HYBRID CORONARY REVASCULARIZATION: IS THE NEW WAY TO GO CPD DAY 2016 HYBRID CORONARY REVASCULARIZATION: IS THE NEW WAY TO GO Md Faizus Sazzad MBBS, MS (CTS), FCPS (CVS), FAMS (Singapore) Fellow Minimal Invasive Heart Surgery (NUH) Specialist Cardiac Surgeon Ibrahim Cardiac Hospital & Research Institute

CPD DAY 2016 Scenario 56yrs old, Male ADL independent, community ambulant Coros: pLAD 100% pCX 50% mRCA 70% dRCA 80% RPDA 80% recommended for CABG - TTE: EF 60%, RWMA

CPD DAY 2016 Decision Making ? CABG PCI OPCABG Hybrid MIDACB

CPD DAY 2016 Introduction Multi-vessel coronary revascularization is always a matter of interest and conflict.

CPD DAY 2016 Introduction… Use of the left internal thoracic (mammary) artery to the left anterior descending artery (LAD), relieves symptoms, improves survival, and decreases recurrence of adverse cardiovascular events 1. Hence internal mammary artery (IMA) still gold standard though the era of drug eluting stent (DES) is expanding.

CPD DAY 2016 Introduction… We took the effort to combine the benefit of both minimal invasive coronary bypass graft surgery (MIS CABG) and percutaneous coronary intervention (PCI) for non-left anterior descending artery (LAD) lesion.

CPD DAY 2016 Methods Patients were selected according to angiogram result with significant LAD lesion and secondary LCx and RCA lesion. Patient with severe obesity and severe pulmonary hypertension were excluded. Peripheral Fem-fem cannulation was carried out. 5-7cm submammary left-anterior incision was fashioned. LIMA harvested in manual fashion under direct vision. Medtronic Octopus-Novo retractor was used. Progressive revascularization was performed in a proximal first-distal second-LIMA to LAD last sequence. Controlled angiography was carried out in the same session followed by PCI to the non-LAD lesion.

CPD DAY 2016 Methods… We applied minimally invasive direct coronary artery bypass graft surgery or MIS CABG (also called minimal or limited access CABG) procedures which is a recognized alternative to standard median sternotomy. All SVG harvested using minimal invasive endoscopic vein harvesting (EVH) technique by using Vesoview EVH 7 XB Maquet instruments. Concomitant PCI with drug-eluting stents was performed immediately or staged shortly after CABG, with post-procedure imaging to ensure patency.

CPD DAY 2016 Methods…

CPD DAY 2016 Results Total 18 cases were done in between October 2014 to June 2015. Average ejection fraction was 58.22%. Thoracotomy wound length 5.50±1.25cm. All patients’ recovery was uneventful. We had one case of conversion due to VF as a result of difficult stenting attempts of a bifurcational stenosis. Average length of hospital stays (LOS) 5±1 days. One patient needed LAD endarterectomy. On table IMA-graphy done, showed all patent vessel. Nil 30 days in hospital mortality. One patient needed intra-aortic balloon pump support and interval PCI.

Discussion Although the median sternotomy incision permits excellent visualization of all mediastinal structures, it is associated with a rate of infection (including osteomyelitis and mediastinitis) of approximately 1 to 1.5 percent. In addition, this approach requires a period of four to six weeks for bony union, limiting the patient's ability to resume full physical activity.

CPD DAY 2016 Discussion… McGinn is the multivessel surgical revascularization with less invasive cardiac surgical technique, such as smaller incisions (mini-thoracotomy) which we applied with concomitant hybrid PCI. Saphenous vein harvest was accomplished through small incisions using video-based surgical techniques, which been reported as decreasing the morbidity associated with leg incision (pain, infection) and permitting more rapid recovery.

CPD DAY 2016 Discussion… In our cases Surgery undertaken before PCI with the consideration of LIMA graft patency; which was assessed at time of PCI in all cases. Overall MACCE rates (defined as death, myocardial infarction [MI], stroke and repeat revascularisation) in our case was nil at 6 month follow up. Recovery was faster with patients returning to work after 27±8 days after operation.

CPD DAY 2016 Conclusion Stand-alone MIS coronary revascularization in McGinn technique and/or Hybrid completion presents powerful tools for coronary revascularization in the modern era of cardiac surgery.

Take Home Consider MIS Hybrid is safe Complete revascularization CPD DAY 2016 Take Home Consider MIS Hybrid is safe Complete revascularization Decision making should include the option of treatment. Time to change the mode of practice.

CPD DAY 2016 Thank you