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
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
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
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
Options? Conventional CAB 2 vessel PCI Medical therapy Hybrid revascularization
Hybrid Revascularization Robotic LITA-LAD PCI OM
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
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
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
DES Outcome PCI CABG n=1800 5-7% 1 year MACE with DES (death, MI, TVR) Serruys et al. NEJM, 2009
5 year SYNTAX trial Lancet 2013;381:629-38
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
What are the steps of hybrid revascularization?
Procedural Steps 3 options: Staged MID-CAB, then PCI Staged PCI, then MID-CAB Simultaneous HCR (MID-CAB, then PCI)
Simultaneous HCR One-stop revascularization Completion angiogram Reduces risk of interstage morbidity Hybrid operating room Logistical issues (coordinating CVT & Cardiology teams)
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
Simultaneous HCR General anaesthetic Single lung ventilation intrathecal block Hybrid OR TEE OPCAB
Option 1: Robot-assisted LITA-LAD
Option #2: Direct Harvest MID-CAB
LITA-LAD Checking doppler flows Construction of anastomosis
Convert to Cath Lab ITA check
Intraprocedural Angiography Immediate Post-procedure 24 hours later
PCI non-lad vessel
Post-procedure Extubate before leaving OR
How do we manage anticoagulation?
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
Anticoagulation
Which patients are ideal candidates for hybrid revascularization?
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
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
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
Computed Tomography
Cardiac-gated Computed Tomography Critical preoperative planning LITA Patent LAD Where is it? Intramyocardial Approach Robotic port placement Incision Minimize intraop conversions
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
Results 146 HCR patients 2004-2012 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%)
Results CAD Intraop PCI LM 2VD 3VD RCA Cx Diagonal
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
Angiographic Patency Single Stage HCR 103/103 90/95 = 94% FitzGibbon Grading Classification
LHSC Hybrid Revasc no mortality @ 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)
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
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 patent @ 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)
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
Fully integrated team
Hybrid MV Repair
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
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
More ideal body habitus > 500 cases Boyd, Kiaii, Chu Largely LAD disease Da Vinci robot LITA harvest MIDCAB TECAB Intraoperative angiography on all patients
Perspective 2004-2014 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
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)
Questions? Michael.Chu@lhsc.on.ca