1. Hybrid procedures – from boxing
ring to synchronized swimming
Dr. Arindam Pande, MD, DM
Associate Consultant, Cardiology
Apollo Gleneagles Hospital,
Kolkata

2. • Introduction
• Hybrid CABG/PCI
• Hybrid Valve/PCI
• Hybrid Arrhythmia/AF procedures
• Hybrid Approach for Complex Thoracic Aortic
Aneurysms/Dissections
• Hybrid Approach in Congenital Heart Disease
• Unresolved issues
• Hybrid cardiovascular procedures: our
experience
• Conclusion

3. Introduction
A hybrid strategy combines the treatments
traditionally available only in the
catheterization laboratory with those
traditionally available only in the operating
room to offer patients the best available
therapies for any given set of cardiovascular
lesions.
The concept is not new.

4. Introduction (Contd.)
• In the modern era, a hybrid procedure refers to the
combination of traditional surgery and percutaneous
intervention, staged by minutes, hours, or at most, days.
• This more compressed staging of hybrid procedures has
regained interest as cardiac surgeons have improved
techniques for minimally invasive surgical approaches, while
interventional cardiologists have at their disposal improved
devices and have developed skills that have enabled them to
become more aggressive in their percutaneous interventions.
• With the increased complexity of patients referred to the
catheterization laboratory and to surgery, a team approach
combining the best available tools of both specialties seems
appealing to minimize the procedural risk.

5. Hybrid CABG/PCI
• The LIMA–LAD graft has excellent patency rates, which
correlates with increased event-free survival. Reports suggest
a 5-year patency rate between 92% and 99% and at 10 years
between 95% and 98%.
• Location of the lesion in the proximal LAD has been identified
as an independent risk factor for in-stent restenosis with
rates between 19% and 44% .
• Failure rates for SVGs have been reported at 1 year between
1.6% and 30%, with an average of 20%. At 10 to 15 years of
follow-up, 40% to 50% of the SVGs will have failed.
• TLR for proximal right/circumflex coronary artery stents has
been reported to be 13.8% at 1 year for BMS
• TLR rate at 2 years follow-up is 5.8% with DES, compared with
21.3% in the BMS group (SIRIUS Study)

6. Minimally invasive CABG procedures
• MIDCAB (minimally invasive direct coronary artery bypass
grafting )- the LIMA is harvested through a small left anterior
thoracotomy incision or lower hemi-sternotomy. The LIMA–
LAD bypass is crafted through this limited incision on the
beating heart. (1996, Angelini et al.)
• TECAB (Totally endoscopic coronary artery bypass grafting)-
the LIMA–LAD graft created using peripheral access for
cardiopulmonary bypass in a ‘Closed-chest CABG surgery’
performed with robotic systems, which allows manipulation
of tissues within thoracic ports through the use of fine
instruments. At a separate operating console, the surgeon
controls the instruments, while the operation is viewed
stereoscopically (3-dimensional view). (1999, Loulmet et al.)

7. Copyright © The American College of Cardiology.
All rights reserved.
From: Hybrid Cardiovascular Procedures
J Am Coll Cardiol Intv. 2008;1(5):459-468. doi:10.1016/j.jcin.2008.07.002
Minimally Invasive Direct Coronary Artery Bypass Grafting
(A) Minimally invasive direct coronary artery bypass grafting (MIDCAB) of the
left internal mammary artery (LIMA) to left anterior descending coronary artery
(LAD) through an anterior-lateral left thoracotomy on the beating heart. (B)
Postoperative incision after MIDCAB.
Figure Legend:

8. Rationale of Hybrid CABG/PCI
• PCI with DES is a better treatment to the non-
LAD coronary artery disease than an SVG.
• The LIMA-LAD graft may be responsible for
the majority of the benefit of CABG surgery.
• Minimally invasive CABG surgeries reduce the
procedure related co-morbidities.

