How to Perform Hybrid Myocardial Revascularisation: Interventional Perspective

How to Perform Hybrid Myocardial Revascularisation: Interventional Perspective Gerhard Schuler Herzzentrum Leipzig Nothing to disclose

Hybrid An animal or a plant resulting from a cross between genetically unlike individuals, usually sterile To combine useful aspects of different methods

Hybrid Plants

Hybrid Power Plant

Hybrid Procedures Combination of interventional and surgical techniques in order to reduce invasiveness, improve safety and long term results.

Sequential Procedures Time Interval PCI CABG Time Interval PCI TAVI Patient comfort Expenses Efficiency Time in hospital

Hybrid Procedures PCI + CABG PCI + TAVI Patient comfort Expenses Efficiency Time in hospital

Hybrid Procedures Personnel Infrastructure: Hybrid OR Combinations of Procedures Case Presentations

Heart Team Suitability of pt Selection of Appropriate Approach Sequence of procedures Assessment of Risks Definition of Bail Out Strategies

Type of Procedure Determined by Referring Physician Referrals A Referrals B Referrals C

Type of Procedure Determined by Heart Team Referrals A Referrals B Referrals C Heart Team

Hybrid OR

Hybrid OR: Hemodynamic recording system

Hybrid OR 'Safety Line'

DYNA CT

Indications for Hybrid Procedure

Indications for Hybrid Procedure Primary PCI for posterior or inferior STEMI and severe CAD in non culprit vessels better suited for CABG. Emergent PCI prior to surgery in pts with combined valvular and coronary disease, if the pt cannot be transferred to for surgery, or in the presence of acute ischemia. Patients who had previous CABG and now require valve surgery Combination of revascularization with non-sternotomy valve intervention (e.g. PCI and minimally invasive mitral valve repair, or PCI and transapical aortic valve implantation. In pts with conditions likely to prevent healing after sternotomy, surgery can be restricted to the LAD territory using minimally invasive direct coronary bypass (MIDCAB) or left ITA grafting. Remaining lesions in other vessels are treated by PCI.

Suitable Combinations LIMA + PCI Multimorbid high risk pts COPD Pts with malignancies History of sternal wound infections Previous sternotomy TAVI + PCI Valve-in-Valve (TAVI) + PCI Minimal invasive mitral valve repair + PCI Mitraclip + PCI

Which Procedures Have Been Performed? CABG (MIC) + PCI C 13 /26 Simultaneous "hybrid" percutaneous coronary intervention and minimally invasive surgical bypass grafting: feasibility, safety, and clinical outcomes.am Heart J 2008 Apr;155(4):661-7 (ISSN: 1097-6744)Reicher B; Poston RS; Mehra MR; Joshi A; Odonkor P; Kon Z; Reyes PA; Zimrin DA = S 15 /30 Simultaneous hybrid coronary revascularization reduces postoperative morbidity compared with results from conventional off-pump coronary artery bypass.j Thorac Cardiovasc Surg 2008 Feb;135(2):367-75 (ISSN: 1097-685X)Kon ZN; Brown EN; Tran R; Joshi A; Reicher B; Grant MC; Kallam S; Burris N; Connerney I; Zimrin D; Poston RS + S 11 Hybrid revascularization feasibility in minimally invasive direct coronary artery bypass grafting combined with percutaneous transluminal coronary angioplasty in patients with acute coronary syndrome and multivessel disease.jpn J Thorac Cardiovasc Surg 2001 Dec;49(12):700-5 (ISSN: 1344-4964)Matsumoto Y; Endo M; Kasashima F; Abe Y; Kosugi I; Hirano Y; Sasaki H; Ueyama T C 20 /20 Combination of minimally invasive coronary bypass and percutaneous transluminal coronary angioplasty in the treatment of double-vessel coronary disease: Two-year follow-up of a new hybrid procedure compared with "on-pump" double bypass grafting.am Heart J 2001 Oct;142(4):563-70 (ISSN: 1097-6744)de Canniere D; Jansens JL; Goldschmidt-Clermont P; Barvais L; Decroly P; Stoupel E +

