One-stop Hybrid Revascularization for left main and multivessel coronary artery disease Shengshou Hu M.D. National Center for Cardiovascular Disease，China Fuwai Cardiovascular Hospital Chinese Society for Thoracic and Cardiovascular Surgery

Develop of coronary artery disease In China: Commonly seen in clinical scenario Accounted for one million AMI per year Accounted for half million deaths per year CAD incidence will be doubled in the next 20 years Circulation Cardiovascular Quality and Outcomes 2010

Choice for left main and multivessel disease In real world，debate of best choice for multivessel disease never stops：CABG or PCI?

Advantages of catheter based therapy Advantage of PCI Minimally Invasive For non-LAD, DES significantly reduced restenosis rate, similar or lower than failure rate of saphenous vein grafts The need for repeat revascularization is still a big concern N Engl J Med 2009，360（10）961-972 4

LIMA-LAD graft still has optimal long term patency rate Advantages of conventional coronary artery bypass grafting LIMA-LAD graft still has optimal long term patency rate Lower rate of repeat revascularization in long term 5 year patency:>95 % 10 year patency: > 90% N Engl J Med 2009，360（10）961-972

Combination of the advantages of CABG & PCI Changes in techniques have shifted the boundary between CABG and PCI Medical Therapy PCI CABG Minimal invasiveness; Shortens recovery time; Minimize risk of complications. One-stop Hybrid

Preliminary Experience of Staged Hybrid Procedure (1999-2001) Hybrid revascularization：Fuwai experiences Preliminary Experience of Staged Hybrid Procedure (1999-2001) 3 days later

One-stop Hybrid Procedure since 2007 Hybrid revascularization：Fuwai experiences One-stop Hybrid Procedure since 2007 First Hybrid OR in Asia, 2007

Our Protocol: “One-Stop” hybrid revascularization Hybrid revascularization： antiplatelet strategy Our Protocol: “One-Stop” hybrid revascularization Anti platelet strategy Routinely stop Clopidogrel; Continueous Administration of Aspirin 100mg/d. Administration of Clopidogrel 300mg Patients Selection MICAB (LIMA-LAD) Angiography for LIMA OK! PCI with DES In Hybrid O.R. with Fast-track Anesthesia Ann Thorac Surg 2011;91:432-8

Hybrid Vs Off-pump for multivessel disease Midterm clinical outcome： VS off-pumm CABG Hybrid Vs Off-pump for multivessel disease 2007.6 - 2009.12;104 patients with average 18 months follow-up Hybrid significantly reduced ICU、in-hospital time and transfusion rate Lower MACCE rate （99% vs 90.4%）than Off-pump after 18 months follow-up Hybrid (n=104) OPCAB (n=104) Propensity-score matching (1:1) Ann Thorac Surg 2011;91:432-8

One-stop Hybrid vs CABG & PCI：3 year follow-up Midterm clinical outcome： VS CABG and PCI One-stop Hybrid vs CABG & PCI：3 year follow-up One-stop Hybrid 141 cases（2007.6 to 2010.12） CABG 5797 PCI 4254 Propensity match CABG 141 Hybrid 141 PCI 141 Stratify by Euroscore low 0-2，medium 3-5, high >6 Stratify by SYNTAX score low <24，medium 24-30, high >30 Endpoint：MACCE rate in different risk levels

MACCE rate： Hybrid and CABG group was significantly lower than PCI Midterm outcome：hybrid vs CABG & PCI MACCE rate： Hybrid and CABG group was significantly lower than PCI Log Rank Hybrid vs CABG 0.07 Hybrid vs PCI 0.001 CABG vs PCI 0.04 Total MACCE Percent Hybrid 141 9 6.4% CABG 19 13.5% PCI 32 22.7% 423 60 14.2%

Midterm outcome：hybrid vs CABG & PCI In low (< 24) and medium (24-30) Syntax score group，there was no significant difference between three groups In High (> 30)Syntax score group，MACCE in Hybrid and CABG group was significantly lower than PCI

Midterm outcome：hybrid vs CABG & PCI In low (<3) and medium (3-5) Euroscore group，there was no significant difference between three groups In High (>5) Euroscore group，MACCE in Hybrid group was significantly lower than CABG and PCI

Inclusion criteria: high risk for PCI Hybrid revascularization：patients selection Inclusion criteria: high risk for PCI Unfavorable LAD for PCI：chronic total occlusion, excessive tortuosity, severely calcification lesion LAD occlusion Simple non-LAD lesion 本部分研究结论为…… 15

Inclusion criteria: high risk for PCI Midterm outcome：patients selection Inclusion criteria: high risk for PCI Unprotected left main disease Unprotected left main disease 本部分研究结论为…… With LIMA-LAD graft Protected left main disease 16

Inclusion criteria: high risk for conventional CABG Midterm outcome：patients selection Inclusion criteria: high risk for conventional CABG Patients with limitations to traditional CABG pre-existing organs dysfunction heavily calcified proximal aorta lack of suitable graft conduits 本部分研究结论为…… 17

One-stop hybrid vs CABG Midterm outcome：discussion (1) One-stop hybrid vs CABG Minimal invasiveness: avoid cardiac pulmonary bypass & median sternotomy a feasible option to some certain clinically high risk patients who were unable to tolerate median sternotomy, cardiopulmonary bypass or heart rotation during off-pump CABG. JACC Cardiovasc Interv 2008;1:459-68. Circ Cardiovasc Interv 2010;3:511-8.

One-stop hybrid vs CABG Midterm outcome：discussion（1） One-stop hybrid vs CABG LIMA-LAD graft quality was further confirmed by instant angiography , any deficiency could be corrected immediately. Hybrid operation room provides instant feedbacks which were difficult to evaluate with naked, then we could change our surgical behavior. J Am Coll Cardiol 2009;53:232-41.

One-stop hybrid vs CABG Midterm outcome：discussion（1） One-stop hybrid vs CABG Avoid aortic manipulation，significantly decreased neurological events rate (1.4% vs 6.4%). J Thorac Cardiovasc Surg 2005;129:307-13.

One-stop hybrid vs PCI Midterm outcome：discussion（2） Cover patients with LAD chronic total occlusion, excessive tortuosity, severely calcification lesion Cover potential patients for staged PCI with multivessel disease Severe calcification in LAD Proximal RCA lesion

Midterm outcome：discussion（3） A safe and effective Modified Antiplatelet Protocol for hybrid procedure Figure 1 perioperative changes of AA-PAgT: Hybrid vs PCI Figure 2 perioperative changes of ADP-PAgT: Hybrid versus PCI Platelet activity was sufficiently inhibited as standard PCI anti-platelet protocol 3 days postoperatively

Alternative surgical approaches Midterm outcome：discussion（4） Alternative surgical approaches Lower partial ministernotomy Full sternotomy Parasternal incision Less technically demanding Satisfying exposure Easily and rapidly converse to full sternotomy if necessary Robot assited technique：Much cost and time consuming

One-stop hybrid for multivessel coronary artery disease Midterm outcome：conclusion One-stop hybrid for multivessel coronary artery disease combines the durability and survival advantage of LIMA-LAD graft with less-invasive PCI to non-LAD lesions for selected patients with multivessel coronary artery disease, it could provide favorable midterm outcomes in each risk tertile, especially for patients with high syntax score and euroscore

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