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

Maximizing Minimally Invasive Cardiac Surgery With Enhanced Recovery (ERAS)

We convened a group of cardiac surgeons, intensivists, and anesthesiologists with extensive experience in minimally invasive cardiac surgery (MICS) and perioperative care to identify the essential elements of a MICS program and the relationship with Enhanced Recovery After Surgery (ERAS). The MICS incision should minimize tissue invasion without compromising surgical goals. MICS also requires safe management of hemodynamics and preservation of cardiac function, which we have termed myocardial management. Finally, comprehensive perioperative care through an ERAS program should be provided to allow patients to achieve optimal recovery. Therefore, we propose that MICS requires 3 elements: (1) a less invasive surgical incision (non-full sternotomy), (2) optimized myocardial management, and (3) ERAS. We contend that the full benefit of MICS can be achieved only by also utilizing an ERAS platform.

Aspirin dosage for the prevention of graft occlusion in people undergoing coronary surgery: A systematic review and meta-analysis

Background:

Aspirin is almost always used after coronary artery bypass graft (CABG) surgery; however, it is unclear what optimal dose should be prescribed. In this systematic review, we evaluated the effects of high versus low-dose aspirin in patients after CABG.

Methods:

A comprehensive database search was conducted in several databases from date of inception until February 2018. There were no language restrictions. We included studies that compared different doses of aspirin in patients that had undergone CABG surgery. We included studies that evaluated patient-important outcomes (mortality, cardiovascular events, and gastrointestinal bleeding); and if not reported, we collected data on the surrogate outcome thromboxane B2 (TXB2). We collected relevant data and performed a meta-analysis.

Results:

We identified 5903 references, and after two levels of screening by two independent reviewers, we included three randomized controlled trials in the meta-analysis with a total number of 122 participants. Mean age of trial participants was 65.63 years, and 88.68% were male. We planned to analyze all possible clinical outcomes, including mortality, recurrence, and hospitalization. However, no clinical outcomes are reported by the literature. The surrogate biochemical outcome of serum TXB2 was the only outcome reported by the eligible studies. High-dose aspirin (162–325mg once daily) achieved better suppression of TXB2 than low-dose aspirin (75–100mg once daily) (mean difference [MD], 2.00ng/mL, 95% confidence interval [CI]: 0.72–3.32; participants = 122; studies = 3; I² = 0%).

Conclusions:

We found no clinical trials addressing any of the clinical outcomes of interest. High-dose aspirin was superior to low-dose aspirin in suppressing platelet function, a surrogate outcome. Trials evaluating clinical and patient-important outcomes are needed to better inform medical practice and fill this gap in clinical knowledge.

Minimally invasive coronary artery bypass grafting: useful routine option for coronary revascularization in selected cases

OBJECTIVES

The safety and feasibility of minimally invasive coronary artery bypass grafting (MICS CABG) were evaluated.

METHODS

From December 2012 to March 2019, 122 consecutive patients underwent MICS CABG via a left mini-thoracotomy under direct vision. The internal thoracic artery (ITA) was harvested from all, while bilateral ITAs (BITAs) were used in 36 patients, with the second ITA as an in situ (n = 18) or free (n = 18) graft. Proximal anastomosis of the free graft (ITA, radial artery, or saphenous vein segments) was performed directly onto the ascending aorta, or from the ITA as a Y- or I-composite graft.

RESULTS

Patient ages ranged from 38 to 89 years (mean 66.9 ± 9.6 years) and 102 were males. MICS CABG was completed without conversion in 116 patients (95.1%), of whom 76 underwent multivessel bypass grafting, with 2 grafts used in 52 and 3 or more in 24 patients. A cardiopulmonary bypass was performed in 17 patients. Perioperative mortality occurred in 1 patient who died of advanced cancer. There were no cases of reoperation for bleeding, stroke, or chest wound infection. The perioperative transfusion rate was 11.2%. Early graft patency was noted in 97.1%. The rate of freedom from major adverse cardiac and cerebrovascular events (all-cause death, myocardial infarction, stroke, and repeated revascularization) was 89.7% at 5 years.

CONCLUSIONS

MICS CABG is feasible and showed good mid-term outcomes. BITAs can be harvested with this approach; thus, allowing for various graft designs. We recommend this as a useful option for coronary revascularization in selected cases.

Minimally Invasive Multivessel Coronary Surgery and Hybrid Coronary Revascularization: Can We Routinely Achieve Less Invasive Coronary Surgery?

Coronary artery bypass grafting (CABG) is the gold standard in managing severe coronary artery disease. However, it is associated with prolonged recovery and potential complications, in part due to the invasiveness of the procedure. Less invasive CABG techniques attempt to improve the quality and quantity of life in the same way as surgical revascularization but with fewer complications. Minimally invasive coronary surgery (MICS) through a small thoracotomy allows for complete revascularization with good results in graft patency. Perioperative mortality is low, and there is decreased need for blood transfusion, lower surgical site infection rates, and an earlier return to full physical function. Hybrid coronary revascularization (HCR) attempts to combine the advantages of coronary artery bypass grafting with those of percutaneous coronary intervention. Several studies have shown that HCR provides better short-term outcomes with regard to decreased ventilation and ICU time, reduced need for blood transfusion, and shortened hospital stay. However, the rates for major adverse cardiovascular events and mortality are comparable to conventional CABG, except for patients with a high SYNTAX score who displayed increased mortality rates. There is also strong evidence of a higher need for repeat revascularization with HCR compared to CABG. Overall, MICS and HCR appear to be viable alternatives to conventional CABG, offering a less invasive approach to coronary revascularization, which may be especially beneficial to high-risk patients. This article discusses approaches that deliver the advantages of minimally invasive surgical revascularization that can be adapted by surgeons with minimal investment with regards to training and infrastructure.

