Ứng dụng của kỹ thuật hybrid trong tim mạch

Solve a specific problem Traditionally a “binary” problem:– Some problems are better solved with traditional “open surgery” – Some better solved with “catheter-based” procedures – So

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

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

– Aortic stenosis and CAD

– CAD and Carotid Stenosis

Risk vs Benefit

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

Catheter-• Bare Metal

• Drug Eluding

• absorbable

• 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 *

* Google Translate

Chăm sóc bệnh nhân tối ưu

Optimal Patient

Care

Not as easy as it

looks

STEMI – Acute MI Model:

Serial Therapy

1 Initial medical stabilization

2 Immediate catheter therapy

– Stenting

– Medical therapy (BB, Statin, ASA)

3 Recovery (Days? Weeks?)

“Hybrid Therapy”

Optimized teams and therapies for each problem

“Hybrid” Coronary Revascularization (HCR)

– Prolonged recovery

PCI

• PRO’s

– Less invasive – Shorter recovery – Less costs

• CON’s

– Stent thrombosis – Need for repeat revascularization – Suboptimal long-term results

+

“Hybrid” Coronary Revascularization (HCR)

• “Hybrid” operating room

• Performed the same time

• Lower costs

• Shorter hospitalization

HCR vs STEMI Model? All a difference in timing and strategy

•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)

• Patient selection (co-morbidities)

• Ideal coronary anatomy –

– SYNTAX Score

Unanswered Questions / Controversies

Most Importantly: Are the outcomes any

better?

Unclear???

Any better examples?

12

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

– $8 billion/year in stroke management

Cox-Maze III: Cut and Sew

Left Atrial Lesions

• Currently no ideal therapy

• Catheter based endocardial

• Surgical based epicardial

– Complexity (Cox-Maze)

• 80-90% ”cure”

– Limited (PVI)

• 40-60% “cure”

Five-Box Maze Lesion Set

• Technically very difficult with an

• 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)

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)

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

Keys to Success vs Barriers to Implementation?

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

•Close follow-up – Team Approach

•Aggressive management of arrhythmias

•Compliance with medications

Medical Off-Proto On-Proto

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

Hybrid Arch Outcomes

– Wearing out ICD batteries

• Failed medical therapies

• Failed multiple endocardial

ablations

• Not a transplant candidate

Conclusions: Traditional Cardiac Therapies

“Limited/Focal” Problem Solving

Short Hospitalization Shortened Recovery

“Hybrid” Cardiac Surgery: Option #1

Conventional Surgery

Conventional Catheter Interventions

“Hybrid” Cardiac Surgery: Option #2

Conventional Surgery

Conventional Catheter Interventions

Complex Problems in which options (currently) are

limited with only surgery or only a catheter based

procedure

“Best of both procedure”

But sometimes the risks are additive

+

Optimize a plan for each patient:

– 1 size does NOT fit all

– Consider long and short-term risks and

benefits

– Best techniques for the problem or problems

• Newer techniques and tools

• Older established therapies

– Best “people” for the problem or problems – Sometimes need to optimize timing