Declaration of conflict of interest NONE

Transcription

1 Declaration of conflict of interest NONE

2 Claudio Muneretto MD, PhD Director of Division of Cardiac Surgery University of Brescia Medical School Italy

3 Hybrid Chymera Different features and potential advantages in one single body

4 Hybrid Car Optimizes the energy consumption decreasing costs and pollution

5 Rational of Hybrid: joint different entities including technologies and techniques, taking the best of each and eliminating their respective disadvantages

6 When applied to myocardial revascularization Hybrid approach offers the potential advantages of LIMA on LAD combined with the reduced invasiveness of PCI + STENT

7 However hybrid approaches are still limited and debated the main reason being the need for close cooperation among interventional cardiologists and surgeons and a patient centered decision making

8 Myocardial Revascularization Hybrid Approach MIDCAB combined with PCI + STENT

9 Minimizing invasiveness of Surgical Myocardial Revascularization Extracorporeal circulation total body inflammatory response Cardiac arrest (cardioplegia) Embolic/haemorragic risk Elderly patients Median sternotomy Maxi invasiveness Functional impairment Recovery Cosmetics

10 Minimizing invasiveness of Surgical Myocardial Revascularization Extracorporeal circulation Beating heart, off-pump myocardial revascularization Median sternotomy LAST ( left anterior small thoracotomy) Full endoscopic/robotic

11 MIDCABG vs. Full Sternotomy

12 Minimizing!!

13 Off-pump vs. On-pump CABG Clinical evidences: OPCAB better? In-hospital mortality? Perioperative MI Perioperative stroke Perioperative renal failure Transfusion requirements Hospital/ICU stay?/ yes Yes Yes Yes Yes

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17 CABG: which graft? Despite the demonstrated significant long-term benefits, multiarterial grafting is used very unfrequently The Society of Thoracic Surgeons database (2008) indicates that 95% of CABG are LIMA-LAD + Saphenous grafts +sternotomy+cpb (1) Desai ND,Cohen EA,Naylor CD : A randomized comparison of radial artery and saphenous vein coronary bypass grafts N Engl J Med 2004, 351,

18 Occlusion rate of SVG: 13-21% (12 mths) Yun KL, Wu Y, Aharonian V et al. Randomized trial of endoscopic versus open vein harvest for coronary artery bypass grafting: Six-month patency rates. J Thorac Cardiovasc Surg 2005;129: Rate of target vessel revascularisation after PCI+DES: 14.2% (12 mths) Serruys PW, Morice MC, Kappetein AP et al. Percutaneous Coronary Intervention versus Coronary-Artery Bypass Grafting for Severe Coronary Artery Disease. N Engl J Med : Equivalence in short term patency between DES and SVG

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22 MIDCAB standard surgical approach Left mini-thoracotomy

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28 MIDCAB in T1-T2 epidural analgesia in awake patient First Italian case 2001

29 MIDCAB: Early angiographic results 150 consecutive cases VARIABLE % Post-op angiographies 100 Graft patency 100 Grade A anastomoses 99.3 Grade B anastomoses 0.7 Division of Cardiac Surgery, University of Brescia Medical School ESC 2012

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31 MIDCAB Population (810 pts.) 1)Isolated LAD disease: 494 (61%) 2)2 or 3 vessel disease treatable by PCI after revascularization of LAD (hybrid): 316 (39%) Division of Cardiac Surgery, University of Brescia Medical School ESC 2012

32 Left main stenosis plus Rescue-PCI on RCA : Constrained hybrid approach

33 MIDCAB operation MAY JAN patients 18 (2%) pts had MIDCAB converted to median sternotomy for: -intramural LAD (12) -too lateral LAD (4) -too distal LAD anastomotic site (2) No haemodynamic or arrhytmic conversions Division of Cardiac Surgery, University of Brescia Medical School ESC 2012

34 MIDCAB main features A Repossini et al Ann Thorac Surg 2000; 70 :74-8 LIMA-LAD graft patency 100% Mortality 2/810 (0.24%) Lenght of procedure h Mean bleeding 250 cc NO ICU stay 11% ICU stay < 24 h 89% Discharge within 4th PO day 98% Division of Cardiac Surgery, University of Brescia Medical School ESC 2012

35 Post-operative data Hospital Mortality 2(0.24%) AMI 18 (2,4%) Early redo 5 (1.1%) Reoperation for bleeding 10 (2.2%) Orotracheal intubation (hrs) mean 3±2 Bleeding (ml) mean 255±65 Transfusion 34 (4.1%) Division of Cardiac Surgery, University of Brescia Medical School ESC 2012

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37 multicentric,prospectic randomized, 25 EU Heart Teams Coordinator : Cardiac Surgery University of Brescia

38 NSTEMI de novo (previously untreated) patients with lesions, 70% (>50% Left Main) target vessel stenosis with stable/unstable angina or evidence of ischemia 2VD with proximal LAD, 3VD simple lesions SYNTAX score <22, LM + 2VD or 3VD SYNTAX score <32.

39 Previous PCI (within 6 mths for BMS /DES) Previous CABG, Recurrence of in stent restenosis of a DES or BMS STEMI within 15 days from randomization The need for concomitant cardiac surgery. Previous thoracic surgery involving the left chest Contraindication for concomitant ASA-Clopidogrel therapy

40 Syntax Trial ESC EACTS Guidelines 2010

41 Conclusions The only limitations for a wide use of an hybrid strategy are the lack of close cooperation of surgical and interventional teams and the limited diffusion of MIDCAB in cardiac surgery environment Division of Cardiac Surgery, University of Brescia Medical School ESC 2012

42 Hybrid OR Simultaneous treatment Thanks for your attention Division of Cardiac Surgery, University of Brescia Medical School ESC 2012