9. 2-Staged Hybrid Versus 1-Stop Hybrid
CABG/PCI
All hybrid procedures are staged, the only
distinction being the duration of the staging.
• 2-staged: PCI and CABG performed in 2
different operative suites, the 2 procedures
separated by hours, days, or weeks
• 1-stop: hybrid CABG/PCI performed in a
hybrid suite in 1 setting, staged by minutes

10. 2-Staged Hybrid CABG/PCI
PCI before CABG:
Advantages-
• allows aggressive multivessel stenting (because if a complication arises or PCI is not
successful, CABG can be performed later)
Disadvantages-
• performing PCI in an unprotected environment without the benefit of a LIMA–LAD graft
• performing CABG later under powerful antiplatelet agents
• no mid-term angiographic controls of the LIMA–LAD graft unless a third procedure is
done (the completion angiogram)
PCI after CABG:
Advantages-
• avoids antiplatelet-related bleeding complications during CABG
• protected environment with a LIMA–LAD graft
• LIMA graft patency can be verified at the time of PCI
Disadvantages-
• In the event of PCI complication/failure, a second, higher-risk operation needs to be
performed (however, emergent CABG after PCI has a low incidence of <1%)

11. 1-Stop Hybrid CABG/PCI
Advantages-
• excellent monitoring
• any complications can be resolved in 1 setting
• graft patency can be confirmed
• 1 team- 1 cost
• shorter hospital stay
• lack of logistical challenges
• no potential risks related to handoffs
• patients’ preference
Disadvantages-
• use of antiplatelet agents
• unknown response of DES to heparin reversal with protamine
• need to build an especially dedicated hybrid room with capabilities
of both a complete operating room and a procedural suite

12. Copyright © The American College of Cardiology.
All rights reserved.
From: Hybrid Cardiovascular Procedures
J Am Coll Cardiol Intv. 2008;1(5):459-468. doi:10.1016/j.jcin.2008.07.002
A hybrid operating room.
Figure Legend:

14. Indications of Hybrid CABG/PCI
• multivessel disease who have high-grade proximal disease of the
LAD (e.g. excessive vessel tortuosity or chronic total occlusion)
along with favorable lesions for PCI in the left circumflex and
right coronary artery territories
• lack or poor quality of the conduit
• nongraftable but stentable vessel (e.g., left circumflex lesions in
the atrioventricular groove with small diffuse obtuse marginal)
• repeat operations in which PCI is preferable to avoid full cardiac
dissection
• concomitant pre-existing organs dysfunction
• recent myocardial infarction
• severe atherosclerotic aortic disease (heavily calcified proximal
aorta)

15. Advantages of Hybrid CABG/PCI
• safe with low mortality rates (0% to 2%)
• low morbidity
• shorter intensive care unit and hospital stay
• superior cosmetic results
• faster recovery

16. Disadvantages of Hybrid
CABG/PCI
• longer operating time
• late wound complications
• more late pain because of rib retraction
• technical demands placed on the surgeon (because MIDCAB
and TECAB are technically demanding, anastomosis patency
in the learning curve may be lower than conventional
approaches)
• stent restenosis and the need for repeat revascularization
with BMS (In hybrid series, the stent restenosis at 6 months is
2.3% to 23% with an average across the literature of 11%)

17. ACC/AHA recommendation (2011) for Hybrid
Coronary Revascularization
Class IIa
1. Hybrid coronary revascularization (defined as the planned combination of
LIMA-to-LAD artery grafting and PCI of ≥1 non-LAD coronary arteries) is
reasonable in patients with 1 or more of the following (Level of Evidence: B):
a. Limitations to traditional CABG, such as heavily calcified proximal aorta or poor
target vessels for CABG (but amenable to PCI);
b. Lack of suitable graft conduits;
c. Unfavorable LAD artery for PCI (ie, excessive vessel tortuosity or chronic total
occlusion).
Class IIb
1. Hybrid coronary revascularization (defined as the planned combination of
LIMA-to-LAD artery grafting and PCI of ≥ 1 non-LAD coronary arteries) may be
reasonable as an alternative to multivessel PCI or CABG in an attempt to
improve the overall risk–benefit ratio of the procedures. (Level of Evidence: C)

