Treatment Of Coronary Artery Multi-vessel Disease, One-stop Composite Safety And Efficacy

ABSTRACT (PART ONE): "One-Stop" Hybrid Coronary Revascularization for Multivessel Coronary Artery Disease with a Modified Antiplatelet Protocol:early and mid-term clinical outcomesObjective:"One-stop" hybrid coronary artery revascularization combines minimally invasive direct coronary artery bypass grafting (MIDCAB) and percutaneous coronary intervention (PCI) simultaneously in a single, enhanced operating suite. This study sought to investigate the early and mid-term clinical outcomes of this one-stop hybrid approach with a modified antiplatelet protocol.Materials and Methods:From June 2007 to December 2009,104 consecutive patients were planned to undergo one-stop hybrid coronary revascularization. MIDCAB was first performed to anastomosis the left internal mammary artery (LIMA) to the left anterior descending coronary artery (LAD) through lower partial ministernotomy. LIMA-LAD graft patency was then confirmed by coronary angiography. Catheter-based interventions on non-LAD lesions were then completed in the same setting. The modified antiplatelet regimen included perioperative aspirin; clopidogrel was routinely discontinued 7 days or more before operation, and then administered intraoperatively with a 300-mg loading dose, followed by a maintenance dose of 75 mg/day for 12 months.Results:One-stop hybrid procedure was successfully carried out in 103 (99.0%) patients. Conversion to conventional on-pump coronary artery bypass grafting (CABG) was required in 1 (1.0%) patient. Four major defects (3.8%) were found in the LIMA grafts and were immediately repaired. A total of 188 lesions were treated by PCI, mean number of lesions treated was 1.8±0.9 per patient. Angiographic success of PCI, based on visual analysis, was obtained in 185 of 188 lesions (98.4%). Balloon angiography alone was used in 12 lesions.191 drug-eluting stents (DES) and 3 bare-mental stents (BMS) were implanted. Angiographic success of stents was 100%. There was 1 (1.0%) deaths within 30 days after operation. One patient (1.0%) developed pulmonary thromboembolism, pleural effusion in 5 (4.9%) patients, and transient atrial fibrillation in 12 (11.5%) patients. All the 102 patients survived the follow-up period of 15.0±8.5 months. No deaths, myocardial infarctions, strokes, recurrent angina, severe bleeding, or stent thrombosis occurred. Thirty patients (29.4%) underwent follow-up coronary angiography and 3 patients (2.9%) underwent 64-slice computed tomography. All LITA grafts were confirmed patent. Only one patient (1.0%) underwent repeat revascularization at the 1-year follow-up angiogram.Conclusions:One-stop hybrid coronary revascularization provides a feasible and safe alternative for selected patients with multivessel disease, especially for those at high risk for conventional strategies. ABSTRACT (PART TWO): Comparison of one-stop hybrid coronary revascularization and off-pump coronary artery bypass in the treatment of multivessel coronary artery disease: a propensity score matching analysisObjectives:OPCAB has been widely used as an alternative for the conventional on-pump coronary artery bypass. This study sought to compare the early and short-term clinical outcomes of one-stop hybrid coronary revascularization with those in a matched subset of patients undergoing OPCAB.Materials and Methods:From June 2007 to December 2008,52 consecutive patients underwent planned one-stop hybrid revascularization in our institution. By using propensity score matching method, a matched group of 52 patients were selected from a cohort of 360 patients who underwent conventional OPCAB via median sternotomy in our institution during the same period. We compared the in-hospital clinical outcomes and freedom from major adverse cardiac or cerebrovascular events (MACCEs) at follow-up period.Results:The baseline characteristics were similar between the two groups. Patients in the hybrid group required shorter intubation times ((11.5±6.9) hours versus 18.2±18.2, P=0.03), shorter lengths of stay in ICU ((33.3±28.4) hours versus (49.3±39.0) hours, P=0.003), less stay in hospital after operation ((8.1±1.7) days versus (9.1±3.1) days, P=0.047). Moreover, the one-stop hybrid group also showed significant reduction in total blood loss ((860±460) mL versus (1108±596) mL, P=0.02) and need of blood transfusion (34.6%versus 55.8%, P=0.03) than the OPCAB group. The in-hospital postoperative major complications were of no significant difference between the two groups. During a mean follow-up of 15.4±5.2 months, the hybrid group showed comparable with the OPCAB group in actual survival (100%versus 94.2%, Log-rank P=0.11) and MACCE-freesurvival (96.2%versus 90.4%, Log-rank P=0.84).Conclusions:The one-stop hybrid coronary revascularization shortens patient postoperative recovery, and shows superior in-hospital outcomes and noninferior short-term outcomes compared with