hybrid procedures – from boxing ring to synchronized

Hybrid procedures – from boxing ring to synchronized swimming

Dr. Arindam Pande, MD, DMAssociate Consultant, Cardiology

Apollo Gleneagles Hospital, Kolkata

http://www.123rf.com/photo_10678548_bangkok-thailand-september-25--thai-fight--muay-thai-world.html

• Introduction• Hybrid CABG/PCI• Hybrid Valve/PCI• Hybrid Arrhythmia/AF procedures• Hybrid Approach for Complex Thoracic Aortic

Aneurysms/Dissections• Hybrid Approach in Congenital Heart Disease• Unresolved issues• Hybrid cardiovascular procedures: our

experience• Conclusion

Introduction A hybrid strategy combines the treatments

traditionally available only in the catheterization laboratory with those traditionally available only in the operating room to offer patients the best available therapies for any given set of cardiovascular lesions.

The concept is not new.

Introduction (Contd.)• In the modern era, a hybrid procedure refers to the

combination of traditional surgery and percutaneous intervention, staged by minutes, hours, or at most, days.

• This more compressed staging of hybrid procedures has regained interest as cardiac surgeons have improved techniques for minimally invasive surgical approaches, while interventional cardiologists have at their disposal improved devices and have developed skills that have enabled them to become more aggressive in their percutaneous interventions.

• With the increased complexity of patients referred to the catheterization laboratory and to surgery, a team approach combining the best available tools of both specialties seems appealing to minimize the procedural risk.

Hybrid CABG/PCI• The LIMA–LAD graft has excellent patency rates, which

correlates with increased event-free survival. Reports suggest a 5-year patency rate between 92% and 99% and at 10 years between 95% and 98%.

• Location of the lesion in the proximal LAD has been identified as an independent risk factor for in-stent restenosis with rates between 19% and 44% .

• Failure rates for SVGs have been reported at 1 year between 1.6% and 30%, with an average of 20%. At 10 to 15 years of follow-up, 40% to 50% of the SVGs will have failed.

• TLR for proximal right/circumflex coronary artery stents has been reported to be 13.8% at 1 year for BMS

• TLR rate at 2 years follow-up is 5.8% with DES, compared with 21.3% in the BMS group (SIRIUS Study)

Minimally invasive CABG procedures• MIDCAB (minimally invasive direct coronary artery bypass

grafting )- the LIMA is harvested through a small left anterior thoracotomy incision or lower hemi-sternotomy. The LIMA–LAD bypass is crafted through this limited incision on the beating heart. (1996, Angelini et al.)

• TECAB (Totally endoscopic coronary artery bypass grafting)- the LIMA–LAD graft created using peripheral access for cardiopulmonary bypass in a ‘Closed-chest CABG surgery’ performed with robotic systems, which allows manipulation of tissues within thoracic ports through the use of fine instruments. At a separate operating console, the surgeon controls the instruments, while the operation is viewed stereoscopically (3-dimensional view). (1999, Loulmet et al.)

Copyright © The American College of Cardiology. All rights reserved.

From: Hybrid Cardiovascular Procedures

J Am Coll Cardiol Intv. 2008;1(5):459-468. doi:10.1016/j.jcin.2008.07.002

Minimally Invasive Direct Coronary Artery Bypass Grafting

(A) Minimally invasive direct coronary artery bypass grafting (MIDCAB) of the left internal mammary artery (LIMA) to left anterior descending coronary artery (LAD) through an anterior-lateral left thoracotomy on the beating heart. (B) Postoperative incision after MIDCAB.

Figure Legend:

Rationale of Hybrid CABG/PCI

• PCI with DES is a better treatment to the non-LAD coronary artery disease than an SVG.

• The LIMA-LAD graft may be responsible for the majority of the benefit of CABG surgery.

• Minimally invasive CABG surgeries reduce the procedure related co-morbidities.

