Hybrid Surgery for Severe Mitral Valve Calcification: Limitations and Caveats for an Open Transcatheter Approach

Background and Objectives: Mitral stenosis with extensive mitral annular calcification (MAC) remains surgically challenging in respect to clinical outcome. Prolonged surgery time with imminent ventricular rupture and systolic anterior motion can be considered as a complex of causal factors. The aim of our alternative hybrid approach was to reduce the risk of annual rupture and paravalvular leaks and to avoid obstruction of the outflow tract. A review of the current literature was also carried out. Materials and Methods: Six female patients (mean age 76 ± 9 years) with severe mitral valve stenosis and severely calcified annulus underwent an open implantation of an Edwards Sapien 3 prosthesis on cardiopulmonary bypass. Our hybrid approach involved resection of the anterior mitral leaflet, placement of anchor sutures and the deployment of a balloon expanded prosthesis under visual control. Concomitant procedures were carried out in three patients. Results: The mean duration of cross-clamping was 95 ± 31 min and cardiopulmonary bypass was 137 ± 60 min. The perioperative TEE showed in three patients an inconspicuous, heart valve-typical gradient on all implanted prostheses and a clinically irrelevant paravalvular leakage occurred in the anterior annulus. In the left ventricular outflow tract, mild to moderately elevated gradients were recorded. No adverse cerebrovascular events and pacemaker implantations were observed. All but one patient survived to discharge. Survival at one year was 83.3%. Conclusions: This “off label” implantation of the Edwards Sapien 3 prosthesis may be considered as a suitable bail-out approach for patients at high-risk for mitral valve surgery or deemed inoperable due to extensive MAC.

Investigation into Cervical Spine Biomechanics Following Single, Multilevel and Hybrid Disc Replacement Surgery with Dynamic Cervical Implant and Fusion: A Finite Element Study

Cervical fusion has been a standard procedure for treating abnormalities associated with the cervical spine. However, the reliability of anterior cervical discectomy and fusion (ACDF) has become arguable due to its adverse effects on the biomechanics of adjacent segments. One of the drawbacks associated with ACDF is adjacent segment degeneration (ASD), which has served as the base for the development of dynamic stabilization systems (DSS) and total disc replacement (TDR) devices for cervical spine. However, the hybrid surgical technique has also gained popularity recently, but its effect on the biomechanics of cervical spine is not well researched. Thus, the objective of this FE study was to draw a comparison among single-level, bi-level, and hybrid surgery with dynamic cervical implants (DCIs) with traditional fusion. Reductions in the range of motion (ROM) for all the implanted models were observed for all the motions except extension, compared to for the intact model. The maximum increase in the ROM of 42% was observed at segments C5–C6 in the hybrid DCI model. The maximum increase in the adjacent segment’s ROM of 8.7% was observed in the multilevel fusion model. The maximum von Mises stress in the implant was highest for the multilevel DCI model. Our study also showed that the shape of the DCI permitted flexion/extension relatively more compared to lateral bending and axial rotation.

Hybrid surgery with PEEK rods for lumbar degenerative diseases: a 2-year follow-up study

Background Finite element analyses and biomechanical tests have shown that PEEK rods promote fusion and prevent adjacent segment degeneration. The purpose of this study was to evaluate the effects and complications of hybrid surgery with PEEK rods in lumbar degenerative diseases. Methods From January 2015-December 2017, 28 patients who underwent lumbar posterior hybrid surgery with PEEK rods were included in the study. The patients were diagnosed with lumbar disc herniation, lumbar spinal stenosis, or degenerative grade I spondylolisthesis. Before the operation and at the last follow-up, the patients completed lumbar anteroposterior and lateral X-ray, dynamic X-ray, MRI examinations. In addition, at the last follow-up the patients also completed lumbar CT examinations. The radiographic parameters, clinical visual analog scale (VAS) score and Oswestry disability index (ODI) score were compared. Results The average age of the patients was 44.8 ± 12.6 years, and the average follow-up duration was 26.4 ± 3.6 months. The VAS score improved from 6.3 ± 1.6 to 1.0 ± 0.9, and the ODI score decreased from 38.4 ± 10.8 to 6.8 ± 4.6. The fusion rate of the fused segment was 100%. There were no significant changes in the modified Pfirrmann classifications or disc height index for the nonfused segments and the upper adjacent segments from pre- to postoperatively. No cases of screw loosening, broken screws, broken rods or other mechanical complications were found. Conclusion Hybrid surgery with PEEK rods for lumbar degenerative diseases can yield good clinical results and effectively reduce the incidence of complications such as adjacent segment diseases.