OPCAB. ABSTRACT (PART THREE): Comparison of one-stop hybrid coronary revascularization and percutaneous coronary intervention for the treatment of multivessel coronary artery disease: a propensity score matching analysisObjectives:PCI is the most commonly used intervention for coronary artery disease. This study compared one-stop hybrid approach and PCI for treating patients with multivessel or left main coronary artery disease (or both).Materials and Methods:From June 2007 to December 2008,52 consecutive patients underwent planned one-stop hybrid revascularization in our institution. By using propensity score matching method, a matched group of 52 patients were selected from a cohort of 399 patients who underwent conventional PCI in our institution during the same period. We compared the in-hospital clinical outcomes and freedom from MACCE at follow-up period.Results:Most baseline characteristics were similar between the two groups. No MACCE occurred during the in-hospital period. There were 6 patients (11.5%) with both multivessel and left main coronary artery disease in the one-stop hybrid group. Patients in the hybrid group required less stents implantation in left anterior descending (LAD) artery (0.1±0.3 versus 1.1±0.4, P<0.01) and less stents used per patient (1.7±0.9 versus 2.6±0.7, P<0.001), but achieved more complete revascularization (defined as residual restenosis less than 70%in vessels diameter more than 2.25mm) (96.2%versus 67.3%, P=0.0001). Average total stent length was 34.0±20.1 mm in the one-stop hybrid group versus 42.2±19.9 mm in PCI group (P =0.04). There were no significant differences in success rate of stent implantation and total in-hospital costs between this two groups. During a mean follow-up of (11.2±4.0) months, the hybrid group showed higher MACCE-free survival (96.2%versus 88.0%, Log-rank P=0.001) than the PCI group.Conclusions:One-stop hybrid revascularization is a safe and effective alternative for patients with multivessel and/or left main coronary artery disease. Compared with PCI, one-stop hybrid strategy could reduce the number of stent implantation, achieve more complete revascularization and result in greater clinical benefits at short-term follow-up. ABSTRACT (PART FOUR): Evaluation of antiplatelet effects of a modified protocol by platelet aggregation in patients undergoing "one-stop" hybrid coronary revascularizationObjectives:"One-stop" hybrid coronary revascularization has emerged to be a reliable and attractive alternative for selected patients with multivessel coronary artery disease. However, the optimal antiplatelet regimen of the one-stop hybrid procedure still remains controversial. We modified the antiplatelet protocol in order to reduce the risk of perioperative bleeding and maximally inhibit platelet activity. This study sought to investigate whether the inhibition of platelet activity by this modified antiplatelet protocol is comparable with the conventional protocol widely used and recommended in percutaneous coronary interventions (PCI).Materials and Methods:From September 2008 to February 2009,23 patients undergoing one-stop hybrid procedure and 20 patients undergoing conventional PCI with stenting were enrolled in this prospective study. The modified antiplatelet protocol included perioperative use of aspirin; clopidogrel was administered immediately before PCI with a 300-mg loading dose, followed by a maintenance dose of 75 mg/day for 12 months. Blood samples were obtained before the operation and 2 hours, day 1 and day 3 after operation. Platelet aggregation was induced with:1) arachidonic acid (AA) (final concentration 0.5 mmol/L) to assess the efficacy of aspirin; 2) adenosine diphosphate (ADP) (final concentration 10μmol/L) to assess the specific efficacy of clopidogrel.Results:Platelet counts were statistically lower in the hybrid group than in the PCI control group (160×103/μL versus 207×103/μL, P=0.0018) on day 1 after operation. AA-induced platelet aggregation increased significantly in the one-stop hybrid group in comparison with the preoperative baseline values (5.4%versus 4.4%, P=0.0079) and the PCI control group (5.4%versus 3.5%, P=0.0023) on day 1 after operation. ADP-induced platelet aggregation gradually decreased in the hybrid group, and achieved similar platelet inhibition with the PCI group on 2 hours and day 1 after operation. No major adverse clinical events such as death, perioperative myocardial infarction, stent thrombosis, or reoperation for bleeding occurred in both groups within 30 days after procedure.Conclusions:This study demonstrates that our modified antiplatelet therapy can sufficiently inhibit platelet activity similarly as the conventional protocol for PCI early after operation. Thus, this modified protocol, with continuous use of aspirin and intraoperative administration of loading dose clopidogrel, might be a safe and effective antiplatelet strategy for the one-stop hybrid coronary revascularization.