2-Staged Hybrid Versus 1-Stop Hybrid CABG/PCI

All hybrid procedures are staged, the only distinction being the duration of the staging.

• 2-staged: PCI and CABG performed in 2 different operative suites, the 2 procedures separated by hours, days, or weeks

• 1-stop: hybrid CABG/PCI performed in a hybrid suite in 1 setting, staged by minutes

2-Staged Hybrid CABG/PCIPCI before CABG:Advantages-• allows aggressive multivessel stenting (because if a complication arises or PCI is not

successful, CABG can be performed later)

Disadvantages- • performing PCI in an unprotected environment without the benefit of a LIMA–LAD graft • performing CABG later under powerful antiplatelet agents • no mid-term angiographic controls of the LIMA–LAD graft unless a third procedure is

done (the completion angiogram)

PCI after CABG:Advantages-• avoids antiplatelet-related bleeding complications during CABG • protected environment with a LIMA–LAD graft• LIMA graft patency can be verified at the time of PCI

Disadvantages- • In the event of PCI complication/failure, a second, higher-risk operation needs to be

performed (however, emergent CABG after PCI has a low incidence of <1%)

1-Stop Hybrid CABG/PCIAdvantages-• excellent monitoring• any complications can be resolved in 1 setting• graft patency can be confirmed• 1 team- 1 cost• shorter hospital stay• lack of logistical challenges• no potential risks related to handoffs• patients’ preference

Disadvantages-• use of antiplatelet agents• unknown response of DES to heparin reversal with protamine• need to build an especially dedicated hybrid room with capabilities

of both a complete operating room and a procedural suite




A hybrid operating room.Figure Legend:

Indications of Hybrid CABG/PCI• multivessel disease who have high-grade proximal disease of the

LAD (e.g. excessive vessel tortuosity or chronic total occlusion) along with favorable lesions for PCI in the left circumflex and right coronary artery territories

• lack or poor quality of the conduit• nongraftable but stentable vessel (e.g., left circumflex lesions in

the atrioventricular groove with small diffuse obtuse marginal)• repeat operations in which PCI is preferable to avoid full cardiac

dissection • concomitant pre-existing organs dysfunction • recent myocardial infarction• severe atherosclerotic aortic disease (heavily calcified proximal

aorta)

Advantages of Hybrid CABG/PCI

• safe with low mortality rates (0% to 2%)• low morbidity• shorter intensive care unit and hospital stay • superior cosmetic results• faster recovery

Disadvantages of Hybrid CABG/PCI

• longer operating time• late wound complications• more late pain because of rib retraction• technical demands placed on the surgeon (because MIDCAB

and TECAB are technically demanding, anastomosis patency in the learning curve may be lower than conventional approaches)

• stent restenosis and the need for repeat revascularization with BMS (In hybrid series, the stent restenosis at 6 months is 2.3% to 23% with an average across the literature of 11%)

ACC/AHA recommendation (2011) for Hybrid Coronary Revascularization

Class IIa1. Hybrid coronary revascularization (defined as the planned combination of

LIMA-to-LAD artery grafting and PCI of ≥1 non-LAD coronary arteries) is reasonable in patients with 1 or more of the following (Level of Evidence: B):

a. Limitations to traditional CABG, such as heavily calcified proximal aorta or poor target vessels for CABG (but amenable to PCI);

b. Lack of suitable graft conduits;

c. Unfavorable LAD artery for PCI (ie, excessive vessel tortuosity or chronic total occlusion).

