One-stop Hybrid Revascularization for left main
and multivessel coronary artery disease
Shengshou Hu M.D.
National Center for Cardiovascular Disease，China
Fuwai Cardiovascular Hospital
Chinese Society for Thoracic and Cardiovascular Surgery
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Develop of coronary artery disease
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Circulation Cardiovascular Quality and Outcomes 2010
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CAD incidence will be
doubled in the next 20 years
high risked population
（0.1billion）
In China:
Commonly seen in clinical
scenario
Accounted for one million
AMI per year
Accounted for half million
deaths per year
Choice for left main and multivessel disease
In real world，debate of best choice for multivessel disease never
stops：CABG or PCI?
Advantages of catheter based therapy
Advantage of PCI

Minimally Invasive

For non-LAD, DES significantly reduced restenosis rate,
similar or lower than failure rate of saphenous vein grafts

The need for repeat revascularization is still a big concern
N Engl J Med 2009，360（10）961-972
Advantages of conventional coronary artery bypass grafting
LIMA-LAD graft still has optimal long term patency rate
Lower rate of repeat revascularization in long term


5 year patency:>95 %
10 year patency: > 90%
5
N Engl J Med 2009，360（10）961-972
Combination of the advantages of CABG & PCI
Changes in techniques have shifted the boundary
between CABG and PCI
CABG
 Minimal invasiveness;
PCI
Medical
Therapy
One-stop
Hybrid
 Shortens recovery time;
 Minimize risk of complications.
Hybrid revascularization：Fuwai experiences
Preliminary Experience of Staged Hybrid Procedure
(1999-2001)
3 days later
Hybrid revascularization：Fuwai experiences
One-stop Hybrid Procedure since 2007
First Hybrid OR in Asia, 2007
Hybrid revascularization： antiplatelet strategy
Our Protocol: “One-Stop” hybrid revascularization
Anti platelet strategy
Patients Selection
MICAB
(LIMA-LAD)
Angiography
for LIMA
OK!
PCI with DES
In Hybrid O.R.
with Fast-track Anesthesia
Ann Thorac Surg 2011;91:432-8
Midterm clinical outcome： VS off-pumm CABG
Hybrid Vs Off-pump for multivessel disease



2007.6 - 2009.12;104 patients with average 18 months follow-up
Hybrid significantly reduced ICU、in-hospital time and transfusion rate
Lower MACCE rate （99% vs 90.4%）than Off-pump after 18 months follow-up
Hybrid
(n=104)
Propensity-score matching (1:1)
OPCAB
(n=104)
10
Ann Thorac Surg 2011;91:432-8
Midterm clinical outcome： VS CABG and PCI
One-stop Hybrid vs CABG & PCI：3 year follow-up
One-stop Hybrid
CABG 5797
PCI 4254
141 cases（2007.6 to 2010.12）
Propensity match
Hybrid 141
CABG 141
PCI 141
Stratify by Euroscore
Stratify by SYNTAX score
low 0-2，medium 3-5, high >6
low <24，medium 24-30, high >30
Endpoint：MACCE rate in different risk levels
Midterm outcome：hybrid vs CABG & PCI
MACCE rate： Hybrid and CABG group was
significantly lower than PCI
Log Rank
Hybrid vs CABG
0.07
Hybrid vs PCI
0.001
CABG vs PCI
0.04
Hybrid
CABG
PCI
Total
Total MACCE Percent
141
9
6.4%
141
19
13.5%
141
32
22.7%
423
60
14.2%
Midterm outcome：hybrid vs CABG & PCI
 In low (< 24) and medium (24-30) Syntax score group，there
was no significant difference between three groups
 In High (> 30)Syntax score group，MACCE in Hybrid and
CABG group was significantly lower than PCI
Midterm outcome：hybrid vs CABG & PCI
 In low (<3) and medium (3-5) Euroscore group，there was no
significant difference between three groups
 In High (>5) Euroscore group，MACCE in Hybrid group was
significantly lower than CABG and PCI
Hybrid revascularization：patients selection
Inclusion criteria: high risk for PCI

Unfavorable LAD for PCI：chronic total occlusion, excessive
tortuosity, severely calcification lesion
LAD occlusion
Simple non-LAD lesion
Midterm outcome：patients selection
Inclusion criteria: high risk for PCI

Unprotected left main disease
Unprotected left main disease
With LIMA-LAD graft
Protected left main disease
Midterm outcome：patients selection
Inclusion criteria: high risk for conventional CABG

Patients with limitations to traditional CABG

pre-existing organs dysfunction

heavily calcified proximal aorta

lack of suitable graft conduits
Midterm outcome：discussion (1)
One-stop hybrid vs CABG
 Minimal invasiveness: avoid cardiac pulmonary bypass &
median sternotomy
 a feasible option to some certain clinically high risk patients
who were unable to tolerate median sternotomy,
cardiopulmonary bypass or heart rotation during off-pump
CABG.
JACC Cardiovasc Interv 2008;1:459-68.
Circ Cardiovasc Interv 2010;3:511-8.
Midterm outcome：discussion（1）
One-stop hybrid vs CABG
 LIMA-LAD graft quality was further confirmed by instant angiography ,
any deficiency could be corrected immediately.
J Am Coll Cardiol 2009;53:232-41.
Midterm outcome：discussion（1）
One-stop hybrid vs CABG
 Avoid aortic manipulation，significantly decreased
neurological events rate (1.4% vs 6.4%).
J Thorac Cardiovasc Surg 2005;129:307-13.
Midterm outcome：discussion（2）
One-stop hybrid vs PCI
 Cover patients with LAD chronic total occlusion, excessive tortuosity,
severely calcification lesion
 Cover potential patients for staged PCI with multivessel disease
Severe calcification in LAD
Proximal RCA lesion
Midterm outcome：discussion（3）
A safe and effective Modified Antiplatelet Protocol for hybrid
procedure
Figure 1 perioperative changes of AA-PAgT: Hybrid vs PCI
Figure 2 perioperative changes of ADP-PAgT: Hybrid versus PCI
Platelet activity was sufficiently inhibited
as standard PCI anti-platelet protocol 3 days postoperatively
Midterm outcome：discussion（4）
Alternative surgical approaches
Lower partial
ministernotomy
Full sternotomy
Parasternal incision
Less technically demanding
Satisfying exposure
Easily and rapidly converse to full sternotomy if necessary
Robot assited technique：Much cost and time consuming
Midterm outcome：conclusion
One-stop hybrid for multivessel coronary artery disease
 combines the durability and survival advantage of LIMA-LAD
graft with less-invasive PCI to non-LAD lesions
 for selected patients with multivessel coronary artery disease, it
could provide favorable midterm outcomes in each risk tertile,
especially for patients with high syntax score and euroscore
Thanks