In individuals with coronary artery disease, blockages in the coronary arteries reduce or impede the flow of oxygen- and nutrient-rich blood to the heart, potentially causing symptoms such as chest pain, shortness of breath, or even a life-threatening heart attack. When these blockages develop, doctors can help restore blood flow to the heart by opening the affected artery with a stent or by performing bypass surgery using a vein or artery from another part of the body to circumvent the blockage.
The University of Toledo Medical Center Heart and Vascular Center is also now poised to provide an advanced treatment approach for certain patients with multi-vessel coronary artery disease that combines both minimally-invasive bypass surgery and stenting. This treatment modality, called Hybrid Coronary Revascularization (HCR), yields outcomes that are equal or superior to either approach performed in isolation as well as impressively long-lasting.
According to UTMC interventional cardiologist Dr. Ehab Eltahawy, the timing of the two procedures will vary depending on the patient’s needs and based on collaborative decision-making among the “heart team.” In most cases, the bypass is performed first, with the patient returning at a later date for stenting to open remaining blockages. However, in some instances, for example if the patient is experiencing an acute heart attack, stenting will be done first to restore blood flow to the heart immediately and bypass will be performed later.
The type of bypass performed during HCR involves rerouting the left internal mammary artery (LIMA), which normally runs from behind the collar bone down the chest wall, so that it connects to the left anterior descending (LAD) artery at a point beyond the blockage, thereby restoring adequate blood flow to the heart. Dr. Eltahawy explains, “The LIMA to LAD bypass is the most durable revascularization modality available, lasting 20-plus years.”
UTMC cardiothoracic surgeon Dr. Saqib Masroor, adds, “Because the procedure is minimally invasive, there is less trauma to the patient, there are fewer complications, and recovery time is significantly reduced. Patients usually go home in two to three days and return to work in about a week. With the standard open-heart procedure, downtime is around six to eight weeks and the older the patient, the longer the downtime.”
Today’s state-of-the-art stent technology is another reason HCR is so effective and durable. Dr. Eltahawy notes that with earlier stent technology, re-narrowing of the treated artery occurred in 18 to 25 percent of patients within a six- to twelve-month period, meaning it was necessary for them to keep coming back for repeat procedures. “But the re-narrowing rate with the newer technology is in the single digits—only six to nine percent. These stents are also better than using vein grafts, which re-narrow at an even higher rate,” he says.
Dr. Masroor notes that HCR is especially attractive to two groups of people: those in the 55- to 60-year-old age bracket who, for example, work at Jeep and want to get back to work as soon as possible; as well as individuals in their 80s who may be too frail to tolerate the trauma associated with standard bypass surgery.
The effectiveness and durability of the approach notwithstanding, it’s important to understand that not all patients with coronary artery disease are good candidates for HCR. “If patients have severe narrowing that can’t be fixed with stents, the only option is full open bypass. On the other hand, if they have relatively minor disease with discreet blockages, I can usually tackle it with stents alone. The ‘sweet spot’ in the middle of this spectrum is where HCR works best,” says Dr. Eltahawy.
Both Dr. Eltahawy and Dr. Masroor appreciate the collaborative nature of HCR. “Two sets of eyes are better than one,” Dr. Masroor states. This heart-team approach encourages us to sit down together, look at the case, discuss all the options, and decide what’s in the best interest of the patient.” Dr. Eltahawy adds, “The really nice thing about this approach is that it gets the whole team on the same page and thinking along the same lines.”
Patients and referring physicians who would like more information on Hybrid Coronary Revascularization are encouraged to call the University of Toledo Medical Center Heart and Vascular Center at 419-383-5150. ❦