Class IIb1. Hybrid coronary revascularization (defined as the planned combination of

LIMA-to-LAD artery grafting and PCI of ≥ 1 non-LAD coronary arteries) may be reasonable as an alternative to multivessel PCI or CABG in an attempt to improve the overall risk–benefit ratio of the procedures. (Level of Evidence: C)

Completion Angiogram• For a patient who underwent coronary artery bypass grafting, coronary

imaging (completion angiography) for the routine evaluation of the bypass grafts is reasonable, as the one-year re-occlusion rate is significant

• Thereby, defected implantations may be detected• In a study designed and published by the Vanderbilt Heart and Vascular

Institute, routine intraoperative completion angiography performed in a fully functional hybrid operating room detected important defects in 97 of 796 (12% of the grafts) venous coronary artery bypass grafts in 366 adult patients (14% of the patients) with complex coronary artery disease.

• Their findings in completion angiography at the end of the operation included suboptimal anatomies, poor positioning of the venous bypass graft, and bypasses to not diseased vessels.

• Consequently, these defects, which usually would be detected at follow-up, could be rectified immediately, through minor adjustment of the graft or traditional surgical revision or with intraoperative open-chest PCI, resulting in optimal bypass outcomes.

• Hybrid patients had clinical outcomes similar to standard CABG patients




A completion angiogram of a LIMA graft to the LAD after MIDCAB procedure. Figure Legend:

Hybrid Valve/PCI• Alternative approaches to standard sternotomy for valve

surgery have been advocated to reduce operative mortality and morbidity, speed recovery, and improve cosmetics

• These approaches include partial sternotomies and mini-thoracotomies

• Concomitant coronary artery disease has been a contraindication to such approaches because concomitant CABG, and therefore sternotomy, would be mandatory

• Approaching coronary disease with PCI, which may actually be superior to SVG, has given the opportunity to expand the indications for minimally invasive valve surgery to patients with concomitant coronary disease

Minimally Invasive Valve Surgery

Refers to a collection of techniques in which alternative incisions to sternotomy is used

• aortic valve surgery - upper hemi-sternotomy • mitral valve surgery - small right mini-thoracotomy (robotic and

video-assisted mitral valve procedure can be performed through this approach) or lower hemisternotomy

Advantages-• reduced postoperative pain,• faster recovery - shorter hospital stay• less utilization of autologous blood• superior cosmetic results




Incisions for Valve Surgery

(A) Median sternotomy (aortic, mitral, or tricuspid valve). (B) Right thoracotomy (mitral or tricuspid valve). (C) Upper hemi-sternotomy (aortic valve). (D) Lower hemi-sternotomy (mitral or tricuspid valve). Figure illustration by Rob Flewell.

Figure Legend:

Hybrid Valve/PCI: Rationale

• Traditional valve/CABG surgery has twice the mortality of isolated valve surgery

• In high-risk patients with multiple comorbidities such as increased age, low ejection fraction, morbid obesity, and pulmonary and renal dysfunction, it may even be higher

• Strategy of PCI with DES followed within 24 h by minimally invasive aortic valve replacement shown promising result

• Hybrid valve surgery is especially suitable for patients with acute coronary syndrome and known valve disease. In this approach, usually PCI is performed first to the culprit lesion, stabilizing the coronary lesion, and then, during the same hospital stay, the valve lesion is addressed 5 to 7 days after the initial PCI

• Hybrid approach is also helpful for the ease of repeat valve procedure in future

Hybrid Valve/PCI: Limitations

• antiplatelet related bleeding• need for a learning curve for the surgeons • operative times can be longer• exposure of the valve can be difficult• institution of cardiopulmonary bypass and myocardial

protection can be more time consuming and troublesome• satisfactory de-airing may be difficult• increased risk of neurological adverse events (in some series)• inability to fully visualize the heart in case of heart distension,

thus relying almost completely on transesophageal echocardiogram

Hybrid Arrhythmia/AF procedures• Available interventional therapy (by creating lesion sets) for AF

-incisional atriotomies (the Maze procedure)

-epicardial ablation [e.g. thoracoscopic pulmonary vein isolation (PVI) and ganglionated plexus (GP) ablation]