Investigation Into Cervical Spine Biomechanics Following Single, Multilevel and Hybrid Disc Replacement Surgery With Dynamic Cervical Implant and Fusion: A Finite Element Study

Cervical fusion has been a standard procedure for treating the abnormalities associated with the cervical spine. However, the reliability of anterior cervical discectomy and fusion (ACDF) has become arguable due to its adverse effects on the biomechanics of adjacent segments. One of the drawbacks associated with ACDF is adjacent segment degeneration (ASD) which has served as the base for the development of dynamic stabilization systems (DSS) and total disc replacement (TDR) devices for cervical spine. However, the hybrid surgical technique has also gained popularity recently but their effect on the biomechanics of cervical spine is not well researched. Thus, the objective of this FE study was to draw the comparison among single, bi-level and hybrid surgery with DCI implant with traditional fusion. Reduction in range of motion (ROM) for all the implanted models was observed for all the motions except extension, compared to intact model. The maximum increase in ROM of 42% was observed at C5-C6 level in Hybrid-DCI model. The maximum increase in adjacent segment’s ROM of 8.7% was observed in multilevel fusion model. The maximum von Mises stress in the implant was highest for the multilevel DCI model. Our study also showed that the shape of DCI implant permits flexion/extension relatively more compared to lateral bending and axial rotation.

Treatment of patients with occlusive-stenotic diseases of the arteries of the infrarenal aorta by the hybrid method

Annotation. The treatment results of patients with arterial occlusive-stenotic diseases of the lower extremities as a result of obliterating atherosclerosis were analyzed. 79 patients underwent hybrid surgery. Most patients were ranged in age from 46 to 86 years. There were 175 men (72.0%) and 68 women (28.0%). The right lower extremity was affected more often – 148(60.9%) patients than the left ones – 95(39.1%). Of the 20 patients with stenosis of the iliac-femoral segment, 14 hybrid surgeries were completed with stenting. Endarterectomy or profundoplasty with different angioplasty options were mainly performed. Endarterectomy or thrombectomy with various angioplasty options was mainly performed in the occlusion of the femoral-popliteal segment. The main hybrid type of operation in the popliteal segment was thrombectomy of the popliteal segment and balloon angioplasty of the tibial segment. In occlusive stenotic lesions of the arteries of the tibial-foot segment in the vast majority of cases, autovenous plastics of the tibioperoneal trunk with balloon angioplasty of distal arteries were performed. The thrombosis was diagnosed in 8(10,12%) individuals as the most common complication in the early postoperative period. Limb amputation was performed in 3 patients. Mortality rate in the early postoperative period was 4,76%(2 patients died in the comparison group), in the main group there was no mortality. Acute myocardial infarction and stroke are among the most common causes of death.

HYBRID SURGERY IN MULTI-FLOOR ATHEROSCLEROTIC INFLAMMATION OF THE MAIN ARTERIES OF THE LOWER LIMBS

Cardiovascular diseases occupy one of the main groups in the structure of morbidity in most countries. A significant part of this group is affected by the main arteries of the lower extremities. Atherosclerotic diseases of the terminal aorta are combined with stenotic-occlusive lesions of the iliac-femoral, femoral-popliteal and popliteal-tibial arterial segments. Timely diagnosis and choice of treatment to maintain a full life remains one of the most pressing medical problems today. Comprehensive drug therapy used in the treatment of this pathology is ineffective and leads to limb loss, which leads to limited mobility, ability to self-care, contributes to social maladaptation and requires the involvement of the working population to care for the patient. All of the above has led to an expansion of readings to restorative operations aimed at preserving the limbs. However, reconstructive surgery of stenotic-occlusive diseases of the arteries of the lower extremities today is a complex and far from unresolved problem, which contributes to the development of new research to select the optimal method of surgical treatment. The article presents data on hybrid surgical interventions (open surgery and stenting) in 59 patients with chronic ischemia of the lower extremities. The early postoperative period in 4 (6.8%) patients was complicated by hematoma and in 5 patients (8.5%) by postoperative wound lymphorrhea. Hybrid surgeries, in chronic lower extremity ischemia in patients with multilevel lesions of the main arteries, are effective and minimally invasive, especially in patients at high risk of complications. Such technologies allow to save the limb and life of the patient with the minimum trauma, to reduce duration of stay in a hospital.