A nationwide survey on perception, experience, and expectations of hybrid coronary revascularization among top-ranked US hospitals

BACKGROUND

Hybrid coronary revascularization (HCR) combines a surgical and percutaneous approach for treatment of multivessel coronary artery disease.

METHODS

A survey was conducted among 200 cardiologists and cardiac surgeons from 100 top-ranked US hospitals. Questions were asked involving the perception, experience, and future expectations of HCR.

RESULTS

Of physicians invited to the survey, 90 completed the survey (45.5%). Relative to nonresponders, responders were more often affiliated with an academic institution (80.0% vs 61.8%, P=.005), with higher patient volumes, and with the availability of a hybrid operating room (90.0% vs 67.3%, P<.001). Survey responders felt that HCR should be considered in an older and relatively healthy patient population without complex lesions. Cardiac surgeons were more favorable to use HCR in patients with chronic lung disease (42.0% vs 10.0%, P<.001) or renal failure (28.0% vs 15.0%, P=.06). Among responders with HCR experience (n=54), 94% reported good to excellent results, and the learning curve differed depending on the surgical technique used. Inappropriate patient selection (41.2%) was the most common cause for complications. Three-quarter of responders believe that the future role for HCR will expand in the next decade. Important determinants of greater HCR use in the future were collaborative associations between cardiac surgeons and cardiologists (86.7%), appropriate patient selection (67.8%), and the outcomes of ongoing clinical trials (57.8%).

CONCLUSION

In this nationwide survey, cardiologists and cardiac surgeons felt that HCR is a reasonable alternative technique for coronary revascularization among suitable patients. Most felt that use of HCR would increase in the next decade.

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.

Clinical outcomes after hybrid coronary revascularization versus coronary artery bypass surgery: a meta-analysis of 1,190 patients

BACKGROUND

Hybrid coronary revascularization (HCR) represents a minimally invasive revascularization strategy in which the durability of the internal mammary artery to left anterior descending artery graft is combined with percutaneous coronary intervention to treat remaining lesions. We performed a systematic review and meta-analysis to compare clinical outcomes after HCR with conventional coronary artery bypass graft (CABG) surgery.

METHODS

A comprehensive EMBASE and PUBMED search was performed for comparative studies evaluating in-hospital and 1-year death, myocardial infarction (MI), stroke, and repeat revascularization.

RESULTS

Six observational studies (1 case control, 5 propensity adjusted) comprising 1,190 patients were included; 366 (30.8%) patients underwent HCR (185 staged and 181 concurrent), and 824 (69.2%) were treated with CABG (786 off-pump, 38 on-pump). Drug-eluting stents were used in 328 (89.6%) patients undergoing HCR. Hybrid coronary revascularization was associated with lower in-hospital need for blood transfusions, shorter length of stay, and faster return to work. No significant differences were found for the composite of death, MI, stroke, or repeat revascularization during hospitalization (odds ratio 0.63, 95% CI 0.25-1.58, P = .33) and at 1-year follow-up (odds ratio 0.49, 95% CI 0.20-1.24, P = .13). Comparisons of individual components showed no difference in all-cause mortality, MI, or stroke, but higher repeat revascularization among patients treated with HCR.

CONCLUSIONS

Hybrid coronary revascularization is associated with lower morbidity and similar in-hospital and 1-year major adverse cerebrovascular or cardiac events rates, but greater requirement for repeat revascularization compared with CABG. Further exploration of this strategy with adequately powered randomized trials is warranted.

Concurrent Coronary Artery and Valvular Heart Disease - Hybrid Treatment Strategies in 2013

Concomitant coronary artery disease (CAD) and valvular heart disease is an increasingly common problem in the ageing population. Hybrid procedures combine surgical and transcatheter approaches to facilitate minimally invasive surgery or to transform a single high-risk open surgery into two less risky procedures. In ideal circumstances, this strategy may decrease the surgical risk in elderly, high-risk and reoperative surgical candidates, while improving patient comfort, convenience and cost-effectiveness. Hybrid procedures can be performed in a staged fashion or as a 'one-stop' procedure in a hybrid operating suite. Increasing evidence supports the safety and short-term efficacy of hybrid valve repair or replacement and coronary revascularisation procedures. Nevertheless, important questions remain, including the optimal timing of the individual procedures and the optimal antiplatelet therapy after percutaneous coronary intervention. With ongoing advances in procedural techniques and anticoagulation strategies, as well as the accumulation of long-term outcomes data, hybrid approaches to concomitant CAD and valvular heart disease will likely become increasingly common.