous reconstruction of the breast and coronary artery bypass grafting (CABG) are often mutually exclusive as they both require utilisation of the IMA as the preferred arterial conduit. Given the prevalence of both breast cancer and coronary artery disease, this is an important issue for women's health as women with DIEP flap reconstructions and women at increased risk of developing coronary artery disease are potentially restricted from receiving this reconstructive option should the other condition arise. METHODS The largest clinical and cadaveric anatomical study (n=315) to date was performed, investigating four solutions to this predicament by correlating the precise requirements of breast reconstruction and CABG against the anatomical features of the in situ IMAs. This information was supplemented by a thorough literature review. RESULTS Minimum lengths of the left and right IMA needed for grafting to the left-anterior descending artery are 160.08 and 177.80 mm, respectively. Based on anatomical findings, the suitable options for anastomosis to each intercostals space are offered. In addition, 87-91% of patients have IMA perforator vessels to which DIEP flaps can be anastomosed in the first- and second-intercostal spaces. CONCLUSION We outline five methods of preserving the IMA for future CABG: (1) lowering the level of DIEP flaps to the fourth- and fifth-intercostals spaces, (2) using the DIEP pedicle as an intermediary for CABG, (3) using IMA perforators to spare the IMA proper, (4) using and end-to-side anastomosis between the DIEP pedicle and IMA and (5) anastomosis of DIEP flaps using retrograde flow from the distal IMA. With careful patient selection, we hypothesize using the IMA for autologous breast reconstruction need not be an absolute contraindication for future CABG.
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Abstract
The long-term benefits of a left internal mammary artery bypass graft compared to the left anterior descending artery have been well described. The use of drug-eluting stents has minimized the morbidity of revascularization. Hybrid coronary revascularization is the planned use of minimally invasive surgical techniques for left internal mammary artery-left anterior descending artery grafting and the use of percutaneous coronary intervention for nonleft anterior descending coronary artery target revascularization. The optimal timing and order of revascularization in hybrid coronary revascularization remains unclear.
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Bonaros N, Schachner T, Wiedemann D, Weidinger F, Lehr E, Zimrin D, Friedrich G, Bonatti J. Closed chest hybrid coronary revascularization for multivessel disease - current concepts and techniques from a two-center experience. Eur J Cardiothorac Surg 2011; 40:783-7. [PMID: 21459599 DOI: 10.1016/j.ejcts.2011.01.055] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2010] [Revised: 01/24/2011] [Accepted: 01/25/2011] [Indexed: 11/18/2022] Open
Abstract
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.
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Affiliation(s)
- Nikolaos Bonaros
- Department of Cardiac Surgery, Innsbruck Medical University, Anichstrasse 35, A-6020 Innsbruck, Austria.
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Umakanthan R, Leacche M, Zhao DX, Gallion AH, Mishra PC, Byrne JG. Hybrid options for treating cardiac disease. Semin Thorac Cardiovasc Surg 2011; 23:274-80. [PMID: 22443646 DOI: 10.1053/j.semtcvs.2011.12.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2011] [Indexed: 11/11/2022]
Abstract
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.
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Affiliation(s)
- Ramanan Umakanthan
- Department of Cardiac Surgery, Vanderbilt Heart and Vascular Institute, Nashville, Tennessee 37232-8802, USA
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DeRose JJ. Current state of integrated "hybrid" coronary revascularization. Semin Thorac Cardiovasc Surg 2010; 21:229-36. [PMID: 19942121 DOI: 10.1053/j.semtcvs.2009.08.004] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/17/2009] [Indexed: 11/11/2022]
Abstract
The long-term benefits of a left internal mammary artery bypass graft to the left anterior descending artery (LAD) have been well described. As the patient population with multivessel coronary artery disease has grown older with greater comorbidities, less invasive approaches to revascularization have been explored. The use of drug-eluting stents has minimized the morbidity of revascularization but has failed to match the durability of coronary artery bypass grafting (CABG). Hybrid coronary revascularization (HCR) is the planned use of minimally invasive surgical techniques for left internal mammary artery-LAD grafting and the use of percutaneous coronary interventions (PCI) for non-LAD target revascularization. The optimal timing and order of revascularization in HCR remains unclear. Novel operating suites with surgical and fluoroscopic capabilities have begun to support the performance of simultaneous minimally invasive CABG and PCI. The role of HCR compared to both PCI and conventional CABG awaits the results of ongoing randomized clinical trials.
