Ứng dụng của kỹ thuật hybrid trong tim mạch

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 • Introduction / Definition • Coronary Artery Disease • Atrial Fibrillation • Complex Aortic Surgery • Valvular Disease (That is a different story) 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 – – Risk vs Benefit Aortic stenosis and CAD CAD and Carotid Stenosis 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 Medication • • • • • Beta-blockers Statins ACE inhibitors Aspirin Anti-platelet Agents CatheterBased • Bare Metal • Drug Eluding • Bioabsorbable • PTCA Surgery • CABG • On vs Off • Arterial Conduits • 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 phi tuyến Phương trình Schrödinger thay đổi với hệ số biến sợi không đồng * Optimal Patient Care Chăm sóc bệnh nhân tối ưu Not as easy as it looks * Google Translate STEMI – Acute MI Model: Serial Therapy Initial medical stabilization Immediate catheter therapy – – Medical Therapy Surgery Catheter Stenting Medical therapy (BB, Statin, ASA) Recovery (Days? Weeks?) CABG – – – – Complete revascularization Arterial vs Venous Conduits On / Off pump Medical therapy “Hybrid Therapy” Optimized teams and therapies for each problem “Hybrid” Coronary Revascularization (HCR) CABG PCI • PRO’s – LIMA-LAD durability – 95-98% at 10 years – Anterior wall protection • PRO’s – Less invasive – Shorter recovery – Less costs • CON’s – SVG patency • 6-20% failure at year • 50% failure at 15 years – Surgical complications – Prolonged recovery + • CON’s – Stent thrombosis – Need for repeat revascularization – Suboptimal long-term results “Hybrid” Coronary Revascularization (HCR) HCR vs STEMI Model? All a difference in timing and strategy 2-stage approach • Different locations – Cath lab – OR • Separated by hrswks 1-stop shopping • • • • “Hybrid” operating room Performed the same time Lower costs Shorter hospitalization •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? 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 Percutaneous Access The Numeris® & EPiSense ® Guided marketed systems are indicated for endoscopic coagulation of cardiac tissue Breakthrough Locations @ Pericardial Reflections • 67 patients • 20 patients with 24hr Holter – 90% (16) in sinus at year • 42 patients – – – – – – 57% persistent 43% long-standing Failed endocardial ablation obese 89% in sinus rhythm 69% in sinus, off medications Keys to Success vs Barriers to Implementation? Sinus Rhythm: On or Off Protocol On-Proto Percent Off-Proto Medical •Close follow-up – Team Approach •Aggressive management of arrhythmias •Compliance with medications •Patience! Months Post-OP Ad, Henry, Hunt: The implementation of a comprehensive clinical protocol improves long-term success after surgical treatment of atrial fibrillation JTCVS 2010 >90% Success 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 Hybrid (n=27) Open (n=45) p Death (11%) (1%) 0.74 Stroke (4%) (9%) 0.64 (11%) 0.15 Paraplegia (7%) 0.14 Renal Failure (19%) (11%) 0.49 (2%) 1.00 (33%) 13 (29%) 0.79 20.1 17.5 TIA Bleeding Afib Length of Stay (d) Impact of Age on In-hospital Mortality: Hybrid Open < 75 years (14%) (9%) > 75 years (8%) (36%) Case Presentation: • 67 year/old • Severe CHF symptoms • Complex polymorphic refractory ventricular tachycardia/fibrillation – 30-40 shocks day! – Wearing out ICD batteries • Failed medical therapies • Failed multiple endocardial ablations • Not a transplant candidate • Full sternotomy • Epicardial mapping and extensive ablation • years post-op – Minimal VT/VF – Improved symptoms – Improved EF Conclusions: Traditional Cardiac Therapies Conventional Surgery Conventional Catheter Interventions General Anesthesia Full Sternotomy Cardiopulmonary Bypass “Complete” Problem Solving Prolonged Hospitalization Prolonged Recovery Limited Anesthesia Percutaneous Based Normal Physiology “Limited/Focal” Problem Solving Short Hospitalization Shortened Recovery “Hybrid” Cardiac Surgery: Option #1 Conventional Surgery Conventional Catheter Interventions “Less” Surgery “More” Catheter Techniques Balance the risks of each procedure With the benefits of both “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: – 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 • 1- stage • 2- stage – Not all pathologies need immediate management Team Collaboration with shared goals (and incentives) [...]... 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 • 1- stage • 2- stage – Not all pathologies... complex stenting Many case reports and limited series Hybrid Arch Outcomes Hybrid (n=27) Open (n=45) p Death 3 (11%) 7 (1%) 0.74 Stroke 1 (4%) 4 (9%) 0.64 0 5 (11%) 0.15 Paraplegia 2 (7%) 0 0.14 Renal Failure 5 (19%) 5 (11%) 0.49 0 1 (2%) 1.00 9 (33%) 13 (29%) 0.79 20.1 17.5 TIA Bleeding Afib Length of Stay (d) Impact of Age on In-hospital Mortality: Hybrid Open < 75 years 2 (14%) 3 (9%) > 75 years 1... Percutaneous Based Normal Physiology “Limited/Focal” Problem Solving Short Hospitalization Shortened Recovery Hybrid Cardiac Surgery: Option #1 Conventional Surgery Conventional Catheter Interventions “Less” Surgery “More” Catheter Techniques Balance the risks of each procedure With the benefits of both Hybrid Cardiac Surgery: Option #2 Conventional Surgery + Conventional Catheter Interventions Complex... Hybrid Coronary Revascularization (HCR) Unanswered Questions / Controversies • Surgical Techniques – – – – MIDCAB TECAB Robotic Assisted Limited sternotomy Most Importantly: Are the outcomes any better?... NSR) 3x more likely to have CHF Prevalence • 0.1% for 80 • Medicare Costs: – $15.7 billion/year in new diagnosis/treatment – $8 billion/year in stroke management 12 Ideal application for hybrid techniques • Currently no ideal therapy Left Pulm Cox-Maze III: Cut and Sew Veins Left Atrial Lesions MV LAA • Catheter based endocardial • Surgical based epicardial – Complexity (Cox-Maze) • 80-90%... 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) Endocardial Epicardial Posterior Left Atrium The Numeris® & EPiSense ® Guided marketed systems are indicated for endoscopic coagulation of cardiac tissue Anterior