Hybrid concept in

cardiac surgery

Dr. Manoj P Nair

Why talk about hybrid OR ?

Technology is changing

• Minimally invasive cardiovascular surgery

• Drug-eluting stents

• Stent grafts

• Percutaneous valves

Why talk about hybrid OR ?

Patient populations continue to change

• Older

• Sicker-more comorbidities

• More advanced disease

Physicians are changing

• Growing endovascular specialists

• Specialty boundaries are less defined

• Heart team is becoming a new paradigm

Hybrid Operating Room

• A fully functional cardiac cath lab and cardiac surgery OR

• Allows patients to undergo percutaneous

interventions and cardiac surgery simultaneously

• Ideal for treating a variety of conditions: CAD, valve disease, CHD,

aortic disorders,CHF.

Components of a Hybrid OR/Cath lab

• Fully functional Cath lab

• Multipurpose table

• Versatile imaging equipment: Fixed and mobile

modes

• Multimodality imaging:

Cine/CT/IVUS/OCT/Echo gating(TEE)

• Multiple flat-panel monitors

• Traffic/Air flow to maintain sterility (Laminar)

What makes a Hybrid OR successful?

• Infrastructure

• Superior imaging/monitoring equipment

• Integrated imaging equipment

• Teamwork and convergence

• Protocols

• Trained ancillary staff: Cross-training

• Supplies

Teamwork and Convergence

• Bringing multiple specialists together to deliver

the best care to the patient

• Utilizing multiple technologies as appropriate

• Realization that parallel procedures and

technologies are often complementary, rather than competitive

• Collaborative strategy: Patient centric approach

Advantages of Hybrid Surgery

• Hybrid surgery minimizes hurt to patient from more

invasive procedures

• Maximizes treatment spectrum

• For complex heart disorders, maximizes the advantages of

catheter and surgery

• Accelerates recovery time

• Reduces hospital stay

• Improves patient satisfaction

Hybrid surgery in….

Coronary revascularization / Valvular disorders

Aortic aneurysms

Hybrid Coronary Revascularization

Background

In the present DES era, LIMA to LAD graft continues to have unrivaled safety

and efficacy.

Stent restenosis rates (DES) are now lower than reported rates of SVG failure.

PCI is probably a superior strategy to SVG for revascularization of non-LAD

vessels.

Rationale of Hybrid Revascularization

Combining the benefits of LIMA to LAD graft with the

benefits of PCI with DES implantation in non-LAD targets may

minimize risk without diminishing the long term benefits

offered by each strategy in particular.

LIMA to LAD Graft Patency

With PCI, the proximal LAD lesion is an independent risk factor for in-stent

restenosis .

The LIMA–LAD graft has excellent patency rates, which

correlates with increased event-free survival.

5-year patency rate ranges between 92% and 99% and at

10 years between 95% and 98%.

Mortality benefits are attributed to the LIMA- LAD graft rather than SVG

grafts/PCI to non LAD targets.

This is the premise on which the modern era of hybrid

coronary revascularization is based.

Results of Hybrid Revascularization

No randomized trials so far

Multiple small non randomized studies have shown hybrid

coronary revascularization is safe with low mortality rates

(0% to 2%), low morbidity, and shorter intensive care unit

and hospital stay

Sternal sparing surgery

Other clear advantages are superior cosmetic

results and faster recovery

For optimal results……

First step in crisis management is prevention……

Choose the right patient!

Never force too much!

indications, device, techniques……….

Intraoperative Completion Angiography after

CABG

Routine completion angiography detected 12% of

grafts with important angiographic defects.

One-stop hybrid strategy is reasonable, safe, and feasible.

Combining the tools of the cath lab and OR greatly enhances the options

available to the surgeon and cardiologist for patients with complex coronary

artery disease. (J Am Coll Cardiol 2009;53:232–41)

Routine Intraoperative Completion Angiography After

Coronary Artery Bypass Grafting

Hybrid Valve treatment + PCI

The rationale behind hybrid valve surgery is to substitute PCI for CABG

(typically substituting PCI for SVG) to convert a combined valve/CABG

procedure requiring sternotomy into an isolated valve procedure, which can

be performed using minimally invasive techniques.

There are 3 settings in which this may be of benefit.

1.CABG patient with poor conduit for CABG surgery

2.Convert high-risk valve/CABG surgery into a lower-risk isolated valve

3.Convert reoperative valve/CABG into reoperative isolated valve surgery.

Overview

The hybrid OR facilitates a whole new spectrum of cardiac surgical/invasive

therapies

The trend toward hybrid techniques will continue to evolve and is becoming

an essential resource of every cardiovascular center

Requires a highly organized and fully cooperative multidisciplinary team

Hybrid concepts in aortic aneurysm

Limitations of open surgeries

Morbidity and mortality, as well as early clinical outcomes and overall survival

for total aortic arch repair have improved significantly during the last 2

decades.

Nevertheless, open surgical arch replacement still represents a high-risk

procedure with increased morbidity and mortality .

Furthermore, many patients are sometimes denied surgical intervention

secondary to their significant comorbidities.

