Hybrid Coronary Revascularization: An Overview of Options for Anticoagulation and Platelet Inhibition
Background: Hybrid coronary revascularization, in which coronary bypass grafting is combined with percutaneous coronary intervention, is a promising strategy for optimizing outcomes in the treatment of coronary artery disease. Balancing the risk of surgical bleeding with the risk of percutaneous coronary intervention-related thrombosis is a major challenge inherent in carrying out a successful procedure and requires careful selection of antiplatelet and anticoagulant agents.
Methods: Advantages and disadvantages of antiplatelet and anticoagulant agents in use today for hybrid coronary revascularization are reviewed.
Results: Currently available anticoagulants and platelet inhibitors have been used to provide safe and effective protection from thrombosis while limiting surgical bleeding in hybrid coronary revascularization, but there is no agreement on an optimal strategy, and each patient presents a unique pharmacologic and logistic puzzle.
Conclusion: Knowledge of the salient features of the available medications will allow the cardiologist and surgeon to design the optimal strategy for each patient.
Bonaros N, Schachner T, Wiedemann D, et al. 2009. Quality of life improvement after robotically assisted coronary artery bypass grafting. Cardiology 114:59-66.nBonatti J, Lehr E, Vesely MR, Friedrich G, Bonaros N, Zimrin D. 2010. Hybrid coronary revascularization: which patients? When? How? Curr Opin Cardiol 25:568-74.nByrne JG, Leacche M, Vaughan DE, Zhao DX. 2008. Hybrid cardiovascular procedures. JACC Cardiovasc Interv 1:459-68.nCohen MG, Purdy DA, Rossi JS, et al. 2010. First clinical application of an actively reversible direct factor IXa inhibitor as an anticoagulation strategy in patients undergoing percutaneous coronary intervention. Circulation 122:614-22.nDyke CM, Smedira NG, Koster A, et al. 2006. A comparison of bivalirudin to heparin with protamine reversal in patients undergoing cardiac surgery with cardiopulmonary bypass: the EVOLUTION-ON study. J Thorac Cardiovasc Surg 131:533-9.nFerraris VA, Ferraris SP, Moliterno DJ, et al. 2005. The Society of Thoracic Surgeons practice guideline series: aspirin and other antiplatelet agents during operative coronary revascularization (executive summary). Ann Thorac Surg 79:1454-61.nHarrington RA, Stone GW, McNulty S, et al. 2009. Platelet inhibition with cangrelor in patients undergoing PCI. N Eng J Med 361:2318-29.nHirsh J, Anand SS, Halperin JL, Fuster V. 2001. Mechanism of action and pharmacology of unfractionated heparin. Arterioscler Thromb Vasc Biol 21:1094-6.nKiaii B, McClure RS, Stewart P, et al. 2008. Simultaneous integrated coronary artery revascularization with long-term angiographic follow-up. J Thorac Cardiovasc Surg 136:702-8.nKon ZN, Brown EN, Tran R, et al. 2008. Simultaneous hybrid coronary revascularization reduces postoperative morbidity compared with results from conventional off-pump coronary artery bypass. J Thorac Cardiovasc Surg 135:367-75.nLeon MB, Baim DS, Popma JJ, et al. 1998. A clinical trial comparing three antithrombotic-drug regimens after coronary-artery stenting. Stent Anticoagulation Restenosis Study Investigators. N Engl J Med 339:1665-71.nLeonardi S, Rao SV, Harrington RA, et al. 2010. Rationale and design of the randomized, double-blind trial testing INtraveNous and Oral administration of elinogrel, a selective and reversible P2Y(12)-receptor inhibitor, versus clopidogrel to eVAluate Tolerability and Efficacy in nonurgent Percutaneous Coronary Interventions patients (INNOVATE-PCI). Am Heart J 160:65-72.nPoston R, Gu J, Manchio J, et al. 2005. Platelet function tests predict bleeding and thrombotic events after off-pump coronary bypass grafting. Eur J Cardiothorac Surg 27:584-91.nReicher B, Poston RS, Mehra MR, et al. 2008. Simultaneous "hybrid" percutaneous coronary intervention and minimally invasive surgical bypass grafting: feasibility, safety, and clinical outcomes. Am Heart J 155:661-7.nSmedira NG, Dyke CM, Koster A, et al. 2006. Anticoagulation with bivalirudin for off-pump coronary artery bypass grafting: the results of the EVOLUTION-OFF study. J Thorac Cardiovasc Surg 131:686-92.nVivas D, Angiolillo DJ. 2010. Platelet P2Y12 receptor inhibition: an update on clinical drug development. Am J Cardiovasc Drugs 10:217-26.nWiviott SD, Antman EM, Braunwald E. 2010. Prasugrel. Circulation 122:394-403.nZhao DX, Leacche M, Balaguer JM, et al. 2009. Routine intraoperative completion angiography after coronary artery bypass grafting and 1-stop hybrid revascularization results from a fully integrated hybrid catheterization laboratory/operating room. J Am Coll Cardiol 53:232-41.n