18. Completion Angiogram
• For a patient who underwent coronary artery bypass grafting, coronary
imaging (completion angiography) for the routine evaluation of the bypass
grafts is reasonable, as the one-year re-occlusion rate is significant
• Thereby, defected implantations may be detected
• In a study designed and published by the Vanderbilt Heart and Vascular
Institute, routine intraoperative completion angiography performed in a fully
functional hybrid operating room detected important defects in 97 of 796
(12% of the grafts) venous coronary artery bypass grafts in 366 adult patients
(14% of the patients) with complex coronary artery disease.
• Their findings in completion angiography at the end of the operation
included suboptimal anatomies, poor positioning of the venous bypass graft,
and bypasses to not diseased vessels.
• Consequently, these defects, which usually would be detected at follow-up,
could be rectified immediately, through minor adjustment of the graft or
traditional surgical revision or with intraoperative open-chest PCI, resulting in
optimal bypass outcomes.
• Hybrid patients had clinical outcomes similar to standard CABG patients

20. Copyright © The American College of Cardiology.
All rights reserved.
From: Hybrid Cardiovascular Procedures
J Am Coll Cardiol Intv. 2008;1(5):459-468. doi:10.1016/j.jcin.2008.07.002
A completion angiogram of a LIMA graft to the LAD after MIDCAB procedure.
Figure Legend:

23. Hybrid Valve/PCI
• Alternative approaches to standard sternotomy for valve
surgery have been advocated to reduce operative mortality
and morbidity, speed recovery, and improve cosmetics
• These approaches include partial sternotomies and mini-
thoracotomies
• Concomitant coronary artery disease has been a
contraindication to such approaches because concomitant
CABG, and therefore sternotomy, would be mandatory
• Approaching coronary disease with PCI, which may actually
be superior to SVG, has given the opportunity to expand the
indications for minimally invasive valve surgery to patients
with concomitant coronary disease

24. Minimally Invasive Valve Surgery
Refers to a collection of techniques in which alternative incisions to
sternotomy is used
• aortic valve surgery - upper hemi-sternotomy
• mitral valve surgery - small right mini-thoracotomy (robotic and
video-assisted mitral valve procedure can be performed through
this approach) or lower hemisternotomy
Advantages-
• reduced postoperative pain,
• faster recovery - shorter hospital stay
• less utilization of autologous blood
• superior cosmetic results

25. Copyright © The American College of Cardiology.
All rights reserved.
From: Hybrid Cardiovascular Procedures
J Am Coll Cardiol Intv. 2008;1(5):459-468. doi:10.1016/j.jcin.2008.07.002
Incisions for Valve Surgery
(A) Median sternotomy (aortic, mitral, or tricuspid valve). (B) Right thoracotomy
(mitral or tricuspid valve). (C) Upper hemi-sternotomy (aortic valve). (D) Lower
hemi-sternotomy (mitral or tricuspid valve). Figure illustration by Rob Flewell.
Figure Legend:

26. Hybrid Valve/PCI: Rationale
• Traditional valve/CABG surgery has twice the mortality of isolated valve
surgery
• In high-risk patients with multiple comorbidities such as increased age,
low ejection fraction, morbid obesity, and pulmonary and renal
dysfunction, it may even be higher
• Strategy of PCI with DES followed within 24 h by minimally invasive aortic
valve replacement shown promising result
• Hybrid valve surgery is especially suitable for patients with acute coronary
syndrome and known valve disease. In this approach, usually PCI is
performed first to the culprit lesion, stabilizing the coronary lesion, and
then, during the same hospital stay, the valve lesion is addressed 5 to 7
days after the initial PCI
• Hybrid approach is also helpful for the ease of repeat valve procedure in
future

27. Hybrid Valve/PCI: Limitations
• antiplatelet related bleeding
• need for a learning curve for the surgeons
• operative times can be longer
• exposure of the valve can be difficult
• institution of cardiopulmonary bypass and myocardial
protection can be more time consuming and troublesome
• satisfactory de-airing may be difficult
• increased risk of neurological adverse events (in some series)
• inability to fully visualize the heart in case of heart distension,
thus relying almost completely on transesophageal
echocardiogram