Two- and three-year outcomes of minimally invasive and hybrid correction of adult spinal deformity

OBJECTIVE Previous studies have demonstrated the short-term radiographic and clinical benefits of circumferential minimally invasive surgery (cMIS) and hybrid (i.e., minimally invasive anterior or lateral interbody fusion with an open posterior approach) techniques to correct adult spinal deformity (ASD). However, it is not known if these benefits are maintained over longer periods of time. This study evaluated the 2- and 3-year outcomes of cMIS and hybrid correction of ASD. METHODS A multicenter database was retrospectively reviewed for patients undergoing cMIS or hybrid surgery for ASD. Patients were ≥ 18 years of age and had one of the following: maximum coronal Cobb angle (CC) ≥ 20°, sagittal vertical axis (SVA) > 5 cm, pelvic incidence–lumbar lordosis mismatch (PI-LL) ≥ 10°, or pelvic tilt (PT) > 20°. Radiographic parameters were evaluated at the latest follow-up. Clinical outcomes were compared at 2- and 3-year time points and adjusted for age, preoperative CC, levels operated, levels with interbody fusion, presence of L5–S1 anterior lumbar interbody fusion, and upper and lower instrumented vertebral level. RESULTS Overall, 197 (108 cMIS, 89 hybrid) patients were included with 187 (99 cMIS, 88 hybrid) and 111 (60 cMIS, 51 hybrid) patients evaluated at 2 and 3 years, respectively. The mean (± SD) follow-up duration for cMIS (39.0 ± 13.3 months, range 22–74 months) and hybrid correction (39.9 ± 16.8 months, range 22–94 months) were similar for both cohorts. Hybrid procedures corrected the CC greater than the cMIS technique (adjusted p = 0.022). There were no significant differences in postoperative SVA, PI-LL, PT, and sacral slope (SS). At 2 years, cMIS had lower Oswestry Disability Index (ODI) scores (adjusted p < 0.001), greater ODI change as a percentage of baseline (adjusted p = 0.006), less visual analog scale (VAS) back pain (adjusted p = 0.006), and greater VAS back pain change as a percentage of baseline (adjusted p = 0.001) compared to hybrid techniques. These differences were no longer significant at 3 years. At 3 years, but not 2 years, VAS leg pain was lower for cMIS compared to hybrid techniques (adjusted p = 0.032). Those undergoing cMIS had fewer overall complications compared to hybrid techniques (adjusted p = 0.006), but a higher odds of pseudarthrosis (adjusted p = 0.039). CONCLUSIONS In this review of a multicenter database for patients undergoing cMIS and hybrid surgery for ASD, hybrid procedures were associated with a greater CC improvement compared to cMIS techniques. cMIS was associated with superior ODI and back pain at 2 years, but this difference was no longer evident at 3 years. However, cMIS was associated with superior leg pain at 3 years. There were fewer complications following cMIS, with the exception of pseudarthrosis.

Hybrid vascular interventin for multilevel peripheral arterial disease

Objective To increase the effectiveness of intervention for the lower limb arteries multilevel lesion (MPAD) in patients with type C and D lesions by TASC II classification. Materials and methods 87 hybrid vascular reconstructions (74 male and 13 female, 59% (n=52) smokers) for MPAD were performed from 2017 to 2020. The average age was 64,6±8,1y. CLI was diagnosed in 47% (n=41) by Fontaine- Pokrovsky classification. Following concomitant disease were diagnosed: stage 2–3 of CHF by HYHA classification 33% (n=29), COPD 23% (n=20), arterial hypertension stage 2–3 54% (n=47), CAD 66% (n=58), postinfarction cardiosclerosis 29% (n=26). Registered lesion of iliac-femoral segment type A/B=44 (51%) and C/D=43 (49%); registered lesion of femoro-tibial segment A/B=14 (16%), C/D=73 (84%) by TASC-II classification. Common femoral artery (CFA) bifurcation was most important to perform hybrid intervention. Through CFA with patented method (RU 2621395C) we performed remote endartherectomy from external iliac or superficial femoral arteries, that allowed us to remove a total prolonged occlusion (&gt;15–20 cm), reducing the time and complexity of the endovascular stage. The key note is that we perform CFA plasty with using an autovenous patch with a “trunk” through which we provide endovascular stage of hybrid intervention on natural blood flow, restored after open endartherectomy. This technique allows you to change the direction of introducer in both distal and proximal direction without the need for extra punctures or temporary clamping of the arteries. Results Technical success rate was 98%. Local aneurysm of EIA was found in one case that restricted to provide the loop endarterectomy. The average duration of hybrid operation was 223,7±88,2 min (134,2±72,3 min for open and 89,9±52,9 for endovascular stages). Average blood loss was 225,3±130,7 ml. ICU staying duration was 20,6±2,8 hours. 30-days patency was 98,8%, 12 and 36 months primary patency was 98% and 88,5% respectively. There were no deaths within 30 days after hybrid operation. The following complications occurred: bleeding n=2 (2,3%), acute thrombosis n=1 (1,2%), surgical site infection n=1 (1,2%) but cured safely. Limb salvage in critical ischemia was in 100% of patients for 20 months. Conclusion Hybrid surgery of MPAD is highly effective, reduces operation trauma, improves its results and limb salvage. By reducing trauma of surgical intervention reduces admition in ICU, postoperative risks, especially in patients with severe concomitant pathology. FUNDunding Acknowledgement Type of funding sources: None.

