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International Society For Minimally Invasive Cardiothoracic Surgery

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Hybrid Coronary Revascularization - Who Can Benefit Most?
Janusz Konstanty-Kalandyk, Anna Kedziora, Jacek Piatek, Jacek Legutko, Wojciech Zajdel, Lukasz Wiewiorka, Boguslaw Kapelak.
John Paul II Hospital, Krakow, Poland.

OBJECTIVE: Despite the development in interventional cardiology, the clinical benefit of LIMA-LAD graft remains undisputable among a whole spectrum of patients, concerning age and comorbidities. Nevertheless, conventional open-chest CABG is a relatively invasive, high-risk procedure with poor long-term vein grafts patency. Minimally invasive LIMA-LAD technique allows avoiding the burden of the open-chest procedure, and combined with PCI to non-LAD coronary lesions can be an effective alternative that diminishes periprocedural risk and grants complete revascularization.METHODS: 40 consecutive patients, qualifying for CABG based on the SYNTAX score results, in whom hybrid revascularization strategy was implemented. Patients were assesed and qualified for revascularization either upon non-ST-elevation acute coronary syndrome (NSTE-ACS) - culprit lesion PCI with subsequent MIDCAB, or as staged strategy for stable coronary artery disease (SCAD) management with either MIDCAB or PCI as the first step. Contraindications to multivessel CABG were evaluated as a composite of surgical inability to achieve complete revascularization and contraindications to full median sternotomy. Periprocedural morbidity included need for conversion for open-chest CABG, myocardial infarction, low cardiac output syndrome, re-exploration for bleeding, need for thoracentesis, pneumonia, arrhythmia with hemodynamic instability, renal or neurological complications.RESULTS: In spite of a high overall SYNTAX score, LAD lesions comprised most of the result. Advanced age combined with frailty syndrome and obesity were the most common contraindications to full median sternotomy, however 1 case of previous cardiac surgery was noted. Surgical inability to achieve complete revascularization mostly arose from low arteries diameter peripheral to the lesions, however lack of vein graft material was also observed in 1 patient. No periprocedural deaths were reported, and observed complications were: 1 case of post-surgery low cardiac output syndrome (SCAD group), 1 case of postoperative myocardial infarction with sudden cardiac arrest and successful emergent LM/Cx PCI (SCAD group), and 1 case of pleural hematoma requiring surgical intervention (NSTE-ACS group) (Table 1).CONCLUSIONS: In spite of high SYNTAX score, hybrid coronary revascularization is a safe alternative in patients with contraindications to conventional CABG and LAD lesions that are unsuitable for PCI.


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Poland
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