-endocardial ablation (cryoablation or radiofrequency)• Surgical approaches have the advantages of being faster and more extensive

than percutaneous approaches• However, some lesions may be more easily created by percutaneous

approach• Further development of the closed-chest or minimally invasive technique by

surgeons (surgical access with subxiphoid window and limited anterior thoracotomy in the electrophysiology lab is feasible and safe) has expanded the horizon to lone epicardial atrial fibrillation surgery in conjunction with percutaneous endocardial techniques with intraoperative electrophysiological confirmation in order to decrease recurrences of AF during follow-up

• Ideally, this would be done in a specially designed hybrid electrophysiologist operating room to further modify treatment or to assess effects of lesions created

• Some groups have been using this strategy in a staged fashion• There are not only first results available for atrial fibrillation, but also for

treating drug-refractory ventricular tachycardia (surgical ablation with an epicardial approach with concomitant electrophysiological mapping)

• Pacemakers and implantable cardioverter defibrillators (ICD), particularly bi-ventricular systems, may be optimally implanted in a hybrid OR environment, because the hybrid operating theatre offers the required superior angulation and imaging capabilities in comparison to mobile C-Arms, and the higher hygienic standards compared to cath labs.

• Rotational angiography (3D imaging) may prove useful for imaging the venous system of the heart. The coronary sinus can be depicted in 3D and can be overlaid over the fluoroscopy image to better guide placement of the left ventricular lead.

Hybrid Arrhythmia/AF procedures (contd.)

A large antral lesion (arrow) is created using a bipolar radiofrequency clamp, resulting in complete isolation of the right pulmonary veins (PVs). The antrum of the right PVs (*) is clearly visible. RL right lung.

Placement of Ports on the Left Side of the Patient

Linear Lesion at the Mitral Isthmus

Hybrid Approach for Complex Thoracic Aortic Aneurysms/Dissections

• Currently, the treatment of complex thoracic aneurysms is mostly endovascular

• Open repair is reserved for cases that are not suitable for endovascular stenting because of anatomic characteristics of the aneurysm

• A combination of surgical and endovascular treatment is reserved for a highly selected group of patients who are too high-risk for surgical open repair and have inadequate length of the landing zone (distal or proximal) for deployment of endovascular stenting

• In the treatment of aortic arch aneurysm, an aorto-innominate bypass is typically constructed followed by bypass of the head vessels of this graft, which allows proximal extension of stent grafts into the transverse aortic arch.

• Such procedures has been reported with acceptable mortality and morbidity, with a higher incidence of early endovascular leaks [natural history of these leaks seems favorable, with high resolution at 6 months of follow-up (90%)].

Hybrid Approach for Complex Thoracic Aortic Aneurysms/Dissections (contd.)

• Debranching procedures for complex thoracoabdominal aneurysms- bypasses and/or transposition of visceral vessels to enable distal extension in the visceral portion of the aorta of the stent graft (there is concern regarding the long-term patency of prosthetic grafts used for visceral and renal revascularization)

• Rotational angiography, providing CT-like 3D imaging with the angiographic C-arm enables the surgeon to diagnose this complication intraoperatively and correct it right away

• The environment of the hybrid operating room allowed for immediate treatment of the endoleaks

• In the near future, off the shelf fenestrated aortic stents will become available for the treatment of extensive aortic disease. These fenestrated stents have to be rotated in the aorta, such that the fenestrations cover the branches of the aorta. For these highly complex procedures, 3D imaging in a hybrid operating room may be extremely helpful for the navigation of wires and devices.

Hybrid Approach in Congenital Heart Disease

• For congenital cardiac malformations, even though surgery remains the treatment of choice, interventional cardiology approaches are increasingly being used

• However, such percutaneous approaches can be challenging or even impossible because of difficult and complex anatomies (such as double-outlet right ventricle, or transposition of the great arteries, acute turns or kinks in the pulmonary arteries of tetralogy of Fallot patients) and patient characteristics/ complications (low weight, poor vascular access, induced rhythm disturbances, hemodynamic compromise)

• Nevertheless, surgery has its limitations, so that combining interventions and surgery into a single therapeutic procedure potentially leads to reduction of complexity, cardiopulmonary bypass time, risk, and to improved outcomes

Hybrid Approach in Congenital Heart Disease (contd.)

