Ứng dụng của kỹ thuật hybrid trong tim mạch

Clinical Applications of
Hybrid Cardiac Surgery

Michael S Firstenberg, MD FACC
Assistant Professor of Surgery
Northeast Ohio Medical University
Cardiothoracic Surgery
Akron City Hospital - The Summa Health System


But no conflicts related to this
presentation


• Introduction / Definition
• Coronary Artery Disease

• Atrial Fibrillation
• Complex Aortic Surgery

• Valvular Disease
(That is a different story)


Solve a specific problem
Traditionally a “binary” problem:
– Some problems are better solved with
traditional “open surgery”
– Some better solved with “catheter-based”
procedures
– Some patients might benefit from combination

of both?
– In an era of “evidence-based medicine” care
should be individualized for each patient
– Sometimes patients have >1 problem
–
–

Risk vs Benefit

Aortic stenosis and CAD
CAD and Carotid Stenosis


Coronary Artery Disease Model
•
•
•

“Failure” of less invasive therapy
“Progression” of disease
Balance of Co-morbidities

– Various therapies each aim to alter
the risk vs. benefit ratios

Medication
•
•
•
•

•

Beta-blockers
Statins
ACE inhibitors
Aspirin
Anti-platelet
Agents

CatheterBased
• Bare Metal
• Drug Eluding
• Bioabsorbable
• PTCA

Surgery
• CABG
• On vs Off
• Arterial
Conduits
• Anaortic
• Mini-invasive


• Cure or Palliate Disease
• Alleviate symptoms
– Control pain
– Quality of life
– Quantity of life

• Long-term risks vs benefits
• Short-term risks vs benefits
• Costs
– To the patient
– To society
– Short vs long-term

MUST be individualized for each patient


Multi-solution solutions to the modified nonlinear
Schrödinger equation with variable coefficients in
inhomogeneous fibers
Các giải pháp nhiều giải pháp cho các phi tuyến Phương trình Schrödinger thay đổi với hệ
số biến trong sợi không đồng nhất *

Optimal Patient
Care

Chăm sóc bệnh
nhân tối ưu

Not as easy as it
looks

* Google Translate


STEMI – Acute MI Model:
Serial Therapy

1. Initial medical stabilization
2. Immediate catheter therapy
–
–
Medical
Therapy

Surgery

Catheter

Stenting
Medical therapy (BB, Statin, ASA)

3. Recovery (Days? Weeks?)
4. CABG
–
–
–
–

Complete revascularization
Arterial vs Venous Conduits
On / Off pump
Medical therapy

“Hybrid Therapy”
Optimized teams and therapies for each problem

“Hybrid” Coronary Revascularization (HCR)
CABG

PCI

• PRO’s
– LIMA-LAD durability
– 95-98% at 10 years
– Anterior wall protection

• PRO’s
– Less invasive
– Shorter recovery
– Less costs

• CON’s
– SVG patency
• 6-20% failure at 1 year
• 50% failure at 15 years
– Surgical complications
– Prolonged recovery

+

• CON’s
– Stent thrombosis
– Need for repeat
revascularization
– Suboptimal long-term results

“Hybrid” Coronary Revascularization (HCR)
HCR vs STEMI Model? All a difference in timing and strategy

2-stage approach

• Different locations
– Cath lab
– OR

• Separated by hrswks

1-stop shopping
•
•
•
•

“Hybrid” operating room
Performed the same time
Lower costs
Shorter hospitalization

•PCI First, then CABG (LIMA-LAD)
•Multi-vessel stenting
•“Safer” PCI if complication occurs
•But “unprotected”
•CABG with anti-platelet agents

•CABG First, then PCI (Preferred)

•Incomplete revascularization risks
•Risk for second surgery
•Completion angiography – Uncertain value?


“Hybrid” Coronary Revascularization (HCR)
Unanswered Questions / Controversies

• Surgical Techniques
–
–
–
–

MIDCAB
TECAB
Robotic Assisted
Limited sternotomy

Most Importantly:
Are the outcomes any
better?

