Robotic & Hybrid Coronary Revascularization

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Donald Parrish
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University, London Health Sciences Centre, London, ON,

1 Robotic & Hybrid Coronary Revascularization Michael Chu, MD, FRCSC Associate Professor of Surgery Western University, London Health Sciences Centre, London, ON, Canada Saudi Heart Association 2017 Riyadh, KSA March 11, 2017

2 Disclosures Grant support Canadian Institute of Health Research Canadian Foundation for Innovation Ontario Research Fund AMOSO Research lab support from Neochordae, Inc & Medtronic, Canada Speakers honorarium from Medtronic, Canada, Edwards LifeSciences, Symetis, Livanova, Abbott Vascular

3 Learning Objectives Review the steps of robotic assisted coronary bypass and hybrid coronary revascularization (HCR) Discuss our anticoagulation and antiplatelet agent protocal Review patient outcomes

dependant) Prev stroke PVD Renal dysfunction (Scr 200) Asc aortic

4 Case 74 yo female Multiple medical comorbidities 40 yr hx of rheumatoid arthritis (many immune modulating agents, steroid dependant) Prev stroke PVD Renal dysfunction (Scr 200) Asc aortic Ca 2+ Severe osteoporosis (rib#) Large hiatal hernia HTN, lipids obese fragile

5 Options? Conventional CAB 2 vessel PCI Medical therapy Hybrid revascularization

6 Hybrid Revascularization Robotic LITA-LAD PCI OM

7 What is Hybrid Revascularization? Minimally invasive/robotic LITA-LAD + PCI non-lad target Combines best revascularization strategies for specific patients avoids sternotomy and CPB Provides survival benefit of LITA graft with less invasive complete revascularization strategy Faster recovery, greater patient satisfaction Great team building

8 Hybrid Rationale hinges on 3 important assumptions: 1) LITA-LAD confers significant benefit over medicine or stenting in multivessel disease 2) PCI for RCA or Cx disease with DES is better than SVG 3) LITA graft constructed via hybrid technique is equivalent to longterm results from conventional CAB If patient is good candidate for BITA or multiarterial grafting, best for conventional sternotomy revascularization

9 Superior Advantage of the LITA graft Significant survival benefit Patency rate > 95% at 10 years At 10 years after CAB, an ITA- LAD risk of: Death (x1.6) MI (x1.4) Angina (x1.25) Redo surgery (x2) SVG have 50% patency rate at 10 years, of those, 50% are free from atherosclerotic disease

10 DES Outcome PCI CABG n= % 1 year MACE with DES (death, MI, TVR) Serruys et al. NEJM, 2009

12 5 year SYNTAX trial Lancet 2013;381:629-38

13 Hybrid Rationale hinges on 3 important assumptions: 1) LITA-LAD confers significant benefit over medicine or stenting in multivessel disease Hybrid Coronary Revascularization: 2) PCI for RCA or Cx disease with DES is better than SVG 3) LITA graft constructed via hybrid technique is equivalent to longterm results from conventional may provide optimal CAB revascularization strategy in specific patients, combining the best WE have to offer Less invasive Faster recovery Completion angiography

14 What are the steps of hybrid revascularization?

15 Procedural Steps 3 options: Staged MID-CAB, then PCI Staged PCI, then MID-CAB Simultaneous HCR (MID-CAB, then PCI)

16 Simultaneous HCR One-stop revascularization Completion angiogram Reduces risk of interstage morbidity Hybrid operating room Logistical issues (coordinating CVT & Cardiology teams)

17 Step by Step HCR 1) General anaesthetic 2) Robot-assisted CAB first 3) Swing in fluroscopy 4) Puncture femoral artery 5) ITA check 6) PCI non-lad vessel 7) Extubate 8) Fast track/icu

18 Simultaneous HCR General anaesthetic Single lung ventilation intrathecal block Hybrid OR TEE OPCAB

19 Option 1: Robot-assisted LITA-LAD

20 Option #2: Direct Harvest MID-CAB

21 LITA-LAD Checking doppler flows Construction of anastomosis

22 Convert to Cath Lab ITA check

23 Intraprocedural Angiography Immediate Post-procedure 24 hours later

24 PCI non-lad vessel

25 Post-procedure Extubate before leaving OR

26 How do we manage anticoagulation?

27 Anticoagulation Management Daily ASA continues LITA harvest bivalirudin 0.75 mg/kg bolus Bivalirudin 1.75 mg/kg/hr (target ACT > 300s) LITA-LAD anastamosis Clopidogrel 600 mg via NG tube PCI Daily ASA, Clopidogrel

28 Anticoagulation

29 Which patients are ideal candidates for hybrid revascularization?

30 Patient Selection Patient factors Age>70 + comorbidities Calcified aorta Previous stroke Renal dysfunction Peripheral vascular disease Obesity Steroid dependancy Young, active Otherwise well Want early return to work with minimal impact on quality of life