• Another important concept in hybrid procedures is completion angiography, as described before, which in the case of congenital heart disease surgery may detect residual structural lesions, thus reduce postoperative complications

• 3D imaging using rotational angiography should be the concept of choice• Completion angiography in a hybrid OR may even induce a reduction of

contrast media and ionizing radiation dose applied to the patient, as it reduces the need for post-operative examination

• Further dose reduction can be achieved with a combination of intraoperative rotational angiography and intraoperative MRI, when both a fixed C-arm and a MRI system are available in the surgical theatre, and MRI adds functional information

Hybrid for CHD at present

• Pre-operative hybrid operations

• Intra-operative hybrid operations

• Post-operative hybrid operations

Pre-operative hybrid operationsfor CHD

• Balloon atrial septostomy (BAS)

• Occlusion of MAPCAs

• Occlusion of shunts before radical correction

• Laser or radiofrequency valvular perforation and PBPV

BAS

• Indication: TGA/IVS、 HLHS、 TA、 HRHS、 PA/IVS、TAPVC

• Usually used during the first 12 weeks of life, X-ray or ultrasound guided

• After 1 month, balloon with blade on the top is better

• Enlarges communication between two atria to survive the severe patient until later surgery

Occlusion of MAPCAs

• Lead to intraoperative bleeding, increased pulmonary blood flow and postoperative desaturation

• Preoperative occlusion simplifies surgery, increases surgical success rate

• CT & angiography for the origin and distribution of MAPCAs

• SaO2 quickly decreases after MAPCAs occlusion, should come to surgery immediately afterward

• Materials: Coil, balloon, occluders, Plug etc.

Preoperative MAPCA closure in our institution in a patient of TOF

Post-operative MAPCA closure in our institution in a patient of adult TOF with difficulty in weaning from ventilator

Occlusion of shunts before radical correction

• A-P shunt is still most frequently used for cyanotic CHD

• Before Fontan, shunts need to be closed• Difficult for surgical closure because of scar

formation• Transcatheter occlusion with good results and

less occlusion complications

Laser or radiofrequency valvular perforation and PBPV

• PA/IVS: emergency in neonatal period, with high mortality for surgery

• Multiple surgery needed for RV dysplasia• Laser or radiofrequency valvular perforation

and PBPV for PA/IVS• Reconstruction of RVOT-PA connection to

promote RV development

Intra-operative hybrid operationsfor CHD

• Balloon angioplasty and stenting for peripheral pulmonary arterial stenosis

• HLHS

• Perventricular occlusion of muscular VSD

Peripheral pulmonary arterial stenosis

• Patients have to undergo open-chest surgery• Too large stent & sheath for infants and small children

to place percutaneously• Stent shift after percutaneous transcatheter stenting

replace the stent in operation• Straight balloon dilatation and stenting intra-

operatively• Angiography to make sure the diagnosis before surgery• Advantages: fast, good results, less complication, avoid

lesions of peripheral blood vessels

Perventricular occlusion of muscular VSD

• Direct puncture of right ventricle and VSD occlusion after chest open

• No percutaneous route, no restriction of blood vessel and body weight, especially important for infants

• Perventricular occlusion of muscular VSD if surgery is needed for concomitant anomaly in complex CHD

Post-operative hybrid operationsfor CHD

• Residual stenosis or obstruction

• Occlusion of fenestration after Fontan

• Occlusion of residual VSD

• Membrane coated valved stent implantation

Residual stenosis or obstruction

• Stenosisof of A-P shunt

• Stenosisof of anastomosis after cavo-pulmonary connection

• Peripheral pulmonary arterial stenosis

Occlusion of fenestration after Fontan

• Fontan for functional single ventricle

• Fenestration in high risk patients to prevent early systemic venous hypertension

