Hybrid Myocardial Revascularization Research Articles

Transient internal mammary artery graft stenosis on early angiography: navigating pitfalls in hybrid myocardial revascularization.

Left internal mammary artery (LIMA) graft stenoses detected at early coronary angiography may be reversible and consequently prompt unnecessary graft revision. We aim to investigate the frequency, natural course, and clinical significance of internal mammary artery graft stenosis upon early angiography in patients undergoing hybrid myocardial revascularization. In this retrospective sub-study of the Coronary Hybrid Revascularization Study, we compared graft appearance, ie, stenosis degree and flow, on early (in-hospital) and scheduled follow-up coronary angiography after 1 year. We assessed the change in graft patency using the Fitzgibbon classification (grade A: unimpaired runoff; grade B > 50% stenosis; grade O: occlusion), as well as graft association with adverse events (death, myocardial infarction, stroke, and repeat revascularization) at up to 5-year follow-up. We report clinical follow-up data for all 131 patients included in the Coronary Hybrid Revascularization Study. Change in graft patency was analyzed in 86 patients with satisfactory visualization of the LIMA graft on early and follow-up coronary angiography. All LIMA grafts were patent at discharge and follow-up. Twenty-seven of 37 (73%) grade B graft stenoses at early angiography resolved to grade A during follow-up of median 12 months (range, 8-83 months) after surgery. Angiographically significant graft stenoses at early coronary angiography were not associated with adverse clinical outcome up to 5-year follow-up. Our results suggest that the majority of clinically silent LIMA graft stenoses resolve during follow-up and are not associated with adverse clinical outcomes.

The choice of coronary revascularization method depending on comorbid pathology

Coronary heart disease plays a leading role in global mortality statistics. Despite the obvious progress in the development of new drug regimens, surgical treatment remains an important component. The high prevalence and complexity of treatment of patients with CHD and comorbid pathology, especially diabetes mellitus and chronic kidney disease, make researchers think about proper approaches to therapy of such patients. The decision to perform revascularization is made in consultation with all Heart Team members, taking into account the results of the invasive study, the presence of complaints in the patient and his "response" to drug therapy. Percutaneous coronary interventions (PCI) are still statistically more likely to result in restenosis and repeat revascularizations than open surgery. Hybrid myocardial revascularization is an alternative method combining the advantages of coronary artery bypass and PCI and reducing the risks of both procedures adverse complications. The choice of the optimal strategy of surgical treatment in patients with comorbid pathology requires special attention.

P230 A RARE CASE OF INFECTIVE MYOCARDIAL INFARCTION

Abstract Background Prosthetic valve endocarditis (PVE) occurs in 1–6% of patients with valve prostheses. The most common agent of late PVE are S. aureus and Streptococci. Spondylodiscitis may precede the onset of endocarditis or may be the first clinical manifestation. Coronary embolization is a rare but possible complication of endocarditis. Case report: A 61 years–old man was admitted to the Emergency Department for low back pain, fever and chest pain. Four years before he underwent mitral valve bioprosthesis implantation and hybrid myocardial revascularization (percutaneous on right coronary artery). During observation cardiac arrest from ventricular fibrillation occurred, treated with single shock and evidence of anterolateral myocardial infarction at ECG. An urgent coronarography revealed chronic occlusion of CABG on LAD and acute occlusion, of possible embolic origin, involving LAD mid tract, first diagonal branch and intermediate branch. Thromboaspiration and subsequent PTCA was performed. For hemodynamic instability inotropic and vasopressor supports were started. A transthoracic echocardiogram showed severe left ventricular dysfunction (EF 25%) and 3.5x1mm endocardial vegetation on the mitral bioprosthesis without significant bioprosthesis dysfunction (confirmed by transesophageal echocardiogram). Blood cultures resulted positive for Streptococcus gordonii and antibiotic therapy based on the antibiogram was begun. Cardiac surgery was ruled out due to prohibitive surgical risk despite high probability of embolization. Because of the history of back pain spinal MRI was performed with evidence of cervial and lumbosacral spondylodiscitis. Neurosurgical indications were ruled out. Levosimendan infusion allowed weaning of vasopressor and inotropic therapy, however without improvement of left ventricular ejection fraction. Daily echocardiographic follow–up showed disappearance of the vegetation. Antibiotic targeted therapy was continued for 5 months, given the persistence of spondylodiscitis, in anticipation of intracardiac defibrillator (ICD) implantation in primary prevention. Conclusion PVE is a severe clinical condition associated with high morbidity and mortality. Antibiotic therapy is recommended for at least 6 weeks in PVE, in this case prolonged up to 5 months given the need to implant an ICD. Regarding the treatment of embolic infarction thromboaspiration is recommended as the initial strategy and, if successful, may be the only interventional option.

