Hybrid revascularization strategy in coronary artery disease: technic overview and 3 years’ experience of Tbilisi Heart and Vascular Clinic

Abstract

Background: Hybrid myocardial revascularization (HCR) strategy in multivessel coronary disease means the concomitant performance of percutaneous coronary intervention (PCI) and coronary artery bypass grafting with endoscopic minimally invasive atraumatic approach (EndoACAB). PCI and EndoACAB may be done simultaneously, or separately depending on patients' preoperative characteristics and comorbidities.

Aim: Hybrid revascularization strategy was implemented in Georgia for the first time at “Tbilisi Heart and Vascular Clinic” in 2015. Our aim was to retrospectively analyze the early and late outcomes of the intervention.

Methods: We retrospectively studied the case histories of 97 patients who intervened with a hybrid revascularization strategy through 2015-2017. We studied preoperative characteristics and risk factors of the patients, as well as intraoperative and postoperative period complications. The early postoperative period was defined as 30 days after the intervention. The late postoperative period was defined as 4-6 months after the intervention.

Results: Patients’ characteristics were as follows: male - 72 patients (74%), female - 25 (26%), mean age: 62,3±5, mean BMI 26±2.8, mean ejection fraction 46 ±3,4%, smokers - 57 (59%), arterial hypertension 97 (100%), diabetes mellitus 32 (33%), chronic obstructive pulmonary disease - 10 (11%), peripheral vessel disease - 5 (5%) and presence of myocardial infarction preoperatively - 15 patients (16%). 10 patients (9.7%) had undergone one-stage hybrid revascularization with simultaneous PCI and EndoACAB. 88 patients were operated on with a two-step strategy: 29 patients (30%) with the first-moment PCI plus second-moment EndoACAB and 58 patients with the first moment EndoACAB plus second moment PCI. Intraoperative switch from EndoACAB to urgent traditional coronary artery bypass grafting with middle anterior sternotomy (CABG) was needed in 2 patients (2%), Surgical damage of internal thoracic artery was seen in 2 cases (2%). Intraoperative mortality was not detected. Patients were hospitalized 4,8 ± 1,2   days during the first episode and if the second episode 4.0± 2.0, the intensity of pain was described as  6±1 points. During in-hospital stay following complications were observed: hydrothorax which needed drainage - 7 (7,4%), haemotransfusion - 3 (3%), atrial fibrillation/flutter - 2 (2%), haemothorax - 2 (2%), surgical damage of internal thoracic artery - 1 (1%), pneumonia - 1 (1%).  Surgical wound infection, pericarditis, stroke, and reoperation during bleeding were not detected as a complication.  Mortality in the early postoperative period was detected in 1 patient (1%). In all cases where the first-moment EndoACAB plus second PCI was applied coronarography revealed excellent patency of the conduit. During the late postoperative period, no patients had to be reoperated with CABG. Coronarography was performed in 30 patients (31%). In all patients patency of conduits was excellent. Late mortality was not detected.

Conclusion: According to our data hybrid revascularization strategy of multivessel coronary diseases was successful and showed good outcomes in the early and late postoperation period.