1. Hybrid concept in
cardiac surgery
Dr. Manoj P Nair

3. Why talk about hybrid OR ?
Technology is changing
• Minimally invasive cardiovascular surgery
• Drug-eluting stents
• Stent grafts
• Percutaneous valves

4. Why talk about hybrid OR ?
Patient populations continue to change
• Older
• Sicker-more comorbidities
• More advanced disease
Physicians are changing
• Growing endovascular specialists
• Specialty boundaries are less defined
• Heart team is becoming a new paradigm

5. Hybrid Operating Room
• A fully functional cardiac cath lab and cardiac surgery OR
• Allows patients to undergo percutaneous
interventions and cardiac surgery simultaneously
• Ideal for treating a variety of conditions: CAD, valve disease, CHD,
aortic disorders,CHF.

6. Components of a Hybrid OR/Cath lab
• Fully functional Cath lab
• Multipurpose table
• Versatile imaging equipment: Fixed and mobile
modes
• Multimodality imaging:
Cine/CT/IVUS/OCT/Echo gating(TEE)
• Multiple flat-panel monitors
• Traffic/Air flow to maintain sterility (Laminar)

7. What makes a Hybrid OR successful?
• Infrastructure
• Superior imaging/monitoring equipment
• Integrated imaging equipment
• Teamwork and convergence
• Protocols
• Trained ancillary staff: Cross-training
• Supplies

8. Teamwork and Convergence
• Bringing multiple specialists together to deliver
the best care to the patient
• Utilizing multiple technologies as appropriate
• Realization that parallel procedures and
technologies are often complementary, rather than competitive
• Collaborative strategy: Patient centric approach

9. Advantages of Hybrid Surgery
• Hybrid surgery minimizes hurt to patient from more
invasive procedures
• Maximizes treatment spectrum
• For complex heart disorders, maximizes the advantages of
catheter and surgery
• Accelerates recovery time
• Reduces hospital stay
• Improves patient satisfaction

10. Hybrid surgery in….
 Coronary revascularization / Valvular disorders
 Aortic aneurysms

11. Hybrid Coronary Revascularization
Background
 In the present DES era, LIMA to LAD graft continues to have unrivaled safety
and efficacy.
 Stent restenosis rates (DES) are now lower than reported rates of SVG failure.
 PCI is probably a superior strategy to SVG for revascularization of non-LAD
vessels.

12. Rationale of Hybrid Revascularization
 Combining the benefits of LIMA to LAD graft with the
benefits of PCI with DES implantation in non-LAD targets may
minimize risk without diminishing the long term benefits
offered by each strategy in particular.

13. LIMA to LAD Graft Patency
 With PCI, the proximal LAD lesion is an independent risk factor for in-stent
restenosis .
 The LIMA–LAD graft has excellent patency rates, which
correlates with increased event-free survival.
 5-year patency rate ranges between 92% and 99% and at
10 years between 95% and 98%.
 Mortality benefits are attributed to the LIMA- LAD graft rather than SVG
grafts/PCI to non LAD targets.
This is the premise on which the modern era of hybrid
coronary revascularization is based.

14. Results of Hybrid Revascularization
 No randomized trials so far
 Multiple small non randomized studies have shown hybrid
coronary revascularization is safe with low mortality rates
(0% to 2%), low morbidity, and shorter intensive care unit
and hospital stay
Sternal sparing surgery
 Other clear advantages are superior cosmetic
results and faster recovery

15. For optimal results……

16. First step in crisis management is prevention……
Choose the right patient!

17. Never force too much!
indications, device, techniques……….

18. Intraoperative Completion Angiography after
CABG
 Routine completion angiography detected 12% of
grafts with important angiographic defects.
 One-stop hybrid strategy is reasonable, safe, and feasible.
 Combining the tools of the cath lab and OR greatly enhances the options
available to the surgeon and cardiologist for patients with complex coronary
artery disease. (J Am Coll Cardiol 2009;53:232–41)

19. Routine Intraoperative Completion Angiography After
Coronary Artery Bypass Grafting

20. Hybrid Valve treatment + PCI
 The rationale behind hybrid valve surgery is to substitute PCI for CABG
(typically substituting PCI for SVG) to convert a combined valve/CABG
procedure requiring sternotomy into an isolated valve procedure, which can
be performed using minimally invasive techniques.
 There are 3 settings in which this may be of benefit.
1.CABG patient with poor conduit for CABG surgery
2.Convert high-risk valve/CABG surgery into a lower-risk isolated valve
3.Convert reoperative valve/CABG into reoperative isolated valve surgery.

21. Overview
 The hybrid OR facilitates a whole new spectrum of cardiac surgical/invasive
therapies
 The trend toward hybrid techniques will continue to evolve and is becoming
an essential resource of every cardiovascular center
 Requires a highly organized and fully cooperative multidisciplinary team

22. Hybrid concepts in aortic aneurysm

23. Limitations of open surgeries
 Morbidity and mortality, as well as early clinical outcomes and overall survival
for total aortic arch repair have improved significantly during the last 2
decades.
 Nevertheless, open surgical arch replacement still represents a high-risk
procedure with increased morbidity and mortality .
 Furthermore, many patients are sometimes denied surgical intervention
secondary to their significant comorbidities.

