Betty S. Kim, MD, FACS presents on "Current CABG Strategies and Hybrid Procedures" for the March 4 -6, 2016 Cardiac and Thoracic Surgery Associates, Cardiovascular Summit at The Westin Riverfront Resort and Spa.

1. Coronary Bypass Strategies
&
Hybrid Revascularization
Betty Kim MD FACS
Cardiac Surgery
CV Summit 2016

2. “What……not another CABG ?“
• CABG with LIMA and SVGs “sewing
worms”
• > 90% of cardiac surgeons nationally still
do it the conventional way

5. Is BIMA (2 IMAs) really
better than LIMA ?

6. One size does not fit all
• “ Fit the operation to the patient, not the patient to the
operation”
• “ Tailor the operation to the patient”…..BSK
• Conventional, LIMA or BIMA or radial, Offpump, MICS,
hybrid, robot?
Questions to ask oneself when deciding which procedure to do:
-What are you trying to accomplish?
-What are strengths and weaknesses of different techniques?
-Are there certain comorbidities of patient that make one more
successful than another?
Sabik, JF...editorial JTCVS Dec 2015

7. LIMA to LAD
is
Standard of Care

8. Hybrid Revascularization (HCR)
What is it?
• Revascularization Strategy
• Best of Both Worlds of Interventional
Cardiology and Cardiac Surgery
• Defined as minimally invasive LIMA to
LAD (MICS CABG or Robot) with PCI of
non LAD territories
• Less traumatic for patient with avoidance
of sternotomy and faster recovery

9. HCR: Not New
Examples of Staged HCR
1) In AMI setting, PCI of culprit lesion with
surgical revascularization weeks later
2) Postop CABG, PCI of nongrafted coronaries
days later

11. One stop HCR: Clinical Rationale
• Surgical superiority of LIMA to LAD graft
• SVG vs DES to non LAD territories
comparable
• Utilizes the HYBRID OR
• Completion angiogram of LIMA to LAD graft
• Complete revascularization in one setting
• Patient subjectively will feel disease is
completely treated

12. Coronary Trials
• Syntax Trial: 5yr results show that CABG
is often superior to DES for left main and
multivessel CAD
• Freedom Trial: multivessel diabetic
patients treated with CABG to have lower
all-cause Death and MI at 5yrs, compared
to PCI

13. • LIMA patency
• 90-95% patency rate
at 10 yrs

14. FREEDOM FROM PROCEDURAL RISK & INVASION
DURABILITY (Freedom from re-intervention) & SURVIVAL
Less Risk & InvasionLess Risk & Invasion
Higher DurabilityHigher Durability
PCI
HYBRID
CABG

15. LIMA
LAD
1
Circ
LAD
2

16. Outcome?
1) HCR vs multivessel OPCAB:
- HCR had shorter vent time, ICU/hospital stay, shorter
recovery, greater pt satisfaction, better target vessel
patency (Kon et al JTCVS 2008)
2) One stop HCR vs CABG vs PCI :
- Low/Med Euro/Syntax scores MACCE similar
- High Euro score, one stop HCR had lower MACCE
than CABG or PCI
- High Syntax score, one stop HCR had lower MACCE
than PCI but similar to CABG ( Shen et al JACC 2013)

17. HOW to do it
Lessons Learned

18. Minimally Invasive CABG
(MICS CABG)

19. Preop CT Scan

20. Anticoagulation Strategy
(the Canadian way)

22. Tissue Stabilizer

23. Complete Sternotomy (CST) Partial Sternotomy (PST)
Robotic Assistance (ROB)Anterior Thoracotomy

26. LIMA Takedown

27. MICS CABG vs TECAB
• MICS CABG
• Direct vision of IMA
harvest
• Anterolateral
thoracotomy
• Open direct
anastomosis
• TECAB
• Robotic takedown of
IMA
• Endoscopic port
incisions
• Endoscopic robotic
anastomosis

28. • “Single stage hybrid coronary revascularization
with long term followup”
• 96 patients from 2004 to 2012 with robot LIMA
and thoracotomy OPCAB mammary to LAD with
PCI of nonLAD
• Angio at 6mos and CTA/perfusion study at 5yrs
• Acceptable 6mo patency with favorable
survival/freedom from angina/freedom from
revascularization at 5yrs
– 6mo patency 94%
– 5yr 91% survival
– 94% freedom from angina
– 87% freedom from revascularization
C Adams. ..B Kiaii. EJCTS Aug 2013

29. HCR: single center experience: Italy
• 42 patients between Sept 2011 and August 2014,
prospective study
• Complete revascularization using hybrid approach
(MICS CABG+PCI)
• 43% simultaneous hybrid revascularization, others
staged
• Procedural success in 41 patients (98%), one
unsuccessful PCI
• No conversion to full sternotomy, no blood transfusions,
mean LOS 6 days, median vent time 7.7hrs, all alive at
discharge
Mikus,E. et al. European Heart Journal 2015

30. How good is the Mammary graft?
• Is it as good as a sternotomy, on pump LIMA
to LAD? Yes
1) Mohr ATS 2006
- 1300 MIDCAB LIMA to LAD compared to sternotomy
- 96% early graft patency at 6 mos
1) Harskamp JTCVS 2014
- MIDCAB LIMA to LAD had similar outcomes (MACCE) as
DES of LAD
- lower target vessel revascularization
1) Kiaii ATS 2012
- Robot assisted takedown of mammary graft patency showed
93% patency in 8yrs.

31. Patient Selection
Good candidates for HCR
1) Ostial, complex or occluded LAD with simple
lesions in other arteries
2) Elderly patients, left main with low syntax
score
3) Overweight, diabetic patients
4) Comorbidities making sternotomy high risk

32. Contraindications to MICS CABG
Offpump
• LAD is non-graftable, intramyocardial
• Inability to undergo offpump
revascularization
• Previous surgery involving left chest
• Intolerance to one lung ventilation
• Left subclavian stenosis making LIMA
unsuitable for grafting

33. Contraindications to PCI of
nonLAD lesions
• Severe PVD, consider radial artery access
• Complex disease, tortuous calcified
vessels, fresh thrombotic lesions, hi
Syntax score of PCI vessel
• Contraindication to dual antiplatelet
therapy

34. Questions?