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Single-stage hybrid coronary intervention with concomitant minimal invasive valve surgery
Andreas Habertheuer, Arminder Jassar, Bill Matthai, Prashanth Vallabhajosyula, Clark Hargrove, Jacob Gutsche, William Vernick, Wilson Y. Szeto.
Hospital of the University of Pennsylvania, Philadelphia, PA, USA.

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
Stroke/TIA0 (0)
Atrial fibrillation13 (54.2)
Multiple system failure1 (4.2)
Cardiac tamponade0 (0)
Renal failure1 (4.2)
Reoperation for bleeding0 (0)
Intervention for graft occlusion0 (0)
Structural valve dysfunction0 (0)
Non-structural valve dysfunction0 (0)
Residual mitral insufficiency0 (0)
Hospital length of stay (days)8.9±3.4
ICU length of stay (hours)49.7±33.9
Readmission to ICU2 (8.3)
Duration of ventilation (hours)16.0±11.8
Requirement for reintubation2 (8.3)
Total transfusions administered/ patient0.8±1.6
Values are count (%) for categorical variables and mean±SD for continuous variables

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