University Hospitals Harrington Heart & Vascular Institute Expands MIDCAB Program, Launches Hybrid Revascularization Program

New offerings expand options for coronary artery disease patients

UH Clinical Update | December 2021

Cardiac surgeons and interventional cardiologists at University Hospitals Harrington Heart & Vascular Institute are providing new options for patients with coronary artery disease, expanding the existing program in minimally invasive direct coronary artery bypass (MIDCAB) to the UH system’s community hospitals and adding a new hybrid revascularization program that combines the advantages of MIDCAB with percutaneous coronary intervention (PCI) for select patients.

“Traditionally, MIDCABs are only offered at anchor hospitals where patients receive tertiary and quaternary care,” said Mehdi Shishehbor, DO, MPH, PhD, President, UH Harrington Heart & Vascular Institute; Angela and James Hambrick Master Clinician in Innovation; and Professor at the Case Western Reserve University School of Medicine. “We want patients to walk into any University Hospitals facility and receive the same level of care in Elyria, in Parma, on the eastside, that they would at UH Cleveland Medical Center downtown. It’s our mission to bring the highest quality care and procedures closer to where our patients live.”

The new community MIDCAB program is meeting patient demand, says Pablo Ruda Vega, MD, Medical Director of Cardiac Surgery at UH Lake West Medical Center.

“Before we started this program, we did maybe two or three in a year,” he says. “But now in three months, we have done 10. We are trying to develop the program to do more cases. It’s not a new procedure by any means, it has been around for many, many years. But we are becoming more aggressive with indications, so we can reach more patients.”

The hybrid revascularization program at UH is another example of designing services to better meet patients’ needs. For some patients, their specific coronary artery disease and comorbidities don’t place them squarely in the bypass surgery or PCI camp in terms of what would be the best treatment approach, Dr. Ruda Vega says.

“On the spectrum of treatment for coronary disease, you have medical treatment, PCI and surgery,” he says. “But there are some cases in the middle that may require a complex PCI – the cardiologist can do it, but it’s more risky. So we can perform a MIDCAB, which is a low-risk bypass, and facilitate safer PCI with these patients. There are also patients that we as surgeons don’t usually see, because they always receive PCI,  we can also offer them a hybrid approach.”

“Hybrid revascularization combines the best advances of cardiac surgery and interventional cardiology,” Dr. Ruda Vega adds. “The rationale for this approach is based on the known survival advantage of the left internal mammary artery (LIMA) to left anterior descending (LAD) coronary artery graft, and the marked improvement in patency, using state-of-the-art skills and modern drug- eluting stents in non-LAD territories.”

The best candidates for the new hybrid revascularization program at University Hospitals, Dr. Ruda Vega says, are those with ostial or complex or occluded LAD lesión -- with associated simple lesions of other coronary arteries, elderly patients, those with left main (LM) disease with low SYNTAX score and those with co-morbidities making sternotomy high-risk. The preferred procedure sequence is to perform the minimally invasive cardiac surgery LIMA to LAD first, followed by the PCI as a separate procedure.

“This allows for optimal antiplatelet therapy and imaging of the LIMA-LAD graft,” Dr. Ruda Vega says. “PCI of high-risk targets is possible if a patent LITA-LAD bypass is demonstrated.”

Because hybrid revascularization programs require special equipment, clinicians trained and capable of off-pump CABG and significant institutional commitment, they are not offered at all medical centers. But Dr. Ruda Vega says he and his colleagues are pleased to be able to provide this option to patients at UH.

“The reason to offer the hybrid approach is that it provides the patient the most durable treatment, which is LIMA to LAD, with a small incision, and we complement that if needed with PCI,” he says. We know that nowadays these interventions are very good and last for many, many years. We can really do a very complete revascularization with only a small incision in the chest – just about 2.5 inches. These patients are complex and we can perform long-lasting treatment, LIMA to LAD, the best treatment we know, and then we can complement it with PCI. I think we should offer these options to our patients.”