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Affiliation(s)
- Joseph John DeRose
- Cardiothoracic Surgery, Montefiore-Einstein Heart Center, Bronx, New York 10461, USA.
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Popma JJ, Nathan S, Hagberg RC, Khabbaz KR. Hybrid myocardial revascularization: An integrated approach to coronary revascularization. Catheter Cardiovasc Interv 2010; 75 Suppl 1:S28-34. [DOI: 10.1002/ccd.22402] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Vassiliades TA, Kilgo PD, Douglas JS, Babaliaros VC, Block PC, Samady H, Cates CU, Rab ST, Morris DC. Clinical Outcomes after Hybrid Coronary Revascularization versus Off-Pump Coronary Artery Bypass. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2009. [DOI: 10.1177/155698450900400602] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Thomas A. Vassiliades
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, GA USA
| | - Patrick D. Kilgo
- Department of Biostatistics and Bioinformatics, Emory University School of Public Health, Atlanta, GA USA
| | - John S. Douglas
- Division of Cardiology, Emory University School of Medicine, Atlanta, GA USA
| | | | - Peter C. Block
- Division of Cardiology, Emory University School of Medicine, Atlanta, GA USA
| | - Habib Samady
- Division of Cardiology, Emory University School of Medicine, Atlanta, GA USA
| | | | - S. Tanveer Rab
- Division of Cardiology, Emory University School of Medicine, Atlanta, GA USA
| | - Douglas C Morris
- Division of Cardiology, Emory University School of Medicine, Atlanta, GA USA
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Hybrid Cardiovascular Procedures. JACC Cardiovasc Interv 2008; 1:459-68. [PMID: 19463346 DOI: 10.1016/j.jcin.2008.07.002] [Citation(s) in RCA: 113] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2008] [Revised: 07/08/2008] [Accepted: 07/12/2008] [Indexed: 11/22/2022]
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Current status of coronary artery bypass grafting. Gen Thorac Cardiovasc Surg 2008; 56:260-7. [DOI: 10.1007/s11748-008-0251-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2007] [Indexed: 10/21/2022]
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Vassiliades TA, Douglas JS, Morris DC, Block PC, Ghazzal Z, Rab ST, Cates CU. Integrated coronary revascularization with drug-eluting stents: Immediate and seven-month outcome. J Thorac Cardiovasc Surg 2006; 131:956-62. [PMID: 16678575 DOI: 10.1016/j.jtcvs.2005.10.058] [Citation(s) in RCA: 81] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2005] [Revised: 08/25/2005] [Accepted: 10/04/2005] [Indexed: 11/28/2022]
Abstract
OBJECTIVE We sought to demonstrate the safety and feasibility of an integrated coronary revascularization strategy that combines minimally invasive left internal thoracic artery to left anterior descending coronary artery anastomosis with drug-eluting stent implantation to non-left anterior descending coronary artery lesions. METHODS Over 18 months, 47 consecutive patients with multivessel coronary artery disease underwent thoracoscopic harvesting of the left internal thoracic artery to graft the left anterior descending coronary artery. Anastomoses were constructed by hand, off-pump, and under direct vision through a 4-cm non-rib-spreading, muscle-sparing chest incision. Non-left anterior descending coronary artery lesions were then treated percutaneously using sirolimus- or paclitaxel-eluting stents. Angiographic follow-up was performed in all patients. RESULTS Within the first 90 days of hospitalizations, there were no deaths, myocardial infarctions, neurologic events, or wound complications. Forty patients underwent left internal thoracic artery to left anterior descending coronary artery grafting, and 7 patients underwent left internal thoracic artery to left anterior descending coronary artery/diagonal sequential grafting for a total of 54 anastomoses. Angiographic patency scores were FitzGibbon A 96.2% (52/54) and FitzGibbon A + B 100% (54/54). A total of 65 drug-eluting stents were implanted in 61 non-left anterior descending coronary artery coronary lesions of which 49.1% (30/61) were type B2 or C lesions, including 5 left main lesions. Diabetes was present in 53.2% of patients (25/47). At a mean follow-up time of 7.0 +/- 4.8 months, the target lesion or vessel repeat revascularization rate was 6.6% (4/61) for drug-eluting stents and 1.9% (1/54) for left internal thoracic artery to left anterior descending coronary artery grafting. One anastomosis required balloon dilation, but no patients have required repeat coronary artery bypass grafting. CONCLUSIONS Integrated coronary revascularization using drug-eluting stents is feasible and safe. There are sufficient data to justify a randomized comparison of integrated coronary revascularization with standard coronary artery bypass grafting.
