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| Guest Commentary |
By Howard S. Bush, MD
Chairman, Dept. of Cardiology
Cleveland Clinic Florida, Weston, Florida, USA |
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Combination of minimally invasive coronary bypass and percutaneous coronary
intervention in patients with multi-vessel coronary artery disease: a cardiologist’s
perspective
Complete revascularization that involves the use of the internal thoracic artery (LITA) remains the gold standard for many patients with coronary artery disease (CAD). Advances in both surgical and percutaneous techniques have spurred interest in hybrid procedures, in which these two treatment modalities complement each other.
Case: 75 year old male presents with an acute coronary syndrome (positive enzymes) complicated by congestive heart failure. Cardiac catheterization revealed multivessel CAD with moderately severe left ventricular dysfunction. The left anterior descending (LAD) contained a critical lesion proximally and was heavily calcified and diffusely diseased in the mid and distal portion (figure 1). The circumflex (Cx) was a dominant vessel with a focal 90% lesion proximally (figure 2). The ejection fraction was estimated to be 30%. Co-morbidities included age, renal insufficiency, chronic obstructive pulmonary disease, and exogenous obesity. After initial stabilization, the patient was taken to the operating room and underwent placement of the LITA artery to the LAD using a minimally invasive direct coronary artery bypass (midCAB). The patient was extubated shortly after surgery, and the following day a drug eluting stent (DES) was placed to the circumflex (figure 3). Angiography confirmed the LITA to the LAD was widely patent (figure 4). The remainder of the hospital course was unremarkable.
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| Figure 1 : Mid and Distal Portion |
Figure 2 : 90% Lesion Proximally |
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| Figure 3 : Drug Eluting Stent |
Figure 4 : Angiography |
The PCI can be performed either before of after the surgical revascularization. We have
preferred timing the PCI after the midCAB for several reasons. This gives us a chance to
image the LIMA to the LAD and it also allows us to withhold anti-platelet therapy until
after the surgery, thus minimizing peri-operative bleeding. Using this sequence, we
generally take the patient to the cath lab on post-op day 1. Following the intervention, the patient is placed on clopidogrel, the sheath is removed with a closure device, and the patient is transferred to a telemetry unit. Most patients are observed overnight discharged the following day (post op day 2). This case illustrates the use of a hybrid approach to revascularization.
Not all patients are good candidates for sternotomy. Survival in many patients with multi-vessel CAD,
especially in diabetics, is directly linked to placement of a LITA to the LAD. Revascularization of the RCA and Cx often involves placement of saphenous vein grafts (SVG) and the long-term success of these conduits is much less durable. Advances in PCI have included the use of better anti-platelet therapy and DES. Thus, it becomes theoretically attractive to combine the best of the 2 technologies and provide survival benefit with a less invasive approach. Long term follow up and more patient data in a randomized trial are needed to determine which patient subsets are most likely to benefit from this strategy.
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