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CLINICAL RESEARCH: INTERVENTIONAL CARDIOLOGY

Staged initial percutaneous coronary intervention followed by valve surgery ("hybrid approach") for patients with complex coronary and valve disease

John G. Byrne, MD, FACC^*,*, Marzia Leacche, MD^*, Daniel Unic, MD^*, James D. Rawn, MD^*, Daniel I. Simon, MD, FACC, Campbell D. Rogers, MD, FACC and Lawrence H. Cohn, MD, FACC^*

^* Cardiac Surgery
Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts

Manuscript received July 22, 2004; revised manuscript received September 18, 2004, accepted September 21, 2004.

^* Reprint requests and correspondence: Dr. John G. Byrne, Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee 37232-8815 (Email: john.byrne{at}vanderbilt.edu).

Presented at the Annual Scientific Session of the American College of Cardiology, March 7 to 10, 2004, New Orleans, Louisiana.

OBJECTIVES: The goal of this study was to determine if a "hybrid" approach to the treatment of complex combined coronary and valve disease is superior to the results predicted by a Society of Thoracic Surgeons' (STS) algorithm with conventional coronary artery bypass graft (CABG)/valve surgery in high-risk patients.

BACKGROUND: With advancements in percutaneous coronary interventions (PCIs), some patients requiring coronary revascularization and valve surgery may benefit from a hybrid approach involving initial planned PCI followed by valve surgery, rather than conventional CABG/valve surgery.

METHODS: We retrospectively analyzed 26 consecutive patients with coronary artery and valve disease who underwent planned initial PCI followed by valve surgery during the same hospital stay between September 1997 and August 2003. We calculated the predicted mortality at the time of PCI and compared it with the observed mortality.

RESULTS: There were 12 male and 14 female patients with a median age of 72 years (range 53 to 91 years). Balloon angioplasty was performed in all patients, followed by stenting in 22 (85%) patients. Within a median of 5 days (range 0 to 14 days), 15 patients (58%) underwent primary and 11 patients (42%) underwent re-operative valve surgery. Operative mortality was 1 of 26 patients (3.8%), dramatically lower than the STS-predicted mortality of 22%. Median blood loss was 900 ml, and 22 patients (85%) required blood transfusions. Survival at 1, 3, and 5 years was 78%, 56%, and 44%, respectively.

CONCLUSIONS: Hybrid initial PCI followed by staged valve surgery represents an excellent alternative to conventional CABG/valve surgery in some high-risk patients, particularly those who present in shock after myocardial infarction. Lower mortality rates come at the cost of more bleeding and transfusion requirements.

Abbreviations and Acronyms   ACS = acute coronary syndrome   AMI = acute myocardial infarction   CABG = coronary artery bypass graft/grafting   PCI = percutaneous coronary intervention   STS = Society of Thoracic Surgeons

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