Current trends of hybrid myocardial revascularization

Despite the improvement of endovascular technologies , the method of choice for multi-vascular lesions of the coronary arteries today remains coronary bypass surgery . However , in a range of patients , it is possible to perform hybrid revascularization – a technique with minimal injury that preserves good long-term results similar to those of coronary bypass surgery . The review analyzes current data from the world literature and current trends in the choice of the revascularization method .

Outcome of hybrid compared to conventional revascularization in multivessel coronary artery disease

Objectives Evaluation of 3-year clinical outcome of hybrid myocardial revascularization (HMR) compared to conventional revascularization strategies in patients with multivessel coronary artery disease involving the proximal left anterior descending artery. Design. Retrospective matched cohort study based on a prospective feasibility study including 103 elective patients undergoing staged HMR from October 2010 until February 2012. The Western Denmark Heart Registry was used to identify patients who underwent coronary artery bypass grafting (CABG) and multivessel percutaneous coronary intervention (PCI) by matching on number of diseased vessels, age and comorbidity score. Primary endpoint was the composite rate of major adverse cardiovascular and cerebrovascular events (MACCE) at 3-year follow-up. Secondary endpoints included individual MACCE components, acute kidney injury, and cardiovascular readmissions. Results. There was no difference between MACCE in the three groups (HMR 31.1%; CABG 20.4%; PCI 20.4%, p = .11). Estimates of repeat revascularization were significantly increased with HMR versus CABG. In the CABG group, fewest patients required cardiovascular readmissions though with the highest incidence of acute kidney injury. Conclusions. HMR was not superior with respect to MACCE compared with CABG and PCI. It may, however, represent a safe alternative to conventional revascularization treatment considering the specific procedure-associated morbidity.

Long-term outcomes of myocardial and cerebral revascularization with combined or staged percutaneous interventions and carotid endarterectomy

Aim To evaluate in-hospital and long-term outcomes of myocardial and cerebral revascularization with combined or staged PCI and carotid endarterectomy.Methods.263 myocardial and cerebral revascularizations with PCI and CEA in patients with combined cerebral and coronary artery lesions in the period from 2011 to 2017 were performed. Patients were divided into two groups depending on the surgical strategy. Patient (n = 133) who underwent a staged intervention (CEA and PCI) were included in Group 1, whereas patients (n = 130) who underwent a hybrid intervention (CEE+PCI CA) were included in Group 2. The mean follow-up was 3.5 years.Results.100% of patients in Group 2 underwent coronary and internal carotid revascularization according to the results of in-hospital and long-term follow-up. 81.35% of patient in Group 1 underwent PCI and CEA, whereas 3.01% of patients underwent only PCI and 6.77% of patients – CEA. 1.5% of patients in Group 1 did not receive any surgical treatment. The most common causes of incomplete revascularization were the subsequent change of the initially defined treatment for myocardial (6.02%) or cerebral revascularization (0.75%). The rest refused the second stage, or it was associated with extremely high risk and the strategy was switched to the conservative therapy.Conclusion.100% of patients received hybrid myocardial and cerebral revascularization during one hospitalization. It allowed reducing mortality from MI and stroke during the waiting period for the next stage of the treatment in Group 1 (almost 5%). Hybrid interventions can be used in patients with high risk for open-heart surgery, severe comorbidities (obesity, diabetes, renal dysfunction), significant coronary and cerebral artery lesions with high risk of MI and stroke. However, hybrid approach was associated with high rate (almost 7%) of non-fatal MI in the long-term follow-up.