Limitations

Patients were identified as high risk for open surgery

Age over 80 years ,

Poor functional status ,

Presence of severe chronic obstructive pulmonary disease ,

Untreated significant coronary artery disease

Significant renal impairment ,

Prior stroke with poor mobility ,

Need for operation in the second or more redo setting ,

History of cirrhosis

Morbid obesity .

Advances

Thoracic endovascular aortic repair (TEVAR)

First introduced by Dake and associates in 1994.

Initially limited to the descending thoracic aorta, endovascular therapy is now

being applied to treat a wide range of pathologies throughout the aorta .

Definition

By definition, a hybrid arch procedure should have an open, as well as an

endovascular component

Hybrid technique Concepts

To reduce the morbidity and mortality associated with classical open

reconstruction

To expand the patient spectrum for endovascular repair considered otherwise

unsuitable due to anatomical reasons

It is a challenge….

Aortic arch with its curvature and branches represent a formidable

challenge for surgical as well as endovascular treatment

SURGICAL CLASSIFICATION OF HYBRID

PROCEDURES

Type I hybrid arch repair involves standard elephant trunk repair with

downstream placement of the endovascular stent-graft into the distal

elephant trunk graft.

Type II hybrid arch repair involves extra-anatomic revascularization of the

great vessels and endovascular stent-graft exclusion of the diseased aortic

arch.

ELEPHANT TRUNK

Previous elephant

trunk

Replaced

proximal aorta

Operative Techniques

Techniques using CPB

Sternotomy, ascending aortic replacement with the clamp on, and supra-aortic

vessel de-branching followed by retrograde aortic arch exclusion with endografts

from the femoral artery.

Sternotomy, ascending and arch replacement under deep hypothermic circulatory

arrest, with or without an elephant trunk and synchronous or metachronous

deployment of endografts in an antegrade or retrograde fashion with proximal

landing zone on the distal arch graft or the elephant trunk.

Operative Techniques

Techniques not involving the use of CPB include Sternotomy or mini-

sternotomy, application of the aortic side biting clamp on the ascending

aorta,

Supra-aortic vessel de branching (necklace grafting) followed by retrograde

(femoral artery) endograft deployment

NECKLACE GRAFT

HYBRID TYPE 1

Frozen elephant trunk procedures are just one type of approach within the

family of hybrid type I procedures.

The endovascular component of this approach becomes a less invasive

addition to a traditional surgical approach to the arch to help complete the

downstream repair of the distal arch and proximal descending thoracic aorta

HYBRID TYPE 1

HYBRID TYPE 1 –IN TYPE A

DISSECTION

HYBRID TYPE 1

HYBRID TYPE 1- ADVANTAGE

The hybrid type I approach is attractive because it potentially eliminates the

need for a second operative procedure (posterolateral thoracotomy) to

address the diseased descending thoracic aorta at a later date.

In essence, this version of the hybrid arch repair (hybrid type I) builds on the

existing capacity of standard open surgical techniques into a more extensive

repair of the distal aorta.

More importantly, hybrid type I procedures may be best when the arch disease

continues down into the descending thoracic aorta.

HYBRID TYPE 1- DISADVANTAGE

However, this version of hybrid arch repair still involves an open chest incision

and the use of CPB.

The less invasive component relates to the elimination of a second surgery on

the descending thoracic aorta.

HYBRID TYPE 2

The second fundamentally different group of hybrid arch repair patients

Hybrid type II, treated the endovascular repair as the primary arch repair

method (meaning the endovascular stent-graft excluded the arch disease

without surgically replacing the arch)

The open surgical component was an adjunctive procedure to revascularize

the great vessels .

NECKLACE GRAFTING WITH STERNOTOMY

Supra-aortic vessel debranching (necklace grafting) followed by retrograde

(femoral artery) endograft deployment

HYBRID TYPE 2 -NECKLACE GRAFTING

WITH STERNOTOMY

HYBRID TYPE 2 -NECKLACEGRAFTING

WITH STERNOTOMY

HYBRID TYPE 2 -NECKLACE GRAFTING

WITH STERNOTOMY

Aortic arch zones pertaining to

endografting (Ishimaru classification)

HYBRID TYPE 2 –NECKLACE

GRAFTING WITHOUT STERNOTOMY

HYBRID TYPE 2 –NECKLACE

GRAFTING WITHOUT STERNOTOMY

Currently, the main indications for preoperative subclavian artery bypass

Dominant left vertebral artery with a diminutive right vertebral artery

Patent left internal mammary artery graft to the left anterior descending coronary

artery

Both

Partial de branching

Left subclavian artery closure

HYBRID TYPE 2

Different approach to aortic arch disease because it bases the repair not on

traditional open surgical techniques.

Assumption that current endovascular technology can successfully exclude

aortic arch diseases and that the arch does not need to be replaced.

Hybrid type II procedures are significantly less invasive than hybrid type I

procedures.

Type II procedures avoid CPB and hypothermic circulatory arrest and can even

be approached in some without a sternotomy incision.

Conclusion

• Hybrid strategies can be used successfully in patients with complex arch

disease

• Mandates multi disciplinary approach

• Carries not negligible risk of perioperative mortality and morbidity

• Can be offered in patients with prohibitive risk