• Anti-platelet Strategies
– Balance surgical bleeding
– Stent thrombosis

• Patient selection (co-morbidities)
• Ideal coronary anatomy –
– SYNTAX Score

Unclear???
Any better
examples?


The Burden of the Problem
• 2.5 millions adults in the U.S.
–
–
–
–
–

80% > 65 years/old
Incidence to double in 40 years
2x increased in stroke rate (vs NSR)
3x more likely to have CHF
Prevalence
• 0.1% for <55
• 9.0% for >80

• Medicare Costs:
– $15.7 billion/year in new
diagnosis/treatment
– $8 billion/year in stroke management

12

Ideal application for hybrid
techniques
• Currently no ideal therapy
Left Pulm.
Cox-Maze III: Cut and Sew
Veins
Left Atrial Lesions
MV
LAA

• Catheter based endocardial
• Surgical based epicardial
– Complexity (Cox-Maze)
• 80-90% ”cure”

– Limited (PVI)
• 40-60% “cure”

Right Pulm. Veins


Five-Box Maze Lesion Set
•

•
•
•
•

Technically very difficult with an

epicardial or endocardial
approach
Limited lesion sets produce
unpredictable results
Often combined with medical
therapy
Results unpredictable as atrial
tissue scar matures
Mapping-based endocardial
approach are also limited


The Problem: FAST Study
Freedom from Atrial Fibrillation

Freedom from
AFib

Catheter
(n=63)

Surgery (n=61)

P-value

Overall, 12
month

23 (36.5%)

40 (65.6%)

0.0022

Overall, 12
month w meds

27 (42.9%)

48 (78.7%)

0.0001

28 (44%)

41 (67.2%)

0.0178

Overall, 6 month

Boersma LVA, et al. Atrial Fibrillation Catheter Ablation Versus Surgical Ablation Treatment (FAST):
A 2-Center Randomized Clinical Trial. Circulation 2012;125:230-30


Combined the best of both
approaches
Single procedure – Hybrid OR
Intra-Pericardial (Trans Xyphoid)

Endocardial

Epicardial


Posterior Left Atrium
The Numeris® & EPiSense ® Guided marketed
systems are indicated for endoscopic coagulation of
cardiac tissue.


Anterior LPV & Ligament of Marshall
The Numeris® & EPiSense ® Guided marketed
systems are indicated for endoscopic coagulation of
cardiac tissue.


Anterior RPV & Right Atrium
The Numeris® & EPiSense ® Guided marketed
systems are indicated for endoscopic coagulation of
cardiac tissue.


Percutaneous Endocardial Ablation
Percutaneous Access

The Numeris® & EPiSense ® Guided marketed
systems are indicated for endoscopic coagulation of
cardiac tissue.

Breakthrough Locations @ Pericardial
Reflections


• 67 patients
• 20 patients with 24hr Holter
– 90% (16) in sinus at 1 year

• 42 patients
–
–
–
–
–
–

57% persistent
43% long-standing
Failed endocardial ablation
6 obese
89% in sinus rhythm
69% in sinus, off medications


Keys to Success vs Barriers to Implementation?
Sinus Rhythm: On or Off Protocol
On-Proto

Percent

Off-Proto

Medical

•Close follow-up – Team Approach
•Aggressive management of arrhythmias
•Compliance with medications
•Patience!

Months Post-OP

Ad, Henry, Hunt: The implementation of a comprehensive clinical protocol improves long-term
success after surgical treatment of atrial fibrillation. JTCVS 2010.

>90%
Success


Very complex problems
• High risk patients
– Severe co-morbidities
– Often previous surgery

• Surgical options are poor
– High morbidity/mortality
– Technically demanding
– Staged Procedures


Traditional Elephant Trunk

Extra-anatomical debranching

Frozen Elephant trunk


•
•
•
•

Extra-anatomical options
Lower risk surgery
More complex stenting
Many case reports and limited
series