1. One-stop Hybrid Revascularization for left main and multivessel coronary artery disease
Shengshou Hu M.D.
National Center for Cardiovascular Disease，China
Fuwai Cardiovascular Hospital
Chinese Society for Thoracic and Cardiovascular Surgery

2. Develop of coronary artery disease
In China:
Commonly seen in clinical scenario
Accounted for one million AMI per year
Accounted for half million deaths per year
CAD incidence will be doubled in the next 20 years
Circulation Cardiovascular Quality and Outcomes 2010

3. Choice for left main and multivessel disease
In real world，debate of best choice for multivessel disease never stops：CABG or PCI?

4. Advantages of catheter based therapy
Advantage of PCI
Minimally Invasive
For non-LAD, DES significantly reduced restenosis rate, similar or lower than failure rate of saphenous vein grafts
The need for repeat revascularization is still a big concern
N Engl J Med 2009，360（10） 4

5. LIMA-LAD graft still has optimal long term patency rate
Advantages of conventional coronary artery bypass grafting
LIMA-LAD graft still has optimal long term patency rate
Lower rate of repeat revascularization in long term
5 year patency:>95 %
10 year patency: > 90%
N Engl J Med 2009，360（10）

6. Combination of the advantages of CABG & PCI
Changes in techniques have shifted the boundary between CABG and PCI
Medical
Therapy
PCI
CABG
Minimal invasiveness;
Shortens recovery time;
Minimize risk of complications.
One-stop
Hybrid

7. Preliminary Experience of Staged Hybrid Procedure (1999-2001)
Hybrid revascularization：Fuwai experiences
Preliminary Experience of Staged Hybrid Procedure ( )
3 days later

8. One-stop Hybrid Procedure since 2007
Hybrid revascularization：Fuwai experiences
One-stop Hybrid Procedure since 2007
First Hybrid OR in Asia, 2007

9. Our Protocol: “One-Stop” hybrid revascularization
Hybrid revascularization： antiplatelet strategy
Our Protocol: “One-Stop” hybrid revascularization
Anti platelet strategy
Routinely stop Clopidogrel;
Continueous Administration of
Aspirin 100mg/d.
Administration of
Clopidogrel 300mg
Patients Selection
MICAB
(LIMA-LAD)
Angiography
for LIMA
OK!
PCI with DES
In Hybrid O.R.
with Fast-track Anesthesia
Ann Thorac Surg 2011;91:432-8

10. Hybrid Vs Off-pump for multivessel disease
Midterm clinical outcome： VS off-pumm CABG
Hybrid Vs Off-pump for multivessel disease
;104 patients with average 18 months follow-up
Hybrid significantly reduced ICU、in-hospital time and transfusion rate
Lower MACCE rate （99% vs 90.4%）than Off-pump after 18 months follow-up
Hybrid (n=104)
OPCAB (n=104)
Propensity-score matching (1:1)
Ann Thorac Surg 2011;91:432-8

11. One-stop Hybrid vs CABG & PCI：3 year follow-up
Midterm clinical outcome： VS CABG and PCI
One-stop Hybrid vs CABG & PCI：3 year follow-up
One-stop Hybrid
141 cases（ to ）
CABG 5797
PCI 4254
Propensity match
CABG 141
Hybrid 141
PCI 141
Stratify by Euroscore
low 0-2，medium 3-5, high >6
Stratify by SYNTAX score
low <24，medium 24-30, high >30
Endpoint：MACCE rate in different risk levels

12. MACCE rate： Hybrid and CABG group was significantly lower than PCI
Midterm outcome：hybrid vs CABG & PCI
MACCE rate： Hybrid and CABG group was
significantly lower than PCI
Log Rank
Hybrid vs CABG
0.07
Hybrid vs PCI
0.001
CABG vs PCI
0.04
Total
MACCE
Percent
Hybrid
141 9
6.4%
CABG 19
13.5%
PCI 32
22.7%
423 60
14.2%

