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Advanced Hybrid Coronary Revascularization With Bilateral Internal Mammary Arteries In A 45-year-old Woman With Familial Hypercholesterolemia
Xander Jacquemyn, Wouter Oosterlinck.
UZ Leuven, Leuven, Belgium.
OBJECTIVE: Describe a successful case of advanced hybrid coronary revascularization using bilateral internal mammary arteries (BIMA) in a young woman with familial hypercholesterolemia and diffuse coronary artery disease (CAD).
METHODS: In this case report, we present a 45-year-old woman with familial hypercholesterolemia on intensive lipid-lowering therapy, including LDL apheresis, atorvastatin, evolocumab, bempedoic acid, and ezetimibe. Prior medical history included two STEMIs managed with balloon angioplasty in the preceding year. Preoperative coronary angiography revealed severe diffuse CAD with functionally significant LAD disease (fractional flow reserve = 0.76) and non-significant diffuse disease in the Dx and RCA (based on quantitative flow ratio). An advanced hybrid revascularization strategy was preferred through a heart-team approach, involving minimally invasive direct coronary artery bypass (MIDCAB) with BIMA. The LIMA and RIMA were harvested (58 and 38 minutes, respectively), with LIMA to the LAD and RIMA grafted to the Dx.
RESULTS: Total surgical time was approximately 253 minutes (robot assisted: ±139 min; direct: ±114 min), with minimal blood loss (±200 mL). Intraoperative transit time flow measurements confirmed adequate graft flow (LIMA-LAD: 7 mL/min with pulsatility index of 3.7; RIMA-Dx: 12 mL/min with pulsatility index of 2.2). The postoperative course was uneventful, and the patient was discharged after 4 days. At 1-month follow-up, she was clinically well.
CONCLUSIONS: Our case highlights the feasibility and potential benefits of an advanced hybrid coronary revascularization approach in a young, high-risk patient with familial hypercholesterolemia, diffuse CAD, and ongoing intensive lipid-lowering therapy. In this case, long-term follow-up is essential to assess durability of the hybrid revascularization and ensure sustained clinical benefit.
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