Hybrid Coronary Revascularization Shows Promise for High-Risk Patients

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For select patients with multivessel disease, hybrid coronary revascularization may provide favorable outcomes compared with either coronary artery bypass graft (CABG) surgery or percutaneous coronary intervention (PCI). A study scheduled to be published online April 23, 2013, ahead of print in the Journal of the American College of Cardiology suggests that the hybrid procedure is most effective in high-risk patients.

Hybrid revascularization is a minimally invasive alternative that combines the durability and survival advantage of LIMA-LAD graft surgery with less-invasive PCI to treat non-LAD lesions. Moreover, with the introduction of hybrid operating room, surgical and percutaneous procedures can be performed consecutively without the need for relocation.

Researchers led by Shengshou Hu, MD, of Fuwai Hospital (Beijing, China), looked at 141 consecutive patients with multivessel disease who underwent hybrid revascularization at their institution from June 2007 to December 2010. Subjects were propensity score-matched with equal numbers of patients who underwent either CABG or PCI with DES during the same time period.

Less Repeat Revascularization, MACCE

After a mean follow-up of 3 years, there were no differences in survival among the groups, but hybrid revascularization showed a reduction in MACCE (composite of death, MI, neurologic event, TLR, and TVR), driven by fewer repeat revascularizations (table 1).

Table 1. Outcomes at 3 Years

 

Compared with the hybrid group, repeat revascularization in the PCI group was mainly concentrated in the LAD (33.3% vs. 55.5%; P = 0.029), while the repeat revascularization rates for non-LAD lesions were similar in the hybrid and PCI groups (66.7% vs. 44.4%; P = 0.307).

When patients were stratified into tertiles by EuroScore, patients at highest risk receiving hybrid revascularization experienced less MACCE (6.9%) compared with high risk patients who received PCI (45.7%; P = 0.006) and CABG (36.4%; P = 0.030). Repeat revascularization also trended lower for hybrid revascularization (3.4%) compared with PCI (22.9%), but was similar to CABG (3.0%). In stratification by Syntax Score, the highest-risk tertile saw less MACCE with hybrid revascularization (7.7%) compared with PCI (40.0%; P = 0.002) but not with CABG (14.3%; P = 0.362). Likewise, repeat revascularization in high-risk patients by Syntax Score only trended higher for PCI (22.9%) compared with both hybrid revascularization (5.8%) and CABG (3.0%).

Several Advantages Over CABG, PCI

The hybrid procedure “is based on combining the excellent long-term patency of LIMA-LAD graft by surgical procedure and minimal invasiveness of interventional procedures to achieve complete revascularization,” Dr. Hu and colleagues write. “Compared with the staged procedures, one-stop [hybrid revascularization] eliminated logistic concerns about the timing or sequencing of separate procedures, minimized the inconvenience of transferring patients and [exposure] to anesthesia. Especially when PCI complication or failure occurs, CABG can be performed immediately.”

Compared with CABG, hybrid procedures are advantageous because the LIMA-LAD graft quality can be confirmed and potentially corrected immediately, they write. Unlike conventional CABG, they also avoid aortic manipulation.

“Compared with PCI, the main difference of one-stop [hybrid revascularization] lies in LIMA-LAD graft,” the authors continue. Because repeat revascularization in the PCI group was mainly seen in the LAD, “grafting LAD with LIMA combined [with] PCI for the rest [of the] lesions might be a potentially ideal option to conventional revascularization strategies [for multivessel coronary disease with complex LAD lesions].”

They emphasize that the heart team approach is key to this procedure and suggest that “these favorable preliminary findings warrant further investigation of [hybrid revascularization].”

Study Details

After hybrid revascularization, aspirin dosage was 300 mg/day for 1 month and 100 mg/day for a lifetime, while clopidogrel was administered as a maintenance dose of 75 mg/day for 12 months. All of these patients received LIMA-LAD grafts and PCI with DES for non-LAD lesions. The mean number of stents implanted in a patient was 1.9 and the mean total length of the stents was 32.6 ± 15.1 mm.

The types of stents used in both the hybrid and PCI groups included Cypher SES (Cordis/Johnson & Johnson, New Brunswick, NJ), Taxus PES (Boston Scientific, Natick, MA), and Endeavor/Resolute ZES (Medtronic, Minneapolis, MN).

 

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Source:
Shen L, Hu S, Wang H, et al. One-stop hybrid coronary revascularization versus coronary artery bypass graft and percutaneous coronary intervention for the treatment of multivessel coronary artery disease: Three-year follow-up results from a single institution. J Am Coll Cardiol. 2013;Epub ahead of print.

 

 

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