Correspondence

More on “Hybrid Revascularization”

N Engl J Med 1997; 337:861-862September 18, 1997

Article

To the Editor:

In their letter (May 15 issue)1 on minimally invasive coronary-artery byass surgery,2 Friedrich and colleagues advocate what they call a “new approach to coronary revascularization,” in which revascularization of two-vessel disease is achieved with a combined strategy of minimally invasive surgery for one vessel and balloon angioplasty for the other (so-called hybrid revascularization).

In fact, this approach has been used in many centers, including my own, for more than two years, since it is intuitively appealing. However, I believe that the strategy advocated by Friedrich and coworkers, in which the minimally invasive surgery is carried out first and is followed by balloon angioplasty, is illogical, because if the angioplasty fails, the surgical option has already been exercised. If, instead, angioplasty is carried out first and is unsuccessful, the surgical option can be reconsidered to include revascularization of both involved vessels, whenever feasible. My colleagues and I have used the latter strategy successfully and believe it to be the preferred approach for hybrid revascularization.

Lawrence I. Bonchek, M.D.
Cardiothoracic Surgeons of Lancaster, Lancaster, PA 17604-3555

2 References

1. 1

   Friedrich GJ, Bonatti J, Dapunt OE. Preliminary experience with minimally invasive coronary-artery bypass surgery combined with coronary angioplasty. N Engl J Med 1997;336:1454-1455
   Full Text | Web of Science | Medline

2. 2

   Reichenspurner H, Gulielmos V, Daniel WG, Schuler S. Minimally invasive coronary-artery bypass surgery. N Engl J Med 1997;336:67-68
   Full Text | Web of Science | Medline

Author/Editor Response

The authors and a colleague reply:

To the Editor: Before choosing our approach combining surgery and percutaneous transluminal coronary angioplasty (PTCA), we also evaluated the strategy in which PTCA is the first step. During an international course on anatomy, physiology, and surgery in minimally invasive coronary-artery bypass grafting held in March at our institution, cardiac surgeons and interventional cardiologists agreed that both strategies (PTCA before surgery and vice versa) have positive and negative features. The following considerations favor minimally invasive coronary-artery bypass surgery as the first procedure: It is possible to evaluate this new revascularization technique by short-term angiographic documentation of the left-internal-thoracic-artery graft and its anastomosis during the PTCA procedure that does not involve the left anterior descending artery. If PTCA is performed first, it could delay minimally invasive coronary-artery bypass surgery as a result of PTCA-related complications requiring adjunctive pharmacotherapy, such as glycoprotein IIb/IIIa inhibitors, ticlopidine, and aspirin.1,2 Our goal was to complete hybrid revascularization within 10 days. Failure of PTCA resulting in emergency coronary-artery bypass grafting is rare (1 percent), and the incidence has decreased significantly.3,4

Under these conditions, we believe that hybrid revascularization, using minimally invasive coronary-artery bypass surgery as the first approach, is feasible, logical, and a valid alternative strategy.

Guy J. Friedrich, M.D.
Otto E. Dapunt, M.D.
Otmar Pachinger, M.D.
University Hospital Innsbruck, A-6020 Innsbruck, Austria

4 References

1. 1

   EPIC Investigators. Use of a monoclonal antibody directed against the platelet glycoprotein IIb/IIIa receptor in high-risk coronary angioplasty. N Engl J Med 1994;330:956-961
   Full Text | Web of Science | Medline

2. 2

   Gregorini L, Marco J, Fajadet J, et al. Ticlopidine alternates post-angioplasty thrombin generation. Circulation 1995;92:Suppl I:I-608 abstract.
   

3. 3

   Greene MA, Gray LA Jr, Slater AD, Ganzel BL, Mavroudis C. Emergency aortocoronary bypass after failed angioplasty. Ann Thorac Surg 1991;51:194-199
   CrossRef | Web of Science | Medline

4. 4

   Carey JA, Davres SW, Balcon R, et al. Emergency surgical revascularisation for coronary angioplasty complications. Br Heart J 1994;72:428-435
   CrossRef | Web of Science | Medline

Citing Articles (4)

Citing Articles

1. 1

   Bela Balint. (2003) Nepovoljni efekti hemoterapije i njihovo sprečavanje. Vojnosanitetski pregled 60:2, 185-194
   CrossRef

2. 2

   Yasushi Matsumoto, Masamitsu Endo, Fuminori Kasashima, Yoshinobu Abe, Ikuko Kosugi, Yasumitsu Hirano, Hisao Sasaki, Takeshi Ueyama. (2001) Hybrid revascularization feasibility in minimally invasive direct coronary artery bypass grafting combined with percutaneous transluminal coronary angioplasty in patients with acute coronary syndrome and multivessel disease. The Japanese Journal of Thoracic and Cardiovascular Surgery 49:12, 700-705
   CrossRef

3. 3

   J FONGER. (1999) Integrated myocardial revascularization*1. European Journal of Cardio-Thoracic Surgery 16, S12-S17
   CrossRef

4. 4

   Kim A. Eagle, Robert A. Guyton, Ravin Davidoff, Gordon A. Ewy, James Fonger, Timothy J. Gardner, John Parker Gott, Howard C. Herrmann, Robert A. Marlow, William C. Nugent, Gerald T. O’Connor, Thomas A. Orszulak, Richard E. Rieselbach, William L. Winters, Salim Yusuf, Raymond J. Gibbons, Joseph S. Alpert, Kim A. Eagle, Timothy J. Gardner, Arthur Garson, Gabriel Gregoratos, Richard O. Russell, Sidney C. Smith. (1999) ACC/AHA guidelines for coronary artery bypass graft surgery. Journal of the American College of Cardiology 34:4, 1262-1347
   CrossRef