CONGRESS ABSTRACT

Introduction: Hybrid coronary artery revascularization(HCR)brings advantages of both percutaneous(PCI)and surgical revascularization techniques while minimizing risk of complications. In particular, minimally invasive surgical strategy(MICS)for LAD revascularization with the use of the internal thoracic artery harvested either robot-assisted or via left-sided minithoracotomy, provides excellent the long-term benefits that have been extensively demonstrated. In some circumstances, unprotected PCI may represent a clinical challenge for interventional cardiologists, thus, high-risk patients might be considered not suitable for interventions and left untreated. In these cases, MICS revascularization allows for subsequent protected PCI in a very poor candidate otherwise considered at high-risk.      Clinical case: We report a case of an 81yo male with previous left axillo-bifemoral bypass,severe peripheral vasculopathy and multiple risk factors,with persistent angina,poor general conditions and severely sarcopenic (BMI 15 kg/m2). Coronary angiography revealed diffused triple-vessel disease with left main coronary artery(LMCA)critical stenosis. Echocardiography showed severe mitral regurgitation and moderate LVEF impairment.Unprotected PCI to the LMCA was considered at high risk because of the severe peripheral disease hampered bail-out strategies in case of intraprocedural hemodynamic instability. Thus,the patient was centralized for further evaluation. Despite the prohibitive surgical risk(euroSCOREII 8.4%),symptoms recurrences led to the Heart Team decision towards a LIMA to LAD off-pump surgical revascularization through a 5cm left minithoracotomy. Later,staged protected PCI was performed by means of DES to OM. No surgical complications occurred,patient recovery was uneventful and it was then completed with TEEER over the mitral valve. Discussion: A relatively low-risk procedure such as PCI can be a technically unfeasible due to patient-related factors,as per the inability to adequately protect the circulation during high-risk PCI.MICS strategies can provide an excellent adjunct option with the help for complete revascularization. In particular these techniques allow for low risk and low trauma solutions,minimizing risk of complications in high-risk patients while providing the best treatment option for long-term survival. Thus,implementation of MICS for LAD revascularization should be encouraged and be available in the heart team decision making process