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Is the Future of Coronary Arterial Revascularization a Hybrid Approach? The Canadian Experience across Three Centres.
Vincenzo Giambruno, MD1, Ahmad Hafiz, MD1, Stephanie Fox1, Hugues Jeanmart, MD2, Richard Cook, MD3, Feras Khaliel, MD1, Patrick Teefy, MD4, Kumar Sridhar, MD4, Shahar Lavi, MD4, Rodrigo Bagur, MD4, Ivan Iglesias, MD5, Philip Jones, MD5, Christopher Harle, MD5, Daniel Bainbridge, MD5, Michael Chu, MD1, Bob Kiaii, MD1.
1Division of Cardiac Surgery, Department of Surgery, Western University, London Health Sciences Centre, London Ontario, ON, Canada, 2Division of Cardiac Surgery, University of Montreal, Montreal Heart Institute, Montreal, QC, Canada, 3Division od Cardiac Surgery, University of British Columbia, St. Paul's Hosptial, Vancouver, BC, Canada, 4Division of Cardiology, Department of Medicine, Western University, London Health Sciences Centre, London Ontario, ON, Canada, 5Department of Anesthesia and Perioperative Medicine, Western University, London Health Sciences Centre, London Ontario, ON, Canada.

OBJECTIVE: Hybrid Coronary Revascularization (HCR) offers and combines the advantages of both surgical and percutaneous revascularization eliminating at the same time the disadvantages of both procedures. In fact, this evolving revascularization technique utilizes the survival benefit conferred by the left internal thoracic artery (LITA) graft to the left anterior descending coronary artery (LAD) while providing the patients with complete and truly minimally invasive revascularization with PCI to the non-LAD vessels. The objective of this study was to assess graft and stent patency at 6 months, rate of bleeding, ICU and hospital stay, rate of reintervention and long term clinical follow up.
METHODS: From March 2004 to November 2015 a total of 203 patients (61.7±11.0 years; 160 males and 43 females) underwent robotic-assisted minimally invasive direct coronary artery bypass (RADCAB) graft of the LITA to the LAD and PCI in a non-LAD vessel in a single or two stage, in three different centres. Patients underwent 6 months angiographic follow up. The average clinical follow up was 77.82±41.4 months.
RESULTS: Successful HCR occurred in 196 of the 203 patients (7 patients required intraoperative conversion to conventional coronary bypass). 146 patients underwent simultaneous surgical and percutaneous intervention. 19 patient underwent PCI before surgery, 38 patient underwent PCI after surgery. 189 patients were treated with drug-eluting stents, whereas 14 patients were treated with bare metal stents. No in-hospital mortality occurred. The average ICU stay was 1±1 days and the average hospital stay was 5±2 days. Only 13.3% of patients required a blood transfusion. Six-month coronary angiogram follow up has been performed in 95 patients. Angiographic evaluation demonstrated a LITA anastomotic patency of 97.9% and stent patency of 92.6%.
77.8±41.4 months clinical follow up demonstrated 95.1% survival, 92.6% freedom from angina, 90.7% freedom from any form of coronary revascularization (PCI of LITA-to-LAD anastomosis was performed in 5 patients, in one case the anastomosis was surgically revised and PCI was repeated in 13 patients).
CONCLUSIONS: Hybrid revascularization appears to be a promising and safe revascularization strategy. It provides selected patients with an alternative, functionally complete revascularization with minimal surgical trauma and good long term clinical outcomes.

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