Hybrid Coronary Revascularization for the Treatment of Multivessel Coronary Artery Disease

Abstract

BACKGROUND Hybrid coronary revascularization (HCR) combines minimally invasive surgical coronary artery bypass grafting of the left anterior descending artery with percutaneous coronary intervention (PCI) of non–left anterior descending vessels. HCR is increasingly used to treat multivessel coronary artery disease that includes stenoses in the proximal left anterior descending artery and at least 1 other vessel, but its effectiveness has not been rigorously evaluated. OBJECTIVES This National Institutes of Health–funded, multicenter, observational study was conducted to explore the characteristics and outcomes of patients undergoing clinically indicated HCR and multivessel PCI for hybrid-eligible coronary artery disease, to inform the design of a confirmatory comparative effectiveness trial. METHODS Over 18 months, 200 HCR and 98 multivessel PCI patients were enrolled at 11 sites. The primary outcome was major adverse cardiac and cerebrovascular events (MACCE) (i.e., death, stroke, myocardial infarction, repeat revascularization) within 12 months post-intervention. Cox proportional hazards models were used to model time to first MACCE event. Propensity scores were used to balance the groups. RESULTS Mean age was 64.2 ± 11.5 years, 25.5% of patients were female, 38.6% were diabetic, and 4.7% had previous stroke. Thirty-eight percent had 3-vessel coronary artery disease, and the mean SYNTAX (Synergy Between PCI With Taxus and Cardiac Surgery) score was 19.7 ± 9.6. Adjusted for baseline risk, MACCE rates were similar between groups within 12 months post-intervention (hazard ratio [HR]: 1.063; p = 0.80) and during a median 17.6 months of follow-up (HR: 0.868; p = 0.53). CONCLUSIONS These observational data from this first multicenter study of HCR suggest that there is no significant difference in MACCE rates over 12 months between patients treated with multivessel PCI or HCR, an emerging modality. A randomized trial with long-term outcomes is needed to definitively compare the effectiveness of these 2 revascularization strategies. (Hybrid Revascularization Observational Study; NCT01121263)

Is Complete Revascularisation Mandated for all Patients with Multivessel Coronary Artery Disease?

“…32 Guidelines are inconclusive about the most appropriate timing of treatment in patients presenting with NSTE-ACS and MVCAD at present. 22,23 Concerning treatment strategy, in current guidelines CABG is recommended over PCI in patients with a baseline SYNTAX score >22, with left main or three-vessel coronary artery disease involving the proximal LAD.…”

Hybrid coronary revascularization versus coronary artery bypass grafting in patients with multivessel coronary artery disease: A meta‐analysis

“…Thus, the similar patency rates of DES and SVG and the superiority of the LIMA‐LAD graft forms the fundamental basis for a hybrid coronary revascularization (HCR). HCR combines a minimally invasive sternal sparing coronary artery bypass for LIMA–LAD graft and PCI to non‐LAD coronary arteries . In an era focused on minimally invasive interventions, HCR aims to reduce recovery duration, hospital complications, and surgical trauma, while maintaining durability outcomes similar to that of CABG .…”

Off‐Pump Coronary Artery Bypass Grafting: 30 Years of Debate

“…Three main options for the performance of CABG without sternotomy are now available (Table 3): (1) minimally invasive CABG, in which all areas of the heart are bypassed via a small left anterolateral thoracotomy, usually without the use of the heart–lung machine123; (2) robotic total endoscopic coronary bypass grafting, in which robotic techniques are used not only for internal mammary artery harvest but also for the performance of all graft anastomoses124; and (3) HCR, which combines the performance of a single LIMA‐LAD graft via a small anterolateral thoracotomy, with PCI to the other myocardial territories of the heart that require revascularization 125…”

“…So far, observational data have suggested that these procedures are safe and that patients recover significantly faster than with CABG in the early postoperative period 125, 126, 127. Furthermore, there may also be benefits related to periprocedural morbidity compared with CABG 125…”