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OBJECTIVE:
Hybrid Revascularization, combining survival benefit of left internal mammary artery (LIMA) to left anterior descending (LAD) artery with advances of coronary stents, holds promise as a valuable option in treatment of complex coronary disease (CAD). 2011 AHA/ACC listed: Heart Team Approach - collaboration between interventional cardiology and cardiac surgeon for decision making in patients with complex CAD - a Class I, LOE C recommendation. Maintaining patient anonymity, we report our experience in this retrospective consecutive cohort of 275 patients - pre-planned staged hybrid coronary revascularization procedures - using beating heart, sternal sparing, robotic assisted coronary revascularization with percutaneous coronary intervention (PCI).
METHODS:
Since May 2005, over 700 robotic assisted procedures were performed, 275 patients underwent staged hybrid revascularization from September 2005-October 31, 2011, 200 patients had surgery first, 75 underwent PCI first. Hybrid candidates include patients with complex CAD; those with ostial LAD disease, bifurcating disease, long lesions, chronic occlusion; left main with small circumflex amenable to later PCI; it is especially considered for patients at high risk for sternotomy; elderly, frail, obese, other co-morbidities; and for young who may require future surgery.
RESULTS:
Preoperative risks / co-morbidities for hybrids mirrored our institutional data. 44% with double vessel disease, 55% triple vessel and 10.7% left main disease. 45.4% had greater than one distal graft; 34% had bilateral IMA grafts placed. 18% had COPD, posing no difficulty to single lung ventilation; 87.1% were extubated in OR; 1.5% required reintubation and 1.9% remained ventilated > 24hours. 12% were taking Clopidogrel or Prasugrel; which were not deterrents to scheduling surgery. 56 patients required transfusions; 4.5% intra-operatively, 16% postoperatively. Noteworthy, no patients returned to OR. STS predicted risk of mortality was 2.3%, observed mortality 1.09%.
CONCLUSION:
Hybrid coronary revascularization enhances collaboration and team approach to patient care; maximizing the advantages of PCI and surgery; while decreasing complications associated with sternotomy. Precise robotic movements and meticulous attention avert the need for re-exploration. Full cardiology adoption, institutional outcomes, program growth, and patient satisfaction emphasize potential for greater adoption of available technology and minimally invasive functional revascularization - offering patients promising alternatives with individualized treatment plans.