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Beyond Traditional CABG: Multidisciplinary Approach Addresses Complex Coronary Cases​

When it comes to complex coronary cases, the multidisciplinary team at Baylor Scott & White The Heart Hospital – Plano has created a collaborative, coordinated approach to determining the right option for those needing coronary revascularization.

Traditional coronary artery bypass grafting (CABG) procedures remain an integral part of the hospital’s surgical program, but through collaboration between a diverse group of cardiothoracic surgeons and cardiologists, the hospital is providing options for those who may not be a good candidate for traditional bypass surgery. Through its commitment to advancing complex coronary care, the hospital reached record volumes for cardiac revascularization through CABG in 2016.

“We freely share information back and forth about cases, which is the first step toward a good outcome especially for coronary revascularization,” said Kelley Hutcheson, MD, a cardiothoracic surgeon on the medical staff at Baylor Scott & White Heart – Plano. “This allows us to offer the full gamut of what’s available in bypass surgery.”

Surgeons and cardiologists on the multidisciplinary team meet monthly during a Cardiology Cath Conference and weekly for a High-Risk Surgical Case Conference where every coronary case is discussed. This allows for broad input into the relevant factors of each case ahead of time. It also allows for concomitant procedures to be discussed if the patient may benefit from more than one intervention.

Complex Coronary CasesThrough this team, patients have surgical options based on their individual needs, including traditional bypass surgery, total arterial revascularization, off-pump CABG surgery and hybrid/robotic procedures.

During hybrid procedures, physicians use a robotic surgical approach to perform bypass surgery with the left internal mammary artery to the left anterior descending artery (LIMA to LAD), as well as a percutaneous approach with stenting to other arteries. Typically, hybrid procedures result in a shorter hospital stay and recovery time.

“Sometimes there are patient factors that necessitate a minimally invasive approach, such as someone who is much older, very frail, has had a previous surgery to the chest or has factors that would limit the ability to recover from a traditional operation,” Dr. Hutcheson said. “The patient may still benefit from a LIMA graft, and we’re able to do a LIMA graft as long as the patient’s other coronary lesions are amenable to PCI.”

Currently, Baylor Scott & White Heart – Plano is one of the leaders in the area doing these types of procedures. To further evaluate their effectiveness, the hospital is involved in a Hybrid Coronary Revascularization Trial to compare hybrid procedures with PCI alone.

Starting in 2018, the hospital also will be a location for another research study called the VEST trial. The trial will evaluate a support system for vein grafts to try to arterialize them, which would have major implications for bypass surgery conduit and outcomes.

“A lot of people who have coronary artery disease have disease in their arteries everywhere or they are diabetic, which can limit our options for conduit – meaning what we have to sew with,” Dr. Hutcheson said. “If we could get people’s veins to act like arteries, it would provide more options for these patients.”

Through continued research and its multidisciplinary approach, Baylor Scott & White Heart – Plano emphasizes the importance of considering all patient factors and offers a robust program with multiple options, even when surgery may not be appropriate. The team also is available to provide second opinions when patients want further input or reassurance, or when they have been told they have limited choices.

“It is critically important, especially in high-risk cases, that patients are sent to a center with a multidisciplinary approach,” Dr. Hutcheson said. “You want to send people to a place that has options past CABG. Often times we can help when others can’t.”

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​PHYSICIAN CONTRIBUTOR​​

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