31 Patient Selection anatomic factors 2 VD Low-moderate burden coronary disease Poor candidates for bilateral ITA Not high SYNTAX scores Good surgical LAD target, poor surgical non-lad targets

32 Contraindications to Robotic CAB Contraindications to single lung ventilation (FEV1<50%) Poorly prognostic CT scan (special robotic protocal for intraoperative planning) Intramyocardial LAD Accessible LAD? compromised LITA graft (subclavian stenosis) Inadequate intra-thoracic working space Cardiogenic shock

33 Computed Tomography

34 Cardiac-gated Computed Tomography Critical preoperative planning LITA Patent LAD Where is it? Intramyocardial Approach Robotic port placement Incision Minimize intraop conversions

35 Contraindications to PCI of non-lad lesions Inadequate vascular access Vessel size <2-2.5mm Tortuous calcified vessels Complex disease requiring prolonged procedure time High SYNTAX scores (conv CAB) Fresh thrombotic lesions Contraindication to dual anti-platelet therapy

36 Results 146 HCR patients Diabetes 23 (21%) Prev stroke 5 (5%) 39 two staged 107 single staged 79 male, 28 female mean age 61±12 (range 36-89) CCS class III or IV 92 (86%) Grade III-IV LV 8 (7.5%) Elective 79 (72%) Urgent 31 (28%)

37 Results CAD Intraop PCI LM 2VD 3VD RCA Cx Diagonal

38 Results Transit time doppler Mean LITA-LAD graft flow 23±15 cc/min 100% OPCAB 100% postop angiography Mortality 0 Postop MI 1 Stroke 1 Reop for bleeding 5

39 Angiographic Patency Single Stage HCR 103/103 90/95 = 94% FitzGibbon Grading Classification

40 LHSC Hybrid Revasc no 30d, 1 MI, 1 CVA, 4 re-op for bleeding median LOS 4 days 105 stents utilized (95 DES, 10 BMS) 39 RCA, 25 Cx, 21 OM, 19 Diag Adams et al, EJTS 2013 (in press)

41 Follow-up Angiographic Results LITA grafts n=85/96 Stents n=89/105 Adams et al, EJTS 2013 (in press) No F/U 2 conversions, 5 Lost, 4 refused

42 Long-term 5 year follow-up 6 pts underwent angiography for symptoms b/t 6mo and 5 y all grafts patents (4 FG A, 2FG B) 1 DES occluded, which was 6mo n=53 5 y f/u mortality 5/53 (9.4%) 94% of survivors free from angina, 89% free from further revasc 19 pts underwent 5y CT angios, MIBI 17/19 LITA patent, 17/19 stented lesions patent Adams et al, EJTS 2013 (in press)

44 London HCR/TAVI/Perc MV Team 2 cardiac surgeons 2 interventional cardiologists 2 cardiac anaesthesiologists 2 OR nurses 2 cathlab nurses 1 perfusionist 1 cathlab tech Residents, fellows, assistants

45 Fully integrated team

46 Hybrid MV Repair

47 Hybrid AVR 90 yo male Exertional angina & SOB Prev CABx2 (patent SVG, no LITA) Scr 180 Admitted with CHF REDO sternotomy OPCAB LITA-LAD DA TAVI 29 mm CoreValve Severe AS mg/pg 50/90 90% prox LAD

48 HCR Case 67 yo male SOBOE NYHA III EF 20-25% Morbid obesity (BMI 51) HTN, chol, smoker OSA Recurrent pancreatitis x 3 Bilat TKA Significant LAD & Cx disease

49 More ideal body habitus > 500 cases Boyd, Kiaii, Chu Largely LAD disease Da Vinci robot LITA harvest MIDCAB TECAB Intraoperative angiography on all patients

50 Perspective Hybrid Coronary Revascularization: 148 hybrid coronary revascularization patients Careful Patient Selection Not for all 2VD 800 CAB x 10 years = 8, 000 CAB cases (<2%) 1500 Appears PCI x 10 to years provide = 15, excellent 000 PCI cases LITA-LAD (<1%) patency with less invasive complete revascularization Can be advantageous to: 1. Reduce morbidity in higher risk patients 2. May allow faster recovery in younger, healthy patients

51 HCR Conclusions Simultaneous hybrid coronary revascularization is feasible with acceptable results Appears to reduce patient morbidity (avoids sternal wound healing problems, faster recovery, high patient satisfaction) Requires dedicated multi-disciplinary team Careful patient selection Single centre results (randomized evidence is required)

53 Questions?

Declaration of conflict of interest NONE

Declaration of conflict of interest NONE Claudio Muneretto MD, PhD Director of Division of Cardiac Surgery University of Brescia Medical School Italy Hybrid Chymera Different features and potential advantages