Comparability of scintigraphy data with coronary angiography after surgical myocardial revascularization

Introduction. Radionuclide imaging is included in diagnostic methods after PCI and CABG in patients with symptoms, but the recommendations caution against routine testing in all asymptomatic patients after revascularization. The paper shows the results of single-photon emission computed tomography after hybrid coronary myocardial revascularization; an analysis of the sensitivity and specificity of three methods of surgical myocardial revascularization was carried out in 12 months.Aim of the study was to determine the sensitivity and specificity of SPECT in determining coronary artery stenosis ≥ 50 % after performing three methods of surgical myocardial revascularization: CABG, PCI, and hybrid myocardial revascularization in patients with coronary artery disease and multi-vascular coronary lesion.Material and methods. A retrospective analysis of 82 patients with stable forms of coronary artery disease who underwent myocardial revascularization for the presence of the multivascular coronary lesion was carried out. The patients were divided into three groups: the first group consisted of 40 patients who underwent CABG, the second – 29 patients after PCI, and the third – 23 patients who underwent hybrid myocardial revascularization.Results. All patients after myocardial revascularization, on average, after 21.8±8.6 months, were hospitalized, where singlephoton emission computed tomography of the myocardium with 99mTc-technetril (SPECT) and control coronarography/ shuntography were performed. The frequency of the presence of significant stenosis during coronary angiography with a perfusion defect of ≥5 % on SPECT during exercise was 50, 50 and 33 % in the CABG, PCI, and hybrid revascularization, respectively (p=0.894). The least sensitivity of SPECT was after hybrid myocardial revascularization (20 %), while in the CABG group, the sensitivity was 71.4 % (p = 0.190). The SPECT specificity indices were much higher: in the GABG, PCI, and hybrid revascularization groups, respectively, 75.8, 79 and 88.9 % (p=0.530).Conclusion. There is no significant relationship between the size of the defect on SPECT and coronary angiography data, regardless of the type of surgical myocardial revascularization in patients after myocardial revascularization. Detection of a perfusion defect with a load of more than 10% in SPECT after surgical myocardial revascularization is the basis for coronary angiography in order to exclude stent restenosis or shunt dysfunction, as well as progression of coronary atherosclerosis.

Hybrid Myocardial Revascularization or Multivessel Minimally Invasive Direct Coronary Artery Bypass: Two Case Reports

Since the first introduction of direct grafting of the Left Anterior Descending artery (LAD) by Kolessov in 1967, the tendency in myocardial revascularization has been towards less invasive techniques. New developments are increasingly making it possible to extend the indication for Robotically Assisted Minimally Invasive Direct Coronary Artery Bypass (RAMIDCAB) surgery to patients with triple vessel disease. Here, we present two cases in which complete revascularization was successfully achieved. The first patient underwent a hybrid procedure involving RA-MIDCAB followed by Percutaneous Coronary Intervention (PCI); the other patient received RA-MIDCAB in which bilateral internal mammary arteries were used as a conduit for grafting. The implications, limitations and challenges of these interventional strategies are discussed. Furthermore, it is suggested that minimally invasive strategies might have important benefits especially for high-risk patients, and that these strategies should be included in decisionmaking by the Heart Team if available.

Hybrid myocardial revascularization.

In patients with advanced coronary artery disease (CAD), coronary artery bypass grafting (CABG) is associated with improved long-term outcomes while percutaneous coronary intervention (PCI) is associated with lower periprocedural complications. A new approach has emerged in the last decade that attempts to reap the benefits of bypass surgery and stenting while minimizing the shortcomings of each approach, hybrid myocardial revascularization (HMR).Three strategies for timing of the hybrid revascularization exists, each with their own inherent advantages and shortcomings: (1) CABG followed by PCI, (2) PCI followed by CABG, or (3) simultaneous CABG + PCI in a hybrid suite. The results of the first randomized control trial comparing HMR (CABG first) and standard CABG, POL-MIDES (Prospective Randomized PilOt Study EvaLuating the Safety and Efficacy of Hybrid Revascularization in MultIvessel Coronary Artery DisEaSe), show HMR was feasible for 93.9% of patients whereas conversion to standard CABG was required for 6.1%. At 1year, both groups had similar all-cause mortality (CABG 2.9% vs. HMR 2%) and major adverse clinical event (MACE)-free survival rates (CABG 92.2% vs. HMR 89.8%). Results of observational and comparative studies show that minimally invasive HMR procedures in patients with multivessel CAD carry minimal perioperative mortality risk and low morbidity and do not increase the risk of postoperative bleeding. The advantage they offer in comparison to classical surgical revascularization is indeed faster rehabilitation and patient's return to normal life. Hybrid myocardial revascularization has been developed as a promising technique for the treatment of high-risk patients with CAD. Hybrid revascularization using minimally invasive surgical techniques combined with PCI offers to a part of patients an advantage of optimal revascularization of the most important artery of the heart, together with adequate myocardial revascularization in a relatively delicate way. Indeed, to patients with high operative risk of standard surgery, it offers an alternative which should be considered carefully.

