Hybrid coronary revascularization

Hybrid coronary revascularization (HCR) or hybrid coronary bypass is a relatively new type of heart surgery that provides an alternative to traditional coronary artery bypass surgery (CABG) or percutaneous coronary intervention (PCI or PTCA) by combining the two into one operation. It is this combining aspect that "hybrid" refers to. HCR is one of several types of hybrid cardiac surgery; it is not to be confused with a MIDCAB (minimally invasive direct coronary artery bypass) procedure, which uses the smaller thoracotomy incision but does not involve coronary stenting.[1]

Hybrid coronary revascularization
Other namesHybrid coronary bypass
Specialtycardiology

Benefits

Hybrid bypass offers all the benefits of a MIDCAB

  1. A much smaller incision (made through the rib cage as opposed to cutting the sternum and opening the rib cage) than with traditional bypass surgery.
  2. Less pain for the patient and quicker recovery time. Particularly in high risk patients, morbidity and mortality decreases in comparison to conventional surgery.[2][3] A study from FuWai Hospital in Beijing[4] reports on 104 patients with multivessel coronary artery disease who were compared with the same sized group of patients undergoing off pump surgery using propensity score matching. The patients treated with the hybrid approach had a significantly lower ICU stay and intubation time and experienced less complications in terms of bleeding and transfusions needs. At a median follow up of 18 months, patients undergoing the hybrid procedure also had a significantly higher freedom from major adverse cardiac or cerebrovascular events (99% vs. 90.4%; p = 0.03). HCR is also associated with a significant decrease in the need for blood transfusion and a significant reduction in the duration of intubation.[5]
  3. Less risk of complications, infections etc. and also decreases the necessity for two separate cardiac procedures (bypass and stenting).[1] However, it requires the implementation of suitable X-ray equipment in the OR, i.e. a hybrid operating room. Helpful in this regard is the regular use of completion angiography. In a study designed and published by the Vanderbilt Heart and Vascular Institute,[6] routine intraoperative completion angiography performed in a fully functional hybrid operation room detected important defects in 97 of 796 (12% of the grafts) venous coronary artery bypass grafts in 366 adult patients (14% of the patients) with complex coronary artery disease. Their findings in completion angiography at the end of the operation included suboptimal anastomoses, poor lie of the venous bypass graft, and bypasses to not diseased vessels. The angiography findings led to a change in the management, including minor adjustments of the graft, traditional surgical revision or percutaneous coronary interventions, resulting in optimal bypass outcomes.
  4. In the study from FuWai, the hybrid procedure was also less costly than an exclusively percutaneous strategy.[4]

A 2018 Meta Analysis with over 4000 patient cases found HCR to have significant advantages compared with conventional CABG. Reduced incidence of Blood Transfusion, reduced hospital stay duration and reduced intubation duration were all reported. In contrast, HCR was found to be significantly more expensive compared to CABG. [7]

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References
  1. Murphy, Gavin J; Bryan, Alan J; Angelini, Gianni D (2004). "Hybrid Coronary Revascularization in the Era of Drug-Eluting Stents". The Annals of Thoracic Surgery. 78 (5): 1861–7. doi:10.1016/j.athoracsur.2004.07.024. PMID 15511503.
  2. Kon, Zachary N; Brown, Emile N; Tran, Richard; Joshi, Ashish; Reicher, Barry; Grant, Michael C; Kallam, Seeta; Burris, Nicholas; Connerney, Ingrid; Zimrin, David; Poston, Robert S (2008). "Simultaneous hybrid coronary revascularization reduces postoperative morbidity compared with results from conventional off-pump coronary artery bypass". The Journal of Thoracic and Cardiovascular Surgery. 135 (2): 367–75. doi:10.1016/j.jtcvs.2007.09.025. PMC 2962576. PMID 18242270.
  3. Bonatti, J; Schachner, T; Bonaros, N; Jonetzko, P; Ohlinger, A; Ruetzler, E; Kolbitsch, C; Feuchtner, G; Laufer, G; Pachinger, O; Friedrich, G (2008). "Simultaneous hybrid coronary revascularization using totally endoscopic left internal mammary artery bypass grafting and placement of rapamycin eluting stents in the same interventional session. The COMBINATION pilot study". Cardiology. 110 (2): 92–5. doi:10.1159/000110486. PMID 17971657.
  4. Hu, Shengshou; Li, Qi; Gao, Peixian; Xiong, Hui; Zheng, Zhe; Li, Lihuan; Xu, Bo; Gao, Runlin (2011). "Simultaneous Hybrid Revascularization Versus Off-Pump Coronary Artery Bypass for Multivessel Coronary Artery Disease". The Annals of Thoracic Surgery. 91 (2): 432–8. doi:10.1016/j.athoracsur.2010.10.020. PMID 21256284.
  5. Reynolds, AC; King, N (August 2018). "Hybrid coronary revascularization versus conventional coronary artery bypass grafting: Systematic review and meta-analysis". Medicine (Baltimore). 97 (33): e11941. doi:10.1097/MD.0000000000011941. PMC 6112891. PMID 30113498.
  6. Zhao, David X; Leacche, Marzia; Balaguer, Jorge M; Boudoulas, Konstantinos D; Damp, Julie A; Greelish, James P; Byrne, John G (2009). "Routine Intraoperative Completion Angiography After Coronary Artery Bypass Grafting and 1-Stop Hybrid Revascularization". Journal of the American College of Cardiology. 53 (3): 232–41. doi:10.1016/j.jacc.2008.10.011. PMID 19147039.
  7. Reynolds AC, King N. (2018) Hybrid coronary revascularization versus conventional coronary artery bypass grafting: Systematic review and meta-analysis. Medicine (Baltimore). 2018 Aug;97(33):e11941
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