Page 262 - Read Online

Gacad et al. Vessel Plus 2019;3:28 I http://dx.doi.org/10.20517/2574-1209.2019.011 Page 5 of 10

Table 2. 1-Stage vs. 2-stage hybrid coronary revascularization
1-stage 2-stage
Advantages Gives option for off-pump LIMA-LAD bypass, can avoid a Does not require hybrid operating room, increased
median sternotomy by using thoracotomy with minimally time for prevention of post-operative bleeding,
invasive/endoscopic/robotic techniques, shorter ventilation decreased inflammatory response to bypass
and hospital time, verification and correction of LIMA-LAD surgery that may cause in-stent thrombosis,
grafts prior to antiplatelet therapy induction provide option for PCI-first of non-LAD lesions to
avoid ischemia or infarction in those territories
during LIMA-LAD surgery
High cost, long operating time, requirement of hybrid Increased inpatient admission time, no option
operating room, increased coordination requirement for immediate repair of defective LIMA-LAD
Disadvantages
between interventional cardiologist and cardiothoracic anastomosis, increased bleeding risk for PCI-first
surgeon, thoracotomy option has increased pain approach
LIMA: left internal mammary artery; LAD: left anterior descending; PCI: percutaneous coronary intervention

Figure 1. Hybrid Coronary Revascularization process flow-chart. This flow-chart details the steps of Hybrid Coronary Revascularization for
both hybrid OR and non-hybrid OR settings. In LIMA-LAD anastomosis can be through mini-thoracotamy or sternotomy. In the hybrid-
OR 1-step approcach, LIMA-LAD graft can be immediately visualized with angiography. OR: operating room; LIMA: left internal mammary
artery; LAD: left anterior descending; PCI: percutaneous coronary intervention

not require a hybrid OR. When patients have critical lesions of non-LAD arteries, PCI with endovascular
implantation of 2nd generation DES in diseased non-LAD arteries can be first performed to avoid
complications (hypotension and hemodynamic compromise) at the times of thoracotomy and the LIMA
graft to the LAD . The PCI endovascular revascularization first approach increases the risk of bleeding as
[77]
[77]
CABG surgery is then performed in patients who are receiving dual anti-platelet therapy .
HCR IN CLINICAL PRACTICE
Given the complex multi-disciplinary nature of HCR and its pre-procedural planning, its clinical utility
would be in the treatment of stable ischemic heart disease with refractory angina [Figure 2]. Coronary
[78]
physiologic assessments such as fractional flow reserve have shown benefit in selecting a subset of
patients who may benefit from PCI when compared to medical management. At this time there is no
current data for potential use in acute coronary syndrome, but that may change over time with the
increasing number of hybrid ORs and multi-disciplinary heart teams. HCR allows for a less invasive
approach than traditional CABG, while providing added mortality/graft patency benefit of the LIMA-LAD
over the multi-vessel PCI with DES [79-81] .