Occlusion of residual VSD

• TGA+PH : residual VSD on the patch to prevent postoperative pulmonary hypertension crisis. After decrease of pulmonary artery pressure, occluded by catheter intervention

• TOF with hypoplastic pulmonary arteries: RVOT patch pulmonary enlargement with residual VSD, followed by transcatheter occlusion

Transcatheter membrane coated valved stent implantation

• Indications: -Significant pulmonary regurgitation with

hemodynamic importance

-Stenosis or regurgitation of RVOT-PA valved conduit

• Complications: -Stent dislocation

-Restenosis

Unresolved issues in Hybrid Cardiovascular procedure

• Order in which surgery and percutaneous intervention should be performed

• Duration of the staging of the 2 procedures• Antiplatelet strategies• Costs• Logistics

Hybrid cardiovascular procedures: our experience

• CABG followed by PCI: 3 cases have been referred so far -1 patient with TVD opted for LAMA and got the whole procedure

completed by PCI in a separate institution

-Another patient got transferred to CTVS dept. and the whole procedure completed by CABG only, due to cost constraint

-3rd patient has been booked for MIDCAB with LIMA to LAD graft followed by PCI to RCA

• PCI followed by CABG: 1 case

-PTCA & stenting to RCA followed by MIDCAB with LIMA to LAD graft for osteoproximal LAD disease (but, patient don’t want to undergo any further procedure, so kept in medical management)

• Preoperative MAPCA closure: 2 cases (good postoperative outcome)

• Postoperative MAPCA closure: 1 case (patient subsequently expired)

Conclusion• Hybrid CABG/PCI is performed in only few centers, but may

experience renewed interest as technology makes DES better than SVG. Hybrid CABG/PCI may be reserved for higher-risk patients who are not candidates for conventional CABG.

• Hybrid valve/PCI represents an excellent alternative to conventional valve/CABG in some high-risk patients, particularly those who presents after acute coronary syndromes, and in some patients who require reoperative valve surgery.

• Hybrid atrial fibrillation treatments combine percutaneous endomyocardial and surgical epicardial approaches. There may be a role for a hybrid electrophysiologist laboratory for these procedures to be performed in 1 setting with intraoperative mapping.

• Pacemakers and implantable cardioverter defibrillators (ICD), particularly bi-ventricular systems, may be optimally implanted in a hybrid OR environment, because the hybrid operating theatre offers the required superior angulation and imaging capabilities in comparison to mobile C-Arms, and the higher hygienic standards compared to cath labs.

• Aortic debranching procedures enable deployment of endovascular stents with inadequate length of the landing zone. Frequently, these patients are high-risk candidates for the performance of open surgical intervention and because of aneurysm anatomy are not candidate for endovascular repair. More commonly, these procedures are reserved for the treatment of complex thoracoabdominal aneurysm.

• In CHD combining interventions and surgery into a single therapeutic procedure potentially leads to reduction of complexity, cardiopulmonary bypass time, risk, and improve outcomes. Better result has been observed in pre-operative, intra-operative as well as post-operative hybrid operations.

Conclusion (contd.)

The Future… The future of cardiac surgery and interventional cardiology is

headed toward a merger of the fields for tailored approaches to patients who present with complex heart disease. Although the ability to offer hybrid approaches will depend on technological advancements, improved percutaneous and minimally invasive techniques, and the availability of a hybrid suite, the true barrier to entry is the ability of cardiologists and cardiac surgeons to work together, to engage in “hybrid thinking” with close collaboration between the 2 specialties. The willingness and ability to create this collaborative culture is the largest barrier to creating a successful hybrid program.

THANK YOU

hybrid procedures – from boxing ring to synchronized

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