Hybrid coronary revascularization (HCR) is the planned use of a combination of minimally invasive surgical techniques for left internal mammary artery (LIMA) to left anterior descending (LAD) artery bypass grafting and the use of percutaneous coronary intervention (PCI) for revascularization of other territories that is performed during the same procedure. This hybrid approach for treating multivessel coronary artery disease (CAD) may offer the best of both worlds and is an alternative to coronary artery bypass grafting (CABG) through sternotomy alone or multivessel PCI. Ihab Attia, MD, FSCAI, Ain Shams University, Cairo, Egypt, discussed the pros and cons of this approach, pointing out the need for hybrid operating suites with surgical and fluoroscopic capabilities to support the performance of this procedure.

The LIMA is the optimal conduit for the LAD, in that it provides durable patency and is associated with survival advantages, while stenting the circumflex artery and right coronary artery with drug-eluting stents (DES) is also associated with excellent clinical outcomes. When combined with robotically enhanced minimally invasive surgery, this approach may be better tolerated than traditional CABG that is performed with a sternotomy. In addition, a hybrid strategy has the potential to offer optimal revascularization while providing patients with a truly minimally invasive approach that is potentially accompanied by reduced surgical trauma and reduced morbidity. Robotic LIMA is associated with less postthoracotomy syndrome and quicker recovery than minimally invasive direct coronary artery bypass (CAB).

Hybrid surgery may be best targeted to patients who are at high risk for sternotomy (elderly or frail patients and those with comorbidities), younger patients who may need other surgery in the future, those with complex LAD disease, and patients with left main disease when the circumflex is small and could be stented after a LIMA graft has been placed. Prof. Attia believes that the LAD should not be stented when there is ostial, bifurcation, or diffuse disease or if chronic occlusions are present because of the higher risk that is associated with stenting and better outcomes that are expected with CABG.

Aggressive continuous antiplatelet therapy is necessary after PCI and can be implemented if surgery is performed first. PCI of high-risk lesions may also be safer with a patent LIMA-LAD graft in place. The disadvantage of performing surgery first is that the fallback option of conventional CABG leads to higher morbidity if suboptimal PCI occurs. Performing PCI first offers several advantages, including: minimized risk of ischemia during minimally invasive direct-CAB; possibility to convert to a conventional CABG if there are suboptimal PCI results; and possibility of hybrid coronary revascularization in the setting of PCI for myocardial infarction in non-LAD targets. The disadvantages of performing PCI first include: having to perform surgery under aggressive platelet inhibition (increased bleeding); stent thrombosis is possible at reversal of heparin; PCI is performed with an unprotected anterior wall; and there is no angiographic LIMA control. Advantages of performing surgery and PCI in one session include only one intervention; no waiting time with the possibility of myocardial ischemia in nonrevascularized territories; full cardioanesthesia backup; and the possibility of switching from PCI to surgery and vice versa any time. In addition, there is the opportunity for immediate angiography of the LIMA-LAD graft, and aggressive PCI of high-risk lesions can be performed with a documented patent LIMA-LAD. Downsides include a risk of bleeding with dual antiplatelet therapy at the time of surgery and a risk of stent thrombosis in the setting of the inflammatory response to surgery [DeRose JJ. Semin Thorac Cardiovasc Surg 2009].

As the patient population with multivessel CAD ages and presents with more comorbidities, the exploration of less invasive approaches is warranted. HCR offers the potential advantages of improved survival with the use of a LIMA-to-LAD conduit at surgery and reduced symptoms with use of DES with minimal surgical trauma. The optimal timing and order of revascularization in HCR remains unclear.