Quick Case Study

Team-Based Procedure Goes Beyond CABG

A 67-year-old man with a history of coronary artery disease (CAD) was referred to Duke Medicine for a second opinion. He had previously undergone several percutaneous coronary interventions (PCIs) with stent placements, and he had now developed progressive angina that was not responsive to medication. Although his local cardiac surgeon felt that coronary artery bypass graft (CABG) surgery would be beneficial, his referring cardiologist did not think that he was a good candidate because of his complex coronary anatomy and the presence of previous stents.

The patient met with Duke’s interventional cardiologist Magnus Ohman, MD, for evaluation. Imaging and cardiac catheterization revealed that the patient had narrowing of the left anterior descending (LAD) artery at mid-vessel near the location of 2 stents that had been placed previously. However, the same vessel had another 90% blockage distally. “Although the more proximal narrowing could be corrected with CABG, the distal blockage would negate the benefit of a bypass operation,“ Ohman explained. “If the blood flow distal to where the surgeon puts the graft is not good, the bypass graft tends to fail over time.”

Question: What options other than conventional bypass surgery are available to this patient?

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Answer: Hybrid coronary revascularization is an approach that combines minimally invasive bypass operation techniques with PCI.

Ohman consulted with Duke Medicine cardiac surgeon Jacob Schroder, MD, and decided they could offer the patient a hybrid coronary revascularization procedure, combining minimally invasive bypass operation techniques with PCI, taking advantage of the benefits of both.

Hybrid coronary revascularization and other hybrid cardiac procedures are relatively new approaches to treatment that can be used in patients who have complex anatomy or who have comorbidities or other factors that increase the risks associated with open-heart surgery.

For this patient, it was recommended that the minimally invasive grafting of the left internal mammary artery (LIMA) to the LAD artery be performed through a keyhole thoracotomy incision and that the PCI and placement of a drug-eluting stent be performed several days later.

The patient decided to undergo the hybrid procedure. “The surgeon placed the bypass graft to the mid-vessel. Three days later, we came in and verified that the bypass graft looked good,” Ohman explained. “Then we placed a drug-eluting stent distal to this.” The patient went home 1 day later than he would have if he had undergone the bypass surgery alone.

Although outcomes of hybrid cardiovascular procedures appear to be comparable to conventional surgical or interventional treatments, Ohman said that the procedures are not very common, and data on long-term outcomes are still accumulating.

Currently, careful patient selection appears to be the most important element for successful outcomes. For example, one patient who underwent a hybrid procedure at Duke Medicine had aortic stenosis and CAD. The patient's age was too advanced for open-heart surgery, and it was initially expected that she would live less than 1 year from diagnosis, Ohman said. “The patient underwent a minimally invasive aortic valve repair and PCI and lived nearly 10 more years."

Only a handful of tertiary care centers around the country have the technology and team approach needed to offer hybrid cardiac procedures. “These procedures require a very dedicated team for the care of the patient,” Ohman said.

At a 6-month follow-up visit, this patient was doing well, and his symptoms had resolved. The procedure has a good chance of being curative in this case, Ohman said, because LIMA to the LAD and PCI with placement of drug-eluting stents both have more than 90% success rates at 5 to 10 years after the procedures.