13. Midterm outcome：hybrid vs CABG & PCI
In low (< 24) and medium (24-30) Syntax score group，there was no significant difference between three groups
In High (> 30)Syntax score group，MACCE in Hybrid and CABG group was significantly lower than PCI

14. Midterm outcome：hybrid vs CABG & PCI
In low (<3) and medium (3-5) Euroscore group，there was no significant difference between three groups
In High (>5) Euroscore group，MACCE in Hybrid group was significantly lower than CABG and PCI

15. Inclusion criteria: high risk for PCI
Hybrid revascularization：patients selection
Inclusion criteria: high risk for PCI
Unfavorable LAD for PCI：chronic total occlusion, excessive tortuosity, severely calcification lesion
LAD occlusion
Simple non-LAD lesion
本部分研究结论为…… 15

16. Inclusion criteria: high risk for PCI
Midterm outcome：patients selection
Inclusion criteria: high risk for PCI
Unprotected left main disease
Unprotected left main disease
本部分研究结论为……
With LIMA-LAD graft
Protected left main disease 16

17. Inclusion criteria: high risk for conventional CABG
Midterm outcome：patients selection
Inclusion criteria: high risk for conventional CABG
Patients with limitations to traditional CABG
pre-existing organs dysfunction
heavily calcified proximal aorta
lack of suitable graft conduits
本部分研究结论为…… 17

18. One-stop hybrid vs CABG
Midterm outcome：discussion (1)
One-stop hybrid vs CABG
Minimal invasiveness: avoid cardiac pulmonary bypass & median sternotomy
a feasible option to some certain clinically high risk patients who were unable to tolerate median sternotomy, cardiopulmonary bypass or heart rotation during off-pump CABG.
JACC Cardiovasc Interv 2008;1:
Circ Cardiovasc Interv 2010;3:511-8.

19. One-stop hybrid vs CABG
Midterm outcome：discussion（1）
One-stop hybrid vs CABG
LIMA-LAD graft quality was further confirmed by instant angiography , any deficiency could be corrected immediately.
Hybrid operation room provides instant feedbacks which were difficult to evaluate with naked, then we could change our surgical behavior.
J Am Coll Cardiol 2009;53:

20. One-stop hybrid vs CABG
Midterm outcome：discussion（1）
One-stop hybrid vs CABG
Avoid aortic manipulation，significantly decreased neurological events rate (1.4% vs 6.4%).
J Thorac Cardiovasc Surg 2005;129:

21. One-stop hybrid vs PCI Midterm outcome：discussion（2）
Cover patients with LAD chronic total occlusion, excessive tortuosity, severely calcification lesion
Cover potential patients for staged PCI with multivessel disease
Severe calcification in LAD
Proximal RCA lesion

22. Midterm outcome：discussion（3）
A safe and effective Modified Antiplatelet Protocol for hybrid procedure
Figure 1 perioperative changes of AA-PAgT: Hybrid vs PCI
Figure 2 perioperative changes of ADP-PAgT: Hybrid versus PCI
Platelet activity was sufficiently inhibited
as standard PCI anti-platelet protocol 3 days postoperatively

23. Alternative surgical approaches
Midterm outcome：discussion（4）
Alternative surgical approaches
Lower partial
ministernotomy
Full sternotomy
Parasternal incision
Less technically demanding
Satisfying exposure
Easily and rapidly converse to full sternotomy if necessary
Robot assited technique：Much cost and time consuming

24. One-stop hybrid for multivessel coronary artery disease
Midterm outcome：conclusion
One-stop hybrid for multivessel coronary artery disease
combines the durability and survival advantage of LIMA-LAD graft with less-invasive PCI to non-LAD lesions
for selected patients with multivessel coronary artery disease, it could provide favorable midterm outcomes in each risk tertile, especially for patients with high syntax score and euroscore

25. Thanks