RCA 99%

RCA post PCI

Angio LAD 100%

Pat. S.G. MIDCAB

Angio LIMA zur LAD

Which Procedures Have Been Performed? Valve repair/deployment + PCI PCI + MKR MIC 1 Hybrid percutaneous coronary intervention and minimally invasive reoperative mitral valve surgery [In Process Citation] J Card Surg 2009 Mar-Apr;24(2):191-3 Masroor S; Berkowitz R; Nejad K; Alexander JC PCI + AKE MIC 18 Effectiveness of same day percutaneous coronary intervention followed by minimally invasive aortic valve replacement for aortic stenosis and moderate coronary disease ("hybrid approach").am J Cardiol 2006 Dec 1;98(11):1501-3 Brinster DR; Byrne M; Rogers CD; Baim DS; Simon DI; Couper GS; Cohn LH PCI + open valve 26 Staged initial percutaneous coronary intervention followed by valve surgery ("hybrid approach") for patients with complex coronary and valve disease.j Am Coll Cardiol 2005 Jan 4;45(1):14-8 Byrne JG; Leacche M; Unic D; Rawn JD; Simon DI; Rogers CD; Cohn LH

Mitral Valve Prolaps

Minimal Invasive Mitral Valve Repair + PCI

TAVI + PCI in Severe Aortic Stenosis

Survival after TAVI (TF+TA) Impact of CAD Dewey TM et al. Ann Thorac Surg 2010

Leipzig Experience CAD Prevalence 400 consecutive CoreValve patients CAD Grade No CAD 87 21.8% Sclerosis 104 26.0% Relevant Stenoses >50% 209 52.2% VD (209) 1 92 44.0% 2 14 6.8% 3 103 49.2% Woitek F, Linke A, Schuler GC in prep

Leipzig Experience CAD Management Need for Re- Vascularization Staged PCI Concomitant PCI N=39 (9.8%) 33 (8.3%) 6 (1.5%) Days prior to TAVI 8.5±7.8 0 Success 33 (100%) 6 (100%) Renal Failure Stage 3 (VARC) 3 (10%) 1 (16.7%) Procedural MI (VARC) 2 (6.1%) 1 (16.7%) Woitek F, Linke A, Schuler GC

Case Presentation 77 year old male patient NSTEMI 3 vessel disease + LMCA Aortic stenosis III

Pat. S.G. : High grade distal left main

Pat. S.G. : Stenting of Left Main

Pat. S.G. Result after Stenting

Pat. S.G. Valvuloplasty

Pat. S.G. Edwards Sapien Valve transapical

Case Presentation 83 year old male patient 4/2003 resection of an LA tumor & mitral valve replacement (Mosaic 29 mm) 2-vessel disease Admitted with severe CHF and significant mitral stenosis

Pat. H. W. Positioning of Edwards Sapien Valve in Mitral Anulus (transapical Valve-in- Valve)

Pat. H. W. Deployment of Edwards Sapien Valve in Mitral Anulus (transapical Valve-in- Valve)

Pat. H. W. RCA, Dissection and Subtotal Occlusion

Pat. H. W. RCA, Recanalization

Pat. H. W. RCA, Positioning of Balloon 1,5mm

Pat. H. W. RCA, Balloon Dilatation 2.5 mm

Pat. H. W. RCA, Stent Implantation 3.0 mm

Pat. H. W. Final Result

Simultaneous hybrid coronary revascularization reduces postoperative morbidity compared with conventional off-pump coronary artery bypass. Kon Z et al; J Thorac Cardiovasc Surg 2008;135:367-375 Costs

Simultaneous hybrid coronary revascularization reduces postoperative morbidity compared with conventional off-pump coronary artery bypass. Kon Z et al; J Thorac Cardiovasc Surg 2008;135:367-375 Satisfaction

Downside of Hybrid Procedures Imaging system in hybrid OR usually not dedicated to coronary interventions.

Summary Presently few hybrid procedures are performed, studies are small, and no conclusive results have been published. No guideline recommendations have been defined. In the interest of pt comfort, efficiency, and infrastructure hybrid procedures should be performed simultaneously during the same session by a dedicated interdisciplinary team. A truely hybrid environment requires careful planning and synchronization of procedures. A hybrid operating room equipped with a full size x-ray imaging system, cardiopulmonary bypass, and TEE offers optimal conditions.