Hybrid surgery: a comparison of early postoperative outcomes between anterior cervical discectomy and fusion and cervical disc arthroplasty

OBJECTIVE Hybrid surgery (HS) is the combination of anterior cervical discectomy and fusion (ACDF) and cervical disc arthroplasty (CDA) at different levels in the same operation. The aim of this study was to investigate perioperative variables, 30-day postoperative outcomes, and complications of HS in comparison with those of CDA and ACDF. METHODS The authors queried the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) registry for patients who underwent multilevel primary HS, CDA, and ACDF for degenerative disc disease from 2015 to 2019. The authors compared these three operations in terms of 30-day postoperative outcomes, specifically readmission and reoperation rates, discharge destination, and complications. RESULTS This analysis included 439 patients who underwent HS, 976 patients who underwent CDA, and 27,460 patients who underwent ACDF. Patients in the HS and CDA groups were younger, had fewer comorbidities, and myelopathy was less often the indication for surgery compared with patients who underwent ACDF. For the HS group, the unplanned readmission rate was 0.7%, index surgery–related reoperation rate was 0.3%, and nonroutine discharge rate was 2.1%. Major and minor complications were also rare, with rates of 0.2% for each. The mean length of stay in the HS group was 1.5 days. The association of HS with better outcomes in univariate analysis was not evident after adjustment for confounding factors. CONCLUSIONS The authors found that HS was noninferior to ACDF and CDA in terms of early postoperative outcomes among patients treated for degenerative disc disease.

Single-center Retrospective Analysis of One-stop Hybrid Surgery for Brain Arteriovenous Malformations

Objectives To evaluate the safety and effectiveness of one-stop hybrid surgery of microsurgical resection combined with preoperative embolization or intraoperative angiography for brain arteriovenous malformations (bAVMs) and compare the efficacy of one-stop hybrid surgery with nonhybrid surgery (endovascular embolization alone) in the treatment of bAVMs. Methods A single-center retrospective study was performed to recruit 70 patients with bAVMs at our hospital between July 2017 and April 2020. Patients were divided into 2 groups depending on the mode of surgery: hybrid group (i.e., microsurgical resection combined with preoperative endovascular embolization or intraoperative angiography in the hybrid operating room), and nonhybrid group (i.e., endovascular embolization, stereotactic radiosurgery, or microsurgical resection alone). The hybrid group was divided into two subgroups: the microsurgical resection combined with preoperative embolization, and the microsurgical resection combined with intraoperative angiography subgroups. All patients’ demographic variables, clinical manifestations, and imaging features, postoperative complications, and long-term clinical prognosis were recorded and analyzed. Results Among 70 patients, 48 (68.6%) of whom presented cerebral hemorrhage due to bAVMs rupture. 36 (51.4%) patients in the hybrid group were treated with the combination of pre-operative embolization or intraoperative angiography combined with microsurgical resection, whereas 34 (48.6%) in the nonhybrid group underwent embolization alone. There was no statistical difference in gender, age, ruptured bAVM rate, Spetzler-Martin grades between the 2 groups. Regular clinical and radiological follow-up examinations cure rates were 94.4% in the hybrid group compared to 38.3% in the nonhybrid group (P<0.01). The percentage of patients with favorable outcomes was 94.1% in the hybrid group and 90.6% in the nonhybrid group, although this difference was not statistically significant. Conclusions One-stop hybrid surgery could be a safe and effective intervention to treat bAVMs clinically, whereas further follow-up is needed to determine the long-term effects after operation.