Hybrid Coronary Revascularization

Abstract

Through coronary artery by-pass grafting (CABG)is considered the gold standard of the revascularization approaches, the development of newer-generation coronary stents and safer medications have challenged this status. The major advantage of CABG over percutaneous coronary intervention (PCI) remains the use of the left internal mammary artery (LIMA) to bypass the left anterior descending (LAD). In order to combine the advantages of the LIMA-LAD surgical bypass with the minimal invasiveness of the PCI, a hybrid approach to coronary revascularization was introduced. According to the 2011 ACCF/AHA guidelines for coronary artery bypass surgery, hybrid coronary revascularization (HCR) is defined "as the planned combination of LIMA-to-LAD artery grafting and PCI of one or more non-LAD coronary arteries. Angina pectoris (AP) represents the clinical syndrome occurring when myocardial oxygen demand exceeds supply. The term is derived from Latin; the literal meaning is "the choking of the chest;" angere, meaning "to choke" and pectus, meaning "chest." The first English-written account of recurrent angina pectoris was by English nobleman Edward Hyde, Earl of Clarendon. He described his father as having, with exertion, "a pain in the left arm...so much that the torment made him pale". The first description of angina as a medical disorder came from William Heberden. Heberden, a prodigious physician, made many noteworthy contributions to medicine during his career. He presented his observations of dolor pectoris" to the Royal College of Physicians in 1768. Much of his classic description retains its validity today. Acute coronary syndrome usually occurs as a result of one of three problems: ST elevation myocardial infarction (STEMI, 30%), non ST elevation myocardial infarction (NSTEMI, 25%), or unstable angina (38%).These types are named according to the appearance of the electrocardiogram (ECG/EKG) as non-ST segment elevation myocardial infarction and ST segment elevation myocardial infarction. There can be some variation as to which forms of myocardial infarction (MI) are classified under acute coronary syndrome. More serious cases of coronary artery disease require coronary artery bypass graft surgery (CABG), a procedure designed to restore blood flow to the myocardium. Performed since the late 1960s, this is now one of the most common operations in the United States-up to 500,000 are done yearly.

Modes of hybrid coronary revascularization - One stage HCR - Two-stage HCR: PCI followed by CABG - Two-stage HCR: CABG followed by PCI The publications suggested that HCR is feasible, safe and effective for treatment of MCAD, with similar in-hospital and one-year follow-up outcomes, significantly lower requirement for RBC transfusion, and faster recovery compared with CABG. It may provide a safe and effective alternative for treating selected patients with MCAD.