Interact CardioVasc Thorac Surg 2009;9:551-553. doi:10.1510/icvts.2009.208298
© 2009 European Association of Cardio-Thoracic Surgery
One-stage hybrid procedure: association between awake minimally invasive surgical revascularization and percutaneous coronary intervention
Mauro Del Giglioa,
Andrea Dell'Amorea,*,
Andrea Zuffib and
Arvit Sokolic
a Department of Cardiovascular Surgery, Villa Maria Cecilia Hospital, Via Corriera 1, 48018, Cotignola, Lugo, RA, Italy
b Department of Interventional Cardiology, Villa Maria Cecilia Hospital, Cotignola, Lugo, RA, Italy
c Department of Anesthesiology, Villa Maria Cecilia Hospital, Cotignola, Lugo, RA, Italy
Received 26 March 2009;
received in revised form 6 May 2009;
accepted 6 May 2009
*Corresponding author. Tel.: +393356223366; fax: +390545217321.
E-mail address: dellamore76{at}libero.it (A. Dell'Amore).
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Abstract
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Hybrid revascularization provides minimally invasive options for high-risk patients with multivessel coronary artery disease. We used a hybrid approach in two patients. The surgical revascularization with the left internal mammary artery (LIMA) on the left descending coronary artery was performed through an inferior j-shaped mini-sternotomy keeping the patients awake with high-epidural thoracic anesthesia. At the end of the operations the patients were moved to the angiography laboratory to complete the revascularization with angioplasty. No complications were reported.
Key Words: Myocardial infarction; Coronary artery disease; Minimally invasive surgery; Hybrid approach; High-epidural thoracic anesthesia
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1. Introduction
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In 1996, Angelini et al. published the first series of hybrid coronary artery revascularizations [1]. The hybrid approach is particularly promising in high-risk patients who benefit from a limited surgical trauma [2, 3]. To further reduce the invasiveness, high-epidural thoracic anesthesia and lower j-shaped mini-sternotomy were used to avoid mechanical ventilation, leaving the patients awake. To our knowledge this is the first report of a one-day hybrid-procedure in awake patients.
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2. Materials and methods
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The first patient was an 84-year-old man with a distal left main (LM) critical stenosis involving left descending artery (LAD) and circumflex artery (CA) ostia and a critical proximal stenosis of the CA. The right coronary artery (RCA) was chronically proximally occluded without signs of vitality on related territory. He had suffered an acute myocardial infarction (AMI) on the lateral wall three months earlier. The ejection fraction (EF) was 25% with moderate mitral regurgitation. Severe chronic obstructive pulmonary disease (COPD) with a forced expiratory volume (FEV1) <49% of predicted was a further feature. Logistic EuroSCORE was 50.1%.
The second patient was an 88-year-old female with critical stenosis of proximal LAD, the RCA had two lesions at proximal segment and to the crux. EF was 45% with recent AMI. Logistic EuroSCORE was 43.3%.
The epidural catheter was placed the day before operation. The technique for high-epidural thoracic anesthesia for awake surgery has been previously reported [4]. In the operating theater, 15–17 ml of epidural anesthesia solution was administered as bolus, followed by continuous infusion. In all patients the lower j-shaped mini-sternotomy is used to perform off-pump left internal mammary artery (LIMA) on LAD. The technique has been previously described [5]. Surgical step was performed first leaving the patients awake and in continuous breathing. A full dose of heparin and complete reversion with protamine were used. After chest closure, 325 mg of acetyl-salicylic-acid were given and the patients were transferred to angiography laboratory. LIMA-to-LAD graft patency was checked first. Percutaneous coronary angioplasty (PCI) plus stenting completed the second step. In the first patient PCI was performed with the implantation of a bare-metal-stent (BMS) on LM and proximal CA (Fig. 1). In the second patient PCI was performed by implantation of two BMS in proximal and distal RCA (Fig. 1). Clopidogrel loading dose (300 mg) was given on arrival at intensive care unit followed by clopidogrel, 75 mg, and acetyl-salicylic-acid, 100 mg daily, thereafter. The continuous infusion of epidural anesthesia was discontinued after chest tube removal. The postoperative period was uneventful for all patients. The intensive care unit stay was 6 and 8 h, respectively, in our patients. All patients were discharged home on postoperative day 6 in optimal clinical condition.