28. Hybrid Arrhythmia/AF procedures
• Available interventional therapy (by creating lesion sets) for AF
-incisional atriotomies (the Maze procedure)
-epicardial ablation [e.g. thoracoscopic pulmonary vein isolation (PVI) and
ganglionated plexus (GP) ablation]
-endocardial ablation (cryoablation or radiofrequency)
• Surgical approaches have the advantages of being faster and more extensive
than percutaneous approaches
• However, some lesions may be more easily created by percutaneous
approach
• Further development of the closed-chest or minimally invasive technique by
surgeons (surgical access with subxiphoid window and limited anterior
thoracotomy in the electrophysiology lab is feasible and safe) has expanded
the horizon to lone epicardial atrial fibrillation surgery in conjunction with
percutaneous endocardial techniques with intraoperative electrophysiological
confirmation in order to decrease recurrences of AF during follow-up

29. • Ideally, this would be done in a specially designed hybrid
electrophysiologist operating room to further modify treatment or to
assess effects of lesions created
• Some groups have been using this strategy in a staged fashion
• There are not only first results available for atrial fibrillation, but also for
treating drug-refractory ventricular tachycardia (surgical ablation with an
epicardial approach with concomitant electrophysiological mapping)
• Pacemakers and implantable cardioverter defibrillators (ICD), particularly
bi-ventricular systems, may be optimally implanted in a hybrid OR
environment, because the hybrid operating theatre offers the required
superior angulation and imaging capabilities in comparison to mobile C-
Arms, and the higher hygienic standards compared to cath labs.
• Rotational angiography (3D imaging) may prove useful for imaging the
venous system of the heart. The coronary sinus can be depicted in 3D and
can be overlaid over the fluoroscopy image to better guide placement of
the left ventricular lead.
Hybrid Arrhythmia/AF procedures (contd.)

31. A large antral lesion (arrow) is created
using a bipolar radiofrequency clamp,
resulting in complete isolation of the
right pulmonary veins (PVs). The
antrum of the right PVs (*) is clearly
visible. RL right lung.
Placement of Ports on the
Left Side of the Patient

32. Linear Lesion at the Mitral Isthmus

33. Hybrid Approach for Complex Thoracic
Aortic Aneurysms/Dissections
• Currently, the treatment of complex thoracic aneurysms is mostly
endovascular
• Open repair is reserved for cases that are not suitable for endovascular
stenting because of anatomic characteristics of the aneurysm
• A combination of surgical and endovascular treatment is reserved for a
highly selected group of patients who are too high-risk for surgical open
repair and have inadequate length of the landing zone (distal or proximal)
for deployment of endovascular stenting
• In the treatment of aortic arch aneurysm, an aorto-innominate bypass is
typically constructed followed by bypass of the head vessels of this graft,
which allows proximal extension of stent grafts into the transverse aortic
arch.
• Such procedures has been reported with acceptable mortality and
morbidity, with a higher incidence of early endovascular leaks [natural
history of these leaks seems favorable, with high resolution at 6 months of
follow-up (90%)].

34. Hybrid Approach for Complex Thoracic
Aortic Aneurysms/Dissections (contd.)
• Debranching procedures for complex thoracoabdominal aneurysms-
bypasses and/or transposition of visceral vessels to enable distal
extension in the visceral portion of the aorta of the stent graft (there is
concern regarding the long-term patency of prosthetic grafts used for
visceral and renal revascularization)
• Rotational angiography, providing CT-like 3D imaging with the
angiographic C-arm enables the surgeon to diagnose this complication
intraoperatively and correct it right away
• The environment of the hybrid operating room allowed for immediate
treatment of the endoleaks
• In the near future, off the shelf fenestrated aortic stents will become
available for the treatment of extensive aortic disease. These fenestrated
stents have to be rotated in the aorta, such that the fenestrations cover
the branches of the aorta. For these highly complex procedures, 3D
imaging in a hybrid operating room may be extremely helpful for the
navigation of wires and devices.

