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J Thorac Cardiovasc Surg 1999;118:766-767
© 1999 Mosby, Inc.
LETTERS TO THE EDITOR |
Department of Cardiothoracic and Vascular Surgery
Hannover Medical School
Hannover, Germanya
Department of Cardiac and Vascular Surgery
University of Kiel
Kiel, Germany b
To the Editor:
Revascularization of multivessel coronary artery disease with the left internal thoracic artery (LITA) and additional vein grafts using cardiopulmonary bypass (CPB) and cardioplegic arrest currently represents the standard technique in coronary surgery.
1 Aiming for less invasive cardiac surgery, several groups have reported encouraging results with minimally invasive direct coronary artery bypass (MIDCAB) grafting of the left anterior descending coronary artery (LAD) to anterior cardiac vessels on a beating heart without CPB through a left anterolateral minithoracotomy. 2,3 However, due to limited access through the small incision, this approach cannot be applied to multivessel revascularization without additional incisions or use of CPB. So that the benefits of MIDCAB approaches could be extended to patients with multivessel disease, a safe and effective integrated coronary revascularization procedure combining minimally invasive surgical revascularization of the LAD with interventional procedures was introduced. 4,5 Very promising results in a series of 31 patients were recently published by Zenati and associates. 6 Having reported similar initial results in 35 consecutive patients undergoing this integrated "hybrid" procedure in a multicenter experience, 7 we present here subsequent intermediate follow-up results in 26 patients who underwent hybrid revascularization in Hannover, Germany.
Between December 1996 and January 1999, 21 men and 5 women (mean age 56.6 ± 18.8 years) underwent a hybrid revascularization performed as a primary MIDCAB procedure for grafting of the LAD to the LITA followed by staged angioplasty (n = 23) and stenting (n = 8) of additional coronary lesions. Five patients had a moderately reduced left ventricular ejection fraction between 30% and 50% and 3 patients had a left ventricular ejection fraction of less than 30%. The distribution pattern of 1-, 2-, and 3-vessel disease was 4, 14, and 8, respectively. Previous myocardial infarctions were recorded in 16 patients. The degree of revascularization achieved during the operation was "anatomically complete" in 18 patients (69.2%) and "anatomically incomplete but functionally adequate" in 8 patients (30.8%). After an uneventful postoperative course, coronary re-angiography at the time of intervention revealed patent and functioning LITA grafts in all patients. Procedure-related complications did not occur. All patients remained angina-free and had stress electrocardiograms showing no abnormalities within 30 days after the operation.
At a mean interval of 11.4 ± 7.7 months after the operation, all patients are alive. Follow-up information was obtained at the time of follow-up coronary angiography in 15 patients. The remaining 11 patients refused the angiographic examination because of complete absence of any symptoms but were contacted by telephone.
Two patients with angina on moderate exertion required additional interventions because of new significant lesions in other than the previously revascularized coronary arteries. One patient was completely free of symptoms with a subtotal restenosis in the formerly dilated right coronary artery and was maintained on medical therapy alone. All other patients were angina-free without signs of acute ischemia on stress electrocardiogram. Angiographically, LITA anastomoses and interventionally treated coronary arteries were found to be patent. None of the patients had had any ischemic coronary events after the hybrid procedure.
Thus we can confirm the excellent result described by Zenati and associates 6 after integrated coronary revascularization. In our experience, the hybrid approach of myocardial revascularization by means of a LITA-LAD MIDCAB procedure followed by additional interventional therapy appears to be safe and effective in complete or near-complete coronary revascularization in patients with multivessel disease. Subgroups of patients who might receive special benefit from this new approach include the very elderly and patients requiring reoperation with significant comorbidity and a high-risk constellation for CPB with median sternotomy. Also, younger and otherwise healthy patients with aggressive 2-vessel disease, in whom further coronary revascularization procedures seem likely, may benefit from this hybrid approach rather than a less invasive procedure using the Octopus system (Medtronic, Inc, Minneapolis, Minn). 8,9 Although the latter procedure eliminates the potential adverse effects associated with CPB, it still requires a median sternotomy and manipulation of the aorta with a potentially high risk of neurologic damage in case of calcifications. Furthermore, one of the main limitations to the approach with the Octopus tissue stabilizer is the difficult accessibility of target vessels in the circumflex system, 8 whereas these regions are suitable for hybrid percutaneous transluminal angioplasty in most cases.
As progressively more centers achieve excellent experience with this integrated approach, 10 detailed evaluation in larger randomized multicenter studies is warranted to document long-term effectiveness of hybrid revascularization compared with conventional coronary artery bypass grafting or interventional therapy alone.
References
This article has been cited by other articles:
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  C. Gao, M. Yang, Y. Wu, G. Wang, C. Xiao, H. Liu, and C. Lu Hybrid coronary revascularization by endoscopic robotic coronary artery bypass grafting on beating heart and stent placement. Ann. Thorac. Surg., March 1, 2009; 87(3): 737 - 741. [Abstract] [Full Text] [PDF]
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 J. G. Byrne, M. Leacche, D. E. Vaughan, and D. X. Zhao Hybrid Cardiovascular Procedures J. Am. Coll. Cardiol. Intv., October 1, 2008; 1(5): 459 - 468. [Abstract] [Full Text] [PDF]
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 M. R. Katz, F. Van Praet, D. de Canniere, D. Murphy, L. Siwek, U. Seshadri-Kreaden, G. Friedrich, and J. Bonatti Integrated Coronary Revascularization: Percutaneous Coronary Intervention Plus Robotic Totally Endoscopic Coronary Artery Bypass Circulation, July 4, 2006; 114(1_suppl): I-473 - I-476. [Abstract] [Full Text] [PDF]
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 V. J. Amodeo, H. W. Donias, G. D'Ancona, E. L. Hoover, and H. L. Karamanoukian The Hybrid Approach to Coronary Artery Revascularization: Minimally Invasive Direct Coronary Artery Bypass with Percutaneous Coronary Intervention Angiology, November 1, 2002; 53(6): 665 - 669. [Abstract] [PDF]
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