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Fig. 1. Patient 1: the patency of the LIMA-to-LAD is checked first (black arrow), the second lesion on the LM and on CX is treated by PCI with the implantation, after lesion pre-dilatation with cutting balloon, of a long BMS on the LM and LCX proximal segment. Optimal stent apposition was obtained by non-compliant balloon post-dilatations at the proximal and mid LM segment. The procedural time was 35 min with 150 ml total volume contrast. Patient 2: the patency of the LIMA-to-LAD is checked first (white arrows) then PCI is performed by the implantation in the proximal and distal segment of the RCA of two BMS. The procedural time was 45 min with 210 ml of total volume contrast.
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3. Discussion
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The new frontier in the treatment of cardiovascular disease has been represented by the combination of minimally invasive surgical procedure and interventional cardiology called ‘hybrid or integrated’ approach. The aim of hybrid techniques is to reduce invasiveness, mortality and morbidity of single procedure, combining optimal results and the best practice of both techniques. By-passing LAD with the LIMA through a minimally invasive approach offers the best evidence-based treatment in terms of graft patency and survival benefits [6, 7]. The major weakness of hybrid approach remains the high repeat revascularization rate related to PCI. On the other hand, patency of vein grafts is suboptimal. Magee et al. recently reported a vein graft failure at 1 year approximately of 25% [8]. In light of these considerations, we could postulate that the long-term patency of vein grafts is similar to the stent patency and the risk of subsequent revascularization is not so different.
In older patients with a high-risk profile the hybrid approach could be an interesting way to achieve a complete revascularization with minimal risk [1–3, 5]. To reduce further the invasiveness of this hybrid approach, we use the high-epidural thoracic anesthesia technique. This technique yields cardiac sympathectomy, bradycardia and coronary vasodilatation facilitating off-pump surgery and excellent graft flows. Epidural anesthesia preserves the fibrinolitic system, which may reduce the incidence of postoperative grafts and stents thrombosis, and counterbalance the procoagulant activity of off-pump surgery. This technique offers an optimal sensory block with a superb pain control with a virtually painless postoperative period [4]. The avoidance of muscle relaxation and mechanical ventilation give the preservation of respiratory function, less risk of respiratory infections immediate mobilization and respiratory physical therapies which are very important in patients with severe obstructive pulmonary disease [4, 9]. This integrated approach allows for very fast patient mobilization with faster discharge from the intensive care unit and with minimal hospital stay.
The last issue regards the optimal timing of hybrid procedure.
If PCI is performed first these are the major drawback; it is performed with an unprotected LAD territory, surgery must be performed during aggressive antithrombotic therapy and there is a risk of stent's thrombosis after protamine administration. The opportunity for angiographic checking of the LIMA-to-LAD patency is lost.
If surgery is performed first, the stenting is performed with a protected LAD territory, the antiplatelet therapy is, therefore, started at the time of PCI and the patency of LIMA-to-LAD can be investigated. We are in favor of this sequence particularly in the simultaneous fashion. The LIMA-to-LAD patency is investigated almost immediately after the operation, and the correction of every kind of technical problem can be performed immediately, avoiding postoperative AMI or prolonged myocardial ischemia. The second advantage is to achieve a complete revascularization within a few hours, minimizing the risk of ischemic complication during the waiting time between surgery and stenting. A possible complication of this procedure is a major risk of bleeding due to aggressive antiplatelet therapy in the early postoperative period. In our patients rethoracotomy for bleeding was not required.
In conclusion, the hybrid technique is an excellent example of collaboration between cardiac surgeons, anesthesiologist and interventional cardiologist. This promising technique could be very useful in high-risk patients. Further study will be necessary to identify those patients who could benefit from this approach and to verify the long-term results of this new strategy.
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References
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Abstract
1. Introduction