36. Hybrid Approach in Congenital
Heart Disease
• For congenital cardiac malformations, even though surgery remains the
treatment of choice, interventional cardiology approaches are
increasingly being used
• However, such percutaneous approaches can be challenging or even
impossible because of difficult and complex anatomies (such as double-
outlet right ventricle, or transposition of the great arteries, acute turns or
kinks in the pulmonary arteries of tetralogy of Fallot patients) and patient
characteristics/ complications (low weight, poor vascular access, induced
rhythm disturbances, hemodynamic compromise)
• Nevertheless, surgery has its limitations, so that combining interventions
and surgery into a single therapeutic procedure potentially leads to
reduction of complexity, cardiopulmonary bypass time, risk, and to
improved outcomes

37. Hybrid Approach in Congenital
Heart Disease (contd.)
• Another important concept in hybrid procedures is completion
angiography, as described before, which in the case of congenital heart
disease surgery may detect residual structural lesions, thus reduce
postoperative complications
• 3D imaging using rotational angiography should be the concept of choice
• Completion angiography in a hybrid OR may even induce a reduction of
contrast media and ionizing radiation dose applied to the patient, as it
reduces the need for post-operative examination
• Further dose reduction can be achieved with a combination of
intraoperative rotational angiography and intraoperative MRI, when
both a fixed C-arm and a MRI system are available in the surgical theatre,
and MRI adds functional information

38. Hybrid for CHD at present
• Pre-operative hybrid operations
• Intra-operative hybrid operations
• Post-operative hybrid operations

39. Pre-operative hybrid operations
for CHD
• Balloon atrial septostomy (BAS)
• Occlusion of MAPCAs
• Occlusion of shunts before radical correction
• Laser or radiofrequency valvular perforation
and PBPV

40. BAS
• Indication:
TGA/IVS 、 HLHS 、 TA 、 HRHS 、 PA/IVS 、
TAPVC
• Usually used during the first 12 weeks of life,
X-ray or ultrasound guided
• After 1 month, balloon with blade on the top
is better
• Enlarges communication between two atria to
survive the severe patient until later surgery

44. Occlusion of MAPCAs
• Lead to intraoperative bleeding, increased pulmonary
blood flow and postoperative desaturation
• Preoperative occlusion simplifies surgery, increases
surgical success rate
• CT & angiography for the origin and distribution of
MAPCAs
• SaO2 quickly decreases after MAPCAs occlusion,
should come to surgery immediately afterward
• Materials: Coil, balloon, occluders, Plug etc.

45. Preoperative MAPCA closure in our institution in a patient of
TOF

49. Post-operative MAPCA closure in our institution in a patient of
adult TOF with difficulty in weaning from ventilator

54. Occlusion of shunts before radical correction
• A-P shunt is still most frequently used for
cyanotic CHD
• Before Fontan, shunts need to be closed
• Difficult for surgical closure because of scar
formation
• Transcatheter occlusion with good results and
less occlusion complications

55. Laser or radiofrequency valvular
perforation and PBPV
• PA/IVS: emergency in neonatal period, with
high mortality for surgery
• Multiple surgery needed for RV dysplasia
• Laser or radiofrequency valvular perforation
and PBPV for PA/IVS
• Reconstruction of RVOT-PA connection to
promote RV development

60. Intra-operative hybrid operations
for CHD
• Balloon angioplasty and stenting for peripheral
pulmonary arterial stenosis
• HLHS
• Perventricular occlusion of muscular VSD

61. Peripheral pulmonary arterial stenosis
• Patients have to undergo open-chest surgery
• Too large stent & sheath for infants and small children
to place percutaneously
• Stent shift after percutaneous transcatheter stenting
replace the stent in operation
• Straight balloon dilatation and stenting intra-
operatively
• Angiography to make sure the diagnosis before surgery
• Advantages: fast, good results, less complication, avoid
lesions of peripheral blood vessels

68. Perventricular occlusion of muscular VSD
• Direct puncture of right ventricle and VSD
occlusion after chest open
• No percutaneous route, no restriction of
blood vessel and body weight, especially
important for infants
• Perventricular occlusion of muscular VSD if
surgery is needed for concomitant anomaly
in complex CHD

71. Post-operative hybrid operations
for CHD
• Residual stenosis or obstruction
• Occlusion of fenestration after Fontan
• Occlusion of residual VSD
• Membrane coated valved stent implantation

