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Background: Recent advances in minimally invasive/ robotic coronary bypass procedures and percutaneous interventions with DES have allowed surgeons and interventional cardiologists to justify hybrid revascularization strategies in patients with mulitvessel CAD. In the absence of a Hybrid OR this approach can present challenges. We report on our initial experience with hybrid coronary revascularization in mulitvessel CAD using an elective staged approach.
Methods: Between 5/2008 and 11/2011, 41 patients with multi-vessel CAD were scheduled for elective staged hybrid revascularization. Mean age was 65+/-12, and 86% percent were men. The order of procedures was dictated by the clinical presentation. Twenty-nine patients (71%) had TECAB first and 12 patients (29%) had PCI first. TECAB procedures were performed using a da Vinci off pump beating heart approach with anastomotic connectors (Flex A, Cardica). Seventeen (41%) were single vessel and 24 (59%) were mulitvessel procedures (23 double vessel and 1 triple vessel TECAB). The PCI procedures were to branches of the RCA and Distal Circumflex artery. A mean of 1.7+/-1.0 stents was deployed per patient. Of the 29 patients who had surgery first, 5 elected not to undergo the second stage of the hybrid procedure because they had negative postoperative stress tests and/or were asymptomatic.
Results: There was no peri-procedural mortality, stroke, MI, wound infection or conversion to sternotomy. Median length of stay after surgery was 3 days. The average length of time between procedures was 69+/-70 days. In patients who had PCI first, anti-platelet therapy was continued through surgery. There were no re explorations for bleeding. One patient in the surgery first group was converted to femoro-femoral CPB because of RCA distribution ischemia. Patency in 41 grafts evaluated in 25 patients (24 at time of PCI and 1 with CT angiography) was 94% at a mean of 65+/-80 days.
Conclusion: Staged integrated coronary revascularization is feasible in patients with mulitvessel CAD with excellent early outcomes. In the absence of a hybrid OR, clinical presentation should dictate the order of procedures. Continuation of anti-platelet therapy did not result in increased peri-operative bleeding. Early graft patency was excellent. Further follow up is necessary.