Comparative analysis of hybrid myocardial revascularization and multivascular percutaneous coronary interventions in patients with stable coronary artery disease and multivascular coronary disease. 30-day results

Comparative analysis of hybrid myocardial revascularization and multivascular percutaneous coronary interventions in patients with stable coronary artery disease and multivascular coronary disease. 30-day results

Hybrid cardiovascular therapy: interventional (and surgical) procedures in high-risk patients

Cardiovascular consultants are increasingly faced with patients presenting with multiple comorbidities or structural challenges, who are in need for anatomical corrections. In such patients, hybrid cardiovascular procedures often allow for collaborative therapies that integrate the strengths of percutaneous and traditional open surgical treatments, to provide an overarching treatment that cannot be provided by either approach in isolation. While the concept of hybrid cardiovascular therapy is not new, it has seen a resurgence in recent years, with the developement of new devices and approaches. Areas of particular growth within hybrid cardiovascular care include hybrid myocardial revascularization, hybrid therapies for valvular and structural heart diseases and hybrid procedures for aortic diseases. Future growth in this field is inevitable and represents an exciting frontier in cardiovascular medicine.

Hybridní revaskularizace myokardu u pacienta s pectus excavatum

Hybridní revaskularizace myokardu u pacienta s pectus excavatum

Hybrid revascularization, comprising coronary artery bypass graft with exclusive arterial conduits followed by early drug-eluting stent implantation, in multivessel coronary artery disease

To assess the feasibility and safety of a hybrid myocardial revascularization strategy combining "exclusive arterial" conventional coronary artery bypass grafting (CABG) followed by early drug-eluting stent (DES) implantation in multivessel coronary artery disease (CAD). Eighteen consecutive patients with multivessel CAD were enrolled prospectively. Within 48 hours of CABG using left internal mammary artery (IMA) to left anterior descending (LAD) coronary artery with or without right IMA to non-LAD vessel in an open chest approach, DESs were implanted systematically in an additional vessel after a clopidogrel 300-mg preloading dose. This group was compared with 18 matched patients who underwent standard CABG alone using left IMA to LAD and at least one additional graft. Baseline clinical characteristics were similar in both groups. There were 46 grafts in the CABG group and 28 in the hybrid group. In the hybrid group, 27.8% of patients were treated off-pump versus none in the CABG group; a median of 2 (interquartile range: 1-2) stents was implanted per patient. The hybrid procedure was associated with shorter durations of cardiopulmonary bypass (77 [67-100] min versus 97 [90-105] min, P=0.049). Major bleeding rates were higher in the CABG group, but the difference was not statistically significant (44.4% versus 11.1%, P=0.06). Re-intervention for bleeding was not needed in either group. One (5.6%) myocardial infarction occurred in hospital in each group following CABG. At 1 year, the cumulative rates of major adverse cardiac events (death, myocardial infarction, target vessel revascularization) were similar (11.2% in hybrid group versus 5.6% in CABG group, P=0.99). One death occurred in the CABG group and one target vessel revascularization in the hybrid group. A hybrid revascularization strategy, combining conventional CABG with exclusive arterial conduits followed by early DES implantation, is feasible. One-year event rates compare favourably to those with traditional CABG alone.

Hybrid myocardial revascularization: An integrated approach to coronary revascularization

Coronary artery bypass surgery is beneficial in patients with complex coronary artery disease. The longevity of the left internal mammary artery (LIMA) placed to the left anterior descending (LAD) artery (LIMA-LAD) is between 92-99% at 15 years, and contributes substantially to the survival advantage in patients treated with surgical revascularization. The long-term patency of saphenous vein grafts (SVGs), commonly used (>95%) in surgical revascularization procedures, is less well-established, with up to 26% of SVGs failing in the first year. In selected patients, particularly in those patients with vessels poorly suited to SVGs, hybrid myocardial revascularization (HMR) has been used, combining a minimally invasive approach to the LIMA-LAD with drug-eluting stent placement of the non-LAD vessels. The advantages and disadvantages of hybrid myocardial revascularization are reviewed in this report.

