Coronary Bypass Strategies&

Hybrid Revascularization

Betty Kim MD FACSCardiac SurgeryCV Summit 2016

“What……not another CABG ?“

• CABG with LIMA and SVGs “sewing worms”

• > 90% of cardiac surgeons nationally still do it the conventional way

Is BIMA (2 IMAs) really

better than LIMA ?

One size does not fit all• “ Fit the operation to the patient, not the patient to the

operation”• “ Tailor the operation to the patient”…..BSK• Conventional, LIMA or BIMA or radial, Offpump, MICS,

hybrid, robot? Questions to ask oneself when deciding which procedure to do:

-What are you trying to accomplish? -What are strengths and weaknesses of different techniques? -Are there certain comorbidities of patient that make one more

successful than another? Sabik, JF...editorial JTCVS Dec 2015

LIMA to LAD is

Standard of Care

Hybrid Revascularization (HCR)What is it?

• Revascularization Strategy• Best of Both Worlds of Interventional

Cardiology and Cardiac Surgery• Defined as minimally invasive LIMA to

LAD (MICS CABG or Robot) with PCI of non LAD territories

• Less traumatic for patient with avoidance of sternotomy and faster recovery

HCR: Not New Examples of Staged HCR

1) In AMI setting, PCI of culprit lesion with surgical revascularization weeks later

2) Postop CABG, PCI of nongrafted coronaries days later

One stop HCR: Clinical Rationale

• Surgical superiority of LIMA to LAD graft• SVG vs DES to non LAD territories

comparable• Utilizes the HYBRID OR• Completion angiogram of LIMA to LAD graft• Complete revascularization in one setting• Patient subjectively will feel disease is

completely treated

Coronary Trials

• Syntax Trial: 5yr results show that CABG is often superior to DES for left main and multivessel CAD

• Freedom Trial: multivessel diabetic patients treated with CABG to have lower all-cause Death and MI at 5yrs, compared to PCI

• LIMA patency• 90-95% patency rate

at 10 yrs

FREEDOM FROM PROCEDURAL RISK & INVASION

DURABILITY (Freedom from re-intervention) & SURVIVAL

Less Risk & Invasion

Higher Durability

PCI

HYBRID

CABG

LIMA

LAD

1

Circ

LAD

2

Outcome?1) HCR vs multivessel OPCAB:

- HCR had shorter vent time, ICU/hospital stay, shorterrecovery, greater pt satisfaction, better target vesselpatency (Kon et al JTCVS 2008)

2) One stop HCR vs CABG vs PCI : - Low/Med Euro/Syntax scores MACCE similar - High Euro score, one stop HCR had lower MACCE than CABG or PCI- High Syntax score, one stop HCR had lower MACCEthan PCI but similar to CABG ( Shen et al JACC 2013)

HOW to do it

Lessons Learned

Minimally Invasive CABG(MICS CABG)

Preop CT Scan

Anticoagulation Strategy(the Canadian way)

Tissue Stabilizer

Complete Sternotomy (CST) Partial Sternotomy (PST)

Robotic Assistance (ROB)Anterior Thoracotomy

LIMA Takedown

MICS CABG vs TECAB

• MICS CABG• Direct vision of IMA

harvest• Anterolateral

thoracotomy• Open direct

anastomosis

• TECAB • Robotic takedown of

IMA • Endoscopic port

incisions• Endoscopic robotic

anastomosis

• “Single stage hybrid coronary revascularization with long term followup”

• 96 patients from 2004 to 2012 with robot LIMA and thoracotomy OPCAB mammary to LAD with PCI of nonLAD

• Angio at 6mos and CTA/perfusion study at 5yrs

• Acceptable 6mo patency with favorable survival/freedom from angina/freedom from revascularization at 5yrs – 6mo patency 94%– 5yr 91% survival– 94% freedom from angina– 87% freedom from revascularization

C Adams. ..B Kiaii. EJCTS Aug 2013

HCR: single center experience: Italy• 42 patients between Sept 2011 and August 2014,

prospective study• Complete revascularization using hybrid approach (MICS

CABG+PCI)• 43% simultaneous hybrid revascularization, others staged• Procedural success in 41 patients (98%), one

unsuccessful PCI• No conversion to full sternotomy, no blood transfusions,

mean LOS 6 days, median vent time 7.7hrs, all alive at discharge Mikus,E. et al. European Heart Journal 2015

How good is the Mammary graft?• Is it as good as a sternotomy, on pump LIMA to

LAD? Yes

1) Mohr ATS 2006- 1300 MIDCAB LIMA to LAD compared to sternotomy- 96% early graft patency at 6 mos

2) Harskamp JTCVS 2014- MIDCAB LIMA to LAD had similar outcomes (MACCE) as

DES of LAD- lower target vessel revascularization

3) Kiaii ATS 2012- Robot assisted takedown of mammary graft patency showed

93% patency in 8yrs.

Patient SelectionGood candidates for HCR

1) Ostial, complex or occluded LAD with simple lesions in other arteries

2) Elderly patients, left main with low syntax score

3) Overweight, diabetic patients4) Comorbidities making sternotomy high risk

Contraindications to MICS CABG Offpump

• LAD is non-graftable, intramyocardial• Inability to undergo offpump

revascularization• Previous surgery involving left chest• Intolerance to one lung ventilation• Left subclavian stenosis making LIMA

unsuitable for grafting

Contraindications to PCI of nonLAD lesions

• Severe PVD, consider radial artery access• Complex disease, tortuous calcified

vessels, fresh thrombotic lesions, hi Syntax score of PCI vessel

• Contraindication to dual antiplatelet therapy

Questions?