24. Limitations
Patients were identified as high risk for open surgery
 Age over 80 years ,
 Poor functional status ,
 Presence of severe chronic obstructive pulmonary disease ,
 Untreated significant coronary artery disease
 Significant renal impairment ,
 Prior stroke with poor mobility ,
 Need for operation in the second or more redo setting ,
 History of cirrhosis
 Morbid obesity .

25. Advances
 Thoracic endovascular aortic repair (TEVAR)
 First introduced by Dake and associates in 1994.
 Initially limited to the descending thoracic aorta, endovascular therapy is now
being applied to treat a wide range of pathologies throughout the aorta .

26. Definition
By definition, a hybrid arch procedure should have an open, as well as an
endovascular component

27. Hybrid technique Concepts
 To reduce the morbidity and mortality associated with classical open
reconstruction
 To expand the patient spectrum for endovascular repair considered otherwise
unsuitable due to anatomical reasons

28. It is a challenge….
Aortic arch with its curvature and branches represent a formidable
challenge for surgical as well as endovascular treatment

29. SURGICAL CLASSIFICATION OF HYBRID
PROCEDURES
 Type I hybrid arch repair involves standard elephant trunk repair with
downstream placement of the endovascular stent-graft into the distal
elephant trunk graft.
 Type II hybrid arch repair involves extra-anatomic revascularization of the
great vessels and endovascular stent-graft exclusion of the diseased aortic
arch.

30. ELEPHANT TRUNK
Previous elephant
trunk
Replaced
proximal aorta

32. Operative Techniques
Techniques using CPB
 Sternotomy, ascending aortic replacement with the clamp on, and supra-aortic
vessel de-branching followed by retrograde aortic arch exclusion with endografts
from the femoral artery.
 Sternotomy, ascending and arch replacement under deep hypothermic circulatory
arrest, with or without an elephant trunk and synchronous or metachronous
deployment of endografts in an antegrade or retrograde fashion with proximal
landing zone on the distal arch graft or the elephant trunk.

33. Operative Techniques
 Techniques not involving the use of CPB include Sternotomy or mini-
sternotomy, application of the aortic side biting clamp on the ascending
aorta,
 Supra-aortic vessel de branching (necklace grafting) followed by retrograde
(femoral artery) endograft deployment

34. NECKLACE GRAFT

35. HYBRID TYPE 1
 Frozen elephant trunk procedures are just one type of approach within the
family of hybrid type I procedures.
 The endovascular component of this approach becomes a less invasive
addition to a traditional surgical approach to the arch to help complete the
downstream repair of the distal arch and proximal descending thoracic aorta

36. HYBRID TYPE 1

37. HYBRID TYPE 1 –IN TYPE A
DISSECTION

38. HYBRID TYPE 1

39. HYBRID TYPE 1- ADVANTAGE
 The hybrid type I approach is attractive because it potentially eliminates the
need for a second operative procedure (posterolateral thoracotomy) to
address the diseased descending thoracic aorta at a later date.
 In essence, this version of the hybrid arch repair (hybrid type I) builds on the
existing capacity of standard open surgical techniques into a more extensive
repair of the distal aorta.
 More importantly, hybrid type I procedures may be best when the arch disease
continues down into the descending thoracic aorta.

40. HYBRID TYPE 1- DISADVANTAGE
 However, this version of hybrid arch repair still involves an open chest incision
and the use of CPB.
 The less invasive component relates to the elimination of a second surgery on
the descending thoracic aorta.

41. HYBRID TYPE 2
 The second fundamentally different group of hybrid arch repair patients
 Hybrid type II, treated the endovascular repair as the primary arch repair
method (meaning the endovascular stent-graft excluded the arch disease
without surgically replacing the arch)
 The open surgical component was an adjunctive procedure to revascularize
the great vessels .

42. NECKLACE GRAFTING WITH STERNOTOMY
 Supra-aortic vessel debranching (necklace grafting) followed by retrograde
(femoral artery) endograft deployment

43. HYBRID TYPE 2 -NECKLACE GRAFTING
WITH STERNOTOMY

44. HYBRID TYPE 2 -NECKLACEGRAFTING
WITH STERNOTOMY

45. HYBRID TYPE 2 -NECKLACE GRAFTING
WITH STERNOTOMY

46. Aortic arch zones pertaining to
endografting (Ishimaru classification)

47. HYBRID TYPE 2 –NECKLACE
GRAFTING WITHOUT STERNOTOMY

48. HYBRID TYPE 2 –NECKLACE
GRAFTING WITHOUT STERNOTOMY
Currently, the main indications for preoperative subclavian artery bypass
 Dominant left vertebral artery with a diminutive right vertebral artery
 Patent left internal mammary artery graft to the left anterior descending coronary
artery
 Both

50. Partial de branching

53. Left subclavian artery closure

54. HYBRID TYPE 2
 Different approach to aortic arch disease because it bases the repair not on
traditional open surgical techniques.
 Assumption that current endovascular technology can successfully exclude
aortic arch diseases and that the arch does not need to be replaced.
 Hybrid type II procedures are significantly less invasive than hybrid type I
procedures.
 Type II procedures avoid CPB and hypothermic circulatory arrest and can even
be approached in some without a sternotomy incision.

66. Conclusion
• Hybrid strategies can be used successfully in patients with complex arch
disease
• Mandates multi disciplinary approach
• Carries not negligible risk of perioperative mortality and morbidity
• Can be offered in patients with prohibitive risk