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Affiliation(s)
- Thomas A Vassiliades
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Ga, USA.
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Murphy GJ, Bryan AJ, Angelini GD. Hybrid Coronary Revascularization in the Era of Drug-Eluting Stents. Ann Thorac Surg 2004; 78:1861-7. [PMID: 15511503 DOI: 10.1016/j.athoracsur.2004.07.024] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/14/2004] [Indexed: 11/30/2022]
Abstract
Left internal mammary artery to left anterior descending coronary artery bypass grafting integrated with percutaneous coronary angioplasty (hybrid procedure) offers multivessel revascularization with minimal morbidity in high-risk patients. This is caused in part by the avoidance of cardiopulmonary bypass-related morbidity and manipulation of the aorta coupled with minimally invasive techniques. Hybrid revascularization is currently reserved for particularly high-risk patients or those with favorable anatomic variants however, largely because of the emergence of off-pump coronary artery bypass grafting, which permits more complete multivessel revascularization, with low morbidity in high-risk groups. The wider introduction of hybrid revascularization is limited chiefly by the high number of repeat interventions compared with off-pump coronary artery bypass grafting, which occurs because of the target vessel failure rate of percutaneous coronary intervention. Other demerits are the costs and logistic problems associated with performing two procedures with differing periprocedural management protocols. Recently, drug-eluting stents have reduced the need for repeat intervention after percutaneous coronary intervention, and this has raised the possibility that the results of hybrid revascularization may now equal or even better those of off-pump coronary artery bypass grafting. Although undoubtedly effective at reducing in-stent restenosis, drug-eluting stents will not address the issues of incomplete revascularization or the logistic problems associated with hybrid. Uncertainty regarding the long-term effectiveness of drug-eluting stents in many patients, as well as their high cost when compared with those of off-pump coronary artery bypass grafting surgery, also militates against the wider introduction of hybrid revascularization.
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Affiliation(s)
- Gavin J Murphy
- Bristol Heart Institute, University of Bristol, Bristol, United Kingdom
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Nezić D, Milojević P, Knezević A, Cirković M, Lausević-Vuk L, Jović M, Djukanović B. [Surgical revascularization of the myocardium]. ACTA CHIRURGICA IUGOSLAVICA 2003; 50:87-98. [PMID: 14994575 DOI: 10.2298/aci0302087n] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Abstract
It has been 45 years ago when Longmire (1958.) used internal thoracic artery (ITA) for the first time in coronary artery bypass surgery (CABG). In this review, we are presenting novel surgical approaches in CABG surgery. We have also been summarized the best of knowledge, up to date, regarding histology, pharmacology and pathophysiology of conduits (VSM, ITA and alternative venous and arterial grafts) which have been used in CABG surgery, as well as factors influence on its short and long-term patency.
