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Objective: In high-risk patients requiring open heart surgery, hybrid procedures offer less invasive methods of addressing patient cardiac pathology. We report our single institution outcomes of a single-stage hybrid strategy for high-risk patients with concomitant valvular and coronary artery disease (CAD).
Methods: From 2010 to 2015, 24 patients underwent single-stage hybrid surgery consisting of percutaneous coronary intervention (PCI) followed by minimally invasive valve replacement/ repair. In all cases, a loading dose of 300 mg clopidogrel was given before induction of anesthesia and PCI. Aortic valve replacement (n=21) was performed via a partial sternotomy approach, and mitral valve repair (n=3) was done through a right mini-thoracotomy approach. Patient records were retrospectively reviewed.
Results: Mean patient age was 71.2±10.3 years (29.2% female) with the majority of patients presenting with one vessel disease (n= 18). Aortic valvular pathology was severe aortic stenosis in all cases (mean aortic valve area; 0.8±0.2 cm², mean gradient: 41.6±9.5 mmHg). Mitral valvular pathology was severe mitral regurgitation (functional, n=1; leaflet prolapse, n=2). There were no intraoperative conversions to full sternotomy. PCI was successfully performed in 96% (n=23) of cases, with successful minimally invasive surgery in all cases. Mean cardiopulmonary bypass time was 97±24 minutes, and mean aortic cross clamp time was 69±19 minutes, respectively. Intraoperative transfusion requirement was zero. In-hospital/ 30-day mortality was 4% (n=1). Stroke rate, reoperation for bleeding, renal failure rate were zero. Ten patients (42%) required blood product transfusion post-operatively, with mean transfusion rate of 0.8±1.6 units/ per patient for the entire group. On discharge echocardiography, paravalvular leak rate was zero in patients undergoing aortic valve replacement, and mitral regurgitation rate was also zero.
Conclusion: This study demonstrates the feasibility and early safety of single-stage hybrid strategy with PCI followed by valvular surgery in high-risk patients (Table 1). This strategy enables utilization of minimally invasive surgical approaches to treat combined valvular and coronary artery pathology, which may have decrease operative
morbidity in high-risk patients.
Table 1 Postoperative outcomes

Variable	Outcome
Stroke/TIA	0 (0)
Atrial fibrillation	13 (54.2)
Multiple system failure	1 (4.2)
Cardiac tamponade	0 (0)
Renal failure	1 (4.2)
Creatinine	1.1±0.4
Reoperation for bleeding	0 (0)
Intervention for graft occlusion	0 (0)
Structural valve dysfunction	0 (0)
Non-structural valve dysfunction	0 (0)
Residual mitral insufficiency	0 (0)
Hospital length of stay (days)	8.9±3.4
ICU length of stay (hours)	49.7±33.9
Readmission to ICU	2 (8.3)
Duration of ventilation (hours)	16.0±11.8
Requirement for reintubation	2 (8.3)
Total transfusions administered/ patient	0.8±1.6
Values are count (%) for categorical variables and mean±SD for continuous variables