This document discusses hybrid coronary revascularization (HCR), which combines coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI). HCR was introduced in 1996 as a treatment for multivessel coronary artery disease. It aims to reduce surgical trauma while preserving long-term survival and minimizing adverse events. The hybrid approach involves using a left internal mammary artery graft for the left anterior descending artery and PCI for other lesions. This takes advantage of the excellent outcomes of the arterial graft and improvements in stents. HCR may provide benefits for higher surgical risk patients and allow shorter recovery times compared to traditional CABG. However, some debate remains around its additional complexity and costs compared to established treatments.

1. Hybrid Coronary
Revascularization
Dr.Rahatul Quadir
MD Thesis Part Student
NHFRI

2. History & Aim
• Hybrid coronary revascularization (HCR) was first
introduced in the 1996 as a pioneering treatment
approach to multivessel coronary artery disease (CAD)
• HCR aims to reduce surgical trauma while preserving
long-term survival and minimizing adverse
cardiovascular event.

3. Interest
• In the modern era, a hybrid procedure refers to the
combination of CABG and PCI, staged by minutes,
hours, or at most, days.
• It has gained interest, as cardiac surgeons have
improved techniques for minimally invasive surgical
approaches, while interventional cardiologists have
developed skills that have enabled them to become
more aggressive in their percutaneous interventions.

4. Approach
• The hybrid approach includes left internal mammary
artery (LIMA) anastomosis to the left anterior
descending coronary artery (LAD), typically via a
minimally invasive approach, and percutaneous
coronary intervention (PCI) for the remaining (non-LAD)
lesions.

5. Rationale
• The rationale for HCR lies in the well- established
survival benefit conferred by LIMA-to-LAD grafts and
the use of new stent platforms featuring lower stent
restenosis and thrombosis rates compared with
venous graft stenosis and occlusion rates, respectively.

6. Benefits
• LIMA–LAD graft has excellent patency rates, which
correlates with increased eventfree survival in CABG
pts and LIMA-LAD graft may be responsible for the
majority of the benefit of CABG surgery.
• Whether the non LAD lesions are treated with SVG or
PCI?
• It has shown favorable clinical outcomes with DES as
compared to SVG in non LAD territories.

7. Indication
• Multivessel CAD including:
1) A proximal complex LAD lesion with optimal distal
anatomy amenable to LIMA-to-LAD grafting;
2) Non- LAD lesions amenable to PCI, in a patient with
no contraindications to dual antiplatelet therapy (DAPT)
3)Complex distal left main lesions are also ideal for HCR
if the circumflex artery territory is amenable for PCI.

8. CONTRAINDICATIONS
1. LAD is non graftable.
2. LAD is intramyocardial.
3. Previous surgery involving left chest cavity.
4. Left SCA stenosis causing LIMA graft unsuitable.
5. Lack of tolerance of single lung ventilation.

9. PATIENT SELECTION FOR HCR CONCEPT OF
HEART TEAM
• A Heart Team consisting of a clinical/non-invasive
cardiologist, interventional cardiologist, and cardiac
surgeon is considered optimal to best assess the
advantages and disadvantages of the various
treatment strategies.
• Factors to consider are the coronary tree
anatomy,proximal LAD lesion, renal status and history
of previous cardiopulmonary interventions.

10. TECHNICAL ISSUES 1- VERSUS 2-STAGED
APPROACH
• HCR can be performed either simultaneously or as a
“2-staged” procedure.
• The former implies concurrent CABG and PCI in a
single operative suite, with PCI following CABG within
minutes.
• In the “2-staged” approach, the optimal order PCI first
versus CABG first is debated because each approach
has advantages and disadvantages.

11. Simultaneous approach
• CABG is performed first, allowing the interventional
cardiologist to study the LIMA- LAD graft before stent
implantation.
• Thus, PCI to high-risk, non-LAD lesions is performed
with a protected LAD territory.
• In case of unsuccessful stent implantation, surgical
bailout graft implantation remains an option

12. 2-step procedure
• The sequence of PCI and CABG should be guided by
clinical presentation and coronary anatomy.
• 2011 ACC/AHA guidelines favor performing CABG first
followed by PCI.
• This strategy allows
1. Angiographic visualization of the LIMA-LAD graft

13. 2-step procedure
2.Complete antiplatelet inhibition following CABG with
no perioperative bleeding risk
3.Provides a protected anterior wall, lowering
procedural risks during PCI of non-LAD vessels.
4.However, a PCI-first approach is reasonable in
patients presenting with acute coronary syndrome
(ACS) who undergo non-LAD culprit lesion PCI followed
by CABG of the LAD.

14. CONTROVERSIES
• Why should institutes adopt a complex, costly
procedure when similar survival and morbidity
outcomes can be obtained with a well- established,
safe procedure available in most hospitals
• FIRST a recent study, shows signals of improved MACE
outcomes in the HCR versus conventional CABG group
for patients in the highest EuroSCORE tertile (>6),
suggesting a potential target population that would
benefit the most from this complex procedure

15. Thank You

16. CONTROVERSIES
• SECOND, the use of HCR in lower- to intermediate risk
groups could be justified by improved patient
satisfaction, shorter intensive care and hospital stays,
faster return to work and quicker return to normal
daily activities.