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Affiliation(s)
- D Nezić
- Institut za kardiovaskularne bolesti Dedinje, Beograd
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Amodeo VJ, Donias HW, Dancona G, Hoover EL, Karamanoukian HL. The hybrid approach to coronary artery revascularization: minimally invasive direct coronary artery bypass with percutaneous coronary intervention. Angiology 2002; 53:665-9. [PMID: 12463619 DOI: 10.1177/000331970205300606] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
In the past decade, new developments in cardiology and cardiac surgery have begun to offer patients a variety of new, less invasive options for the treatment of coronary artery disease. One such option is the hybrid approach to coronary artery revascularization. This combines minimally invasive direct coronary artery bypass surgery (MIDCAB) of the left anterior descending artery (LAD) with percutaneous coronary intervention (PCI) of the remaining diseased coronary arteries. This approach, as an alternative to conventional coronary artery bypass surgery, retains the benefit of internal mammary artery bypass to the LAD, accomplished with a minimally invasive technique, substitutes PCI for saphenous vein grafts as treatment for low-grade lesions of other coronary arteries, and may provide a maximally beneficial outcome for many patients. Preliminary outcomes of patients receiving the hybrid approach have been strikingly positive. This report highlights the rationale for the development of this procedure, patient selection, results, and future applications of this emerging method of treating coronary artery disease.
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Affiliation(s)
- Victoria J Amodeo
- State University of New York at Buffalo School of Medicine and Biomedical Sciences, USA
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Kollar A, Misra V, Pierson RN. Postoperative coronary revascularization on LVAD support for surgically inaccessible myocardial ischemia. Catheter Cardiovasc Interv 2002; 55:381-4. [PMID: 11870947 DOI: 10.1002/ccd.10099] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The authors have used the concept of hybrid revascularization to salvage a patient in persistent cardiogenic shock after incomplete emergent surgical revascularization. While the patient was on left ventricular assist device support, a complex angioplasty was done on a surgically inaccessible right coronary artery, with subsequent cardiac recovery.
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Affiliation(s)
- Andras Kollar
- Department of Cardiac and Thoracic Surgery, Vanderbilt University Medical Center and Nashville VA Medical Center, Nashville, Tennessee 37232, USA
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ADVANCES IN THE SURGICAL TREATMENT OF CORONARY ARTERY DISEASE. Nurs Clin North Am 2000. [DOI: 10.1016/s0029-6465(22)02646-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Halon DA, Flugelman MY, Merdler A, Rennert HS, Weisz G, Shahla J, Lewis BS. Similar late revascularization rates 10 to 12 years after angioplasty or bypass surgery for multivessel coronary artery disease: a report from the Lady Davis Carmel Medical Center (LDCMC) Registry. Am J Cardiol 2000; 86:1131-4, A6. [PMID: 11074213 DOI: 10.1016/s0002-9149(00)01173-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
We compared completed long-term outcome and late repeat revascularization rates in 272 consecutive patients with multivessel coronary disease who underwent revascularization (95 angioplasty cohort, 177 surgical cohort) between 1984 and 1986. Long-term survival was similar at 12 years in the angioplasty (70%) and surgical (74%) cohorts (p = NS), and repeat revascularization, although more frequent in the angioplasty patients during the first 5 years of follow-up, was performed equally in the 2 patient cohorts after 10 to 12 years of follow-up.
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Affiliation(s)
- D A Halon
- Department of Cardiology, Lady Davis Carmel Medical Center and the Bruce Rappaport School of Medicine, Technion-IIT, Haifa, Israel
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Weber MM. Surgical management of unstable angina and symptomatic coronary artery disease. J Cardiovasc Nurs 2000; 15:27-42. [PMID: 11061219 DOI: 10.1097/00005082-200010000-00004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The treatment of coronary artery disease and, in particular, acute coronary syndromes has evolved from watchful waiting to an early aggressive intervention strategy. Patients are currently receiving either percutaneous or surgical revascularization. Several major clinical trials have identified those patients mostly likely to benefit from surgical intervention. These patients typically include those with left-main coronary artery disease, triple vessel disease with decreased left ventricular function, and other clinical risk factors. As a result of these studies, unique needs and outcomes of special populations have been identified. This article will present an overview of surgical treatment of coronary artery disease with emphasis on patient selection with particular attention to women, older persons, diabetic patients, and innovations in surgical techniques that may improve patient outcomes.
