Читать книгу Practical Cardiovascular Medicine - Elias B. Hanna - Страница 211

The superiority of CABG mainly results from the longevity of the LIMA-to-LAD graft. DES stenting of non-LAD vessels, when feasible (e.g., no CTO, no heavily calcified disease), is likely associated with equal or superior results to placement of venous grafts, ~20% of which occlude by the first year. The so-called hybrid strategy consists of performing LIMA–LAD using off-pump CABG (beating heart), followed by DES PCI of the remaining stenoses during the same hospitalization (hours or days later, with clopidogrel loading after CABG). Occasionally, in patients with critical non-LAD disease, non-LAD disease is stented first, followed by performance of off-pump CABG under clopidogrel therapy.

Table 3.4 Variables analyzed in surgical risk scores (STS and EuroSCORE).

Underlying patient-related factors and comorbidities (i) age (the risk doubles with every 10 yrs >60); (ii) women (~50% higher risk than men); (iii) moderate or severe COPD; (iv) severe CKD; (v) prior disabling stroke or neurological illness; (vi) carotid disease, PAD Underlying EF–HF (i) EF (<50%: mild score; < 30%: severe score); (ii) HF functional class IVPrior cardiac surgery, especially redo CABGIsolated CABG <isolated valve surgery <CABG + valve surgeryCurrent cardiac status(i) recent MI; (ii) unstable vs. stable angina; (iii) hemodynamic or electrical instability and requirements for IABP and/or inotropes

The off-pump LIMA-to-LAD surgery offers the advantage of avoiding aortic manipulation, which is necessary during on-pump CABG or during SVG grafting (whether off- or on-pump). Also, the shorter surgical time, the lower blood loss, and the avoidance of cardioplegia and cardiopulmonary bypass are advantages.

Currently, the hybrid approach is particularly applicable to: (i) patients with heavily calcified, porcelain aorta in whom aortic manipula- tion needs to be avoided; and (ii) patients with good LAD target but poor LCx and RCA targets that, nonetheless, have severe proximal disease amenable to PCI.