72. Residual stenosis or obstruction
• Stenosisof of A-P shunt
• Stenosisof of anastomosis after cavo-
pulmonary connection
• Peripheral pulmonary arterial stenosis

74. Occlusion of fenestration after Fontan
• Fontan for functional single ventricle
• Fenestration in high risk patients to prevent
early systemic venous hypertension

75. Occlusion of residual VSD
• TGA+PH : residual VSD on the patch to
prevent postoperative pulmonary
hypertension crisis. After decrease of
pulmonary artery pressure, occluded by
catheter intervention
• TOF with hypoplastic pulmonary arteries:
RVOT patch pulmonary enlargement with
residual VSD, followed by transcatheter
occlusion

77. Transcatheter membrane coated valved
stent implantation
• Indications:
-Significant pulmonary regurgitation with
hemodynamic importance
-Stenosis or regurgitation of RVOT-PA valved conduit
• Complications:
-Stent dislocation
-Restenosis

80. Unresolved issues in Hybrid
Cardiovascular procedure
• Order in which surgery and percutaneous
intervention should be performed
• Duration of the staging of the 2 procedures
• Antiplatelet strategies
• Costs
• Logistics

81. Hybrid cardiovascular procedures:
our experience
• CABG followed by PCI: 3 cases have been referred so far
-1 patient with TVD opted for LAMA and got the whole procedure
completed by PCI in a separate institution
-Another patient got transferred to CTVS dept. and the whole procedure
completed by CABG only, due to cost constraint
-3rd
patient has been booked for MIDCAB with LIMA to LAD graft followed by
PCI to RCA
• PCI followed by CABG: 1 case
-PTCA & stenting to RCA followed by MIDCAB with LIMA to LAD graft for
osteoproximal LAD disease (but, patient don’t want to undergo any
further procedure, so kept in medical management)
• Preoperative MAPCA closure: 2 cases (good postoperative
outcome)
• Postoperative MAPCA closure: 1 case (patient subsequently
expired)

82. Conclusion
• Hybrid CABG/PCI is performed in only few centers, but may
experience renewed interest as technology makes DES better
than SVG. Hybrid CABG/PCI may be reserved for higher-risk
patients who are not candidates for conventional CABG.
• Hybrid valve/PCI represents an excellent alternative to
conventional valve/CABG in some high-risk patients,
particularly those who presents after acute coronary
syndromes, and in some patients who require reoperative
valve surgery.
• Hybrid atrial fibrillation treatments combine percutaneous
endomyocardial and surgical epicardial approaches. There
may be a role for a hybrid electrophysiologist laboratory for
these procedures to be performed in 1 setting with
intraoperative mapping.

83. • Pacemakers and implantable cardioverter defibrillators (ICD),
particularly bi-ventricular systems, may be optimally implanted in a
hybrid OR environment, because the hybrid operating theatre offers
the required superior angulation and imaging capabilities in
comparison to mobile C-Arms, and the higher hygienic standards
compared to cath labs.
• Aortic debranching procedures enable deployment of endovascular
stents with inadequate length of the landing zone. Frequently, these
patients are high-risk candidates for the performance of open surgical
intervention and because of aneurysm anatomy are not candidate for
endovascular repair. More commonly, these procedures are reserved
for the treatment of complex thoracoabdominal aneurysm.
• In CHD combining interventions and surgery into a single therapeutic
procedure potentially leads to reduction of complexity,
cardiopulmonary bypass time, risk, and improve outcomes. Better
result has been observed in pre-operative, intra-operative as well as
post-operative hybrid operations.
Conclusion (contd.)

84. The Future…
The future of cardiac surgery and interventional cardiology is
headed toward a merger of the fields for tailored approaches
to patients who present with complex heart disease. Although
the ability to offer hybrid approaches will depend on
technological advancements, improved percutaneous and
minimally invasive techniques, and the availability of a hybrid
suite, the true barrier to entry is the ability of
cardiologists and cardiac surgeons to work together,
to engage in “hybrid thinking” with close
collaboration between the 2 specialties. The willingness
and ability to create this collaborative culture is the largest
barrier to creating a successful hybrid program.

85. THANK
YOU