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Affiliation(s)
- M M Weber
- Department of Nursing Research and Education, The Cleveland Clinic Foundation, Ohio, USA
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Locker C, Shapira I, Paz Y, Kramer A, Gurevitch J, Matsa M, Pevni D, Mohr R. Emergency myocardial revascularization for acute myocardial infarction: survival benefits of avoiding cardiopulmonary bypass. Eur J Cardiothorac Surg 2000; 17:234-8. [PMID: 10758381 DOI: 10.1016/s1010-7940(00)00354-7] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE Emergency coronary artery bypass grafting (CABG) for acute myocardial infarction (AMI) is associated with increased operative mortality. It has been suggested that this mortality might be reduced by performing the operation without cardiopulmonary bypass (CPB). METHODS Between January 1992 and April 1998, 77 patients underwent emergency CABG within 48 h of AMI. Thirty seven were operated on with CPB, and 40 without CPB. The two groups were similar regarding age, gender, left-ventricular ejection fraction (EF) and preoperative use of intra-aortic balloon pump (IABP; 50%). The mean number of grafts/patient was 3 in the CPB group, and 1.9 in the No-CPB group (P<0.0001). RESULTS Operative mortality in the CPB group was 24% (nine of 37) compared to 5% (two of 40) without CPB (P=0.015). Follow-up ranged between 6 and 66 months. There were no late deaths in the CPB group compared to nine (22%) in the No-CPB group (P<0.0066). Patients operated on with CPB had lower rates of recurrent angina (0 versus 15%; P=0.04) and re-interventions (0 versus 15%; P=0.04). CONCLUSIONS Our experience suggests that CABG without CPB is the preferred method of myocardial revascularization, due to the fact that it carries lower mortality than CABG with CPB. The trade-off includes increased rates of recurrent angina, re-interventions and late mortality.
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Affiliation(s)
- C Locker
- Department of Thoracic and Cardiovascular Surgery, Tel Aviv Sourasky Medical Center, 6 Weizman St., Tel-Aviv, Israel
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Lewis BS, Porat E, Halon DA, Ammar R, Flugelman MY, Khader N, Merdler A, Weisz G, Uretzky G. Same-day combined coronary angioplasty and minimally invasive coronary surgery. Am J Cardiol 1999; 84:1246-7, A8. [PMID: 10569336 DOI: 10.1016/s0002-9149(99)00538-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Integrated myocardial revascularization combines the advantages of angioplasty, stenting, and minimally invasive surgery to revascularize patients with multivessel coronary artery disease without cardiopulmonary bypass. This pilot study showed that a new same-day management strategy, consisting of percutaneous coronary intervention followed immediately by minimally invasive surgery, was feasible and provided complete all-arterial revascularization with minimal surgical trauma, short hospital stay, and excellent early therapeutic result in 14 patients with multivessel coronary disease.
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Affiliation(s)
- B S Lewis
- Department of Cardiology, Lady Davis Carmel Medical Center, Haifa, Israel.
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Beranek JT. Emerging new concepts of myocardial laser revascularization. J Thorac Cardiovasc Surg 1999; 118:977-8. [PMID: 10534716 DOI: 10.1016/s0022-5223(99)70081-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Wittwer T, Cremer J, Klima U, Wahlers T, Haverich A. Myocardial "hybrid" revascularization: intermediate results of an alternative approach to multivessel coronary artery disease. J Thorac Cardiovasc Surg 1999; 118:766-7. [PMID: 10504652 DOI: 10.1016/s0022-5223(99)70035-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Abstract
The impetus to reduce the trauma of surgery witnessed over the past decade in all fields of surgery has recently extended into the cardiac surgical arena; however, unlike other specialties, the invasiveness of cardiac surgery can be reduced by limiting the size of incisions and by avoiding cardiopulmonary bypass. This article reviews the rationale, clinical experience, and outcomes of the minimally invasive approaches to cardiac surgery that have evolved over the past 2 years and glimpses into the future of this rapidly evolving field.
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Affiliation(s)
- D J Goldstein
- Department of Surgery, Columbia Presbyterian Medical Center, New York, New York, USA.
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