Hybrid myocardial revascularization complicated by delayed anastomotic bleeding

We present a case of hybrid coronary revascularization complicated by delayed bleeding from an anastomotic site. Anastomosis of the left internal mammary artery to the left anterior descending coronary artery was successfully performed via a lateral anterior small thoracotomy. Scheduled subsequent percutaneous coronary intervention of residual stenoses was successfully performed 13 days after the surgery, but cardiac tamponade due to anastomotic site dehiscence was disclosed soon after the percutaneous procedure. We discuss the causation of the delayed bleeding that occurred after the hybrid coronary revascularization.

Concurrent Robotic Hybrid Revascularization Using an Enhanced Operative Suite

Hybrid myocardial revascularization combines coronary surgery with percutaneous intervention as an alternative therapy for ischemic heart disease. The order and sequence of the hybrid approach is not yet clearly defined. We report on the benefits of an enhanced surgical suite equipped with a carbon fiber operating table and digital C-arm for robotic-assisted hybrid revascularization in a single operative sequence. To our knowledge, this is the first reported case of concurrent robotic-assisted hybrid revascularization utilizing an enhanced operative suite.

Integrated minimally invasive direct coronary artery bypass grafting and angioplasty for coronary artery revascularization.

Minimally invasive direct coronary artery bypass (MIDCAB) through the anterolateral minithoracotomy has become a promising therapeutic option in patients with lesion in left anterior descending artery (LAD), especially in multimorbid, elderly and reoperated patients with type C or B lesions. To expand the benefits of MIDCAB concept to patients with multivessel disease, a hybrid myocardial revascularization procedure (HMR) combining surgery of the LAD with interventional procedures for additional coronary lesions has recently been introduced. Between January 1999 and September 2001, 50 patients (37 male, 13 female, mean age 54.8+/-20.1 years) underwent an HMR procedure. MIDCAB with endoscopic left internal thoracic artery (LITA) harvesting, followed by percutaneous coronary intervention (PCI) for additional coronary lesions and percutaneous transluminal coronary angioplasty (PTCA), was performed in 11 patients (22%) and stenting in 39 patients (78%). Angiographic assessment of graft patency was performed in all patients during the PCI procedure. The clinical follow-up period was 3-32 months. There were no early and late deaths. Baseline Canadian Cardiology Society (CCS) class was 2.8+/-0.7 versus 1.1+/-0.9 (P<0.001) 30 days after HMR procedure. There were no major acute in-hospital cardiac events. Angiographic studies showed patent LIMA-LAD graft in 50 patients (100%). We showed good quality of anastomosis in 49 patients (98%). There was a moderate graft stenosis in one patient (2%). At long term follow-up, the rate of major cardiac events was 12%. Five patients (10%) developed restenosis after PCI, and one patient (2%) developed significant stenosis in site of LITA-LAD anastomosis; redo PCI was performed successfully. The hybrid procedure is a safe and effective method for complete revascularization in selected patients with double-vessel coronary artery disease (patients with type B or C lesions in the proximal LAD). This method allows performance of complete revascularization with minimization of surgical trauma. So far, long-term results of HMR are limited by the results of PCI.

Concomitant off-pump myocardial revascularization and pheochromocytoma resection

Surgical management of patients with coexisting ischemic heart disease and pheochromocytoma remains challenging. We present one such case in which hybrid myocardial revascularization (angioplasty with stenting and off-pump coronary artery bypass grafting) and resection of pheochromocytoma were undertaken. Unusual features included simultaneous coronary artery surgery and tumor resection and, in particular, coronary artery surgery being performed without cardiopulmonary bypass.

Hybrid Myocardial Revascularization After Previous Left Pneumonectomy

Previous intrapericardial left pneumonectomy and irradiation necessitated an unorthodox, staged approach to myocardial revascularization in a patient with unstable angina pectoris, left main artery, and three-vessel coronary artery disease. A saphenous vein bypass graft was constructed from the descending thoracic aorta to the left anterior descending coronary artery via left thoracotomy, without cardiopulmonary bypass. Two days later the patient underwent stenting of the left main and circumflex coronary arteries. Recovery was uneventful.