Hybrid coronary revascularization (HCR) provides satisfactory long-term outcomes in patients with multivessel coronary artery disease, similar to those of off-pump coronary artery bypass grafting (CABG) and better than those of percutaneous coronary intervention (PCI), according to a new study.
Tong Ding, MD, PhD, Xin Yuan, MD, PhD, and colleagues from Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, reported these findings in a manuscript published Monday online and in the Jan. 9 issue of JACC: Cardiovascular Interventions.
HCR, combining the techniques of minimally invasive coronary artery bypass grafting (CABG) to the left anterior descending (LAD) coronary artery and percutaneous coronary intervention (PCI) for non-LAD lesions, has been shown to be a safe and feasible option in selected patients with multivessel coronary artery disease. Several randomized controlled trials for HCR assessments were carried out but were generally underpowered for clinical events. Previously, the same group described favorable 3-year outcomes of HCR. The new study reports 10-year outcomes of HCR as compared with conventional CABG and PCI.
Three groups of 540 patients each, who received HCR, CABG or PCI between June 2007 and September 2018, were matched using propensity score matching. Patients were stratified by EuroSCORE (European System for Cardiac Operative Risk Evaluation) II and SYNTAX (Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery) score. Major adverse cardiac and cerebrovascular events (MACCE) and Seattle Angina Questionnaire (SAQ) scores were compared among the three groups.
The primary endpoints included major adverse cardiac and cerebrovascular events (MACCE), all-cause mortality and functional status during follow-up.
HCR performed similarly to off-pump CABG (OPCAB) but significantly outperformed PCI (P < 0.001). In the low-to-medium EuroSCORE II and medium-to-high SYNTAX score tertiles, MACCE rates in the HCR group were significantly lower than those in the PCI (EuroSCORE II: low, 30.7% vs 41.2%; P = 0.006; medium, 31.3% vs 41.7%; P = 0.013; SYNTAX score: medium, 27.6% vs 41.2%; P = 0.018; high, 32.4% vs 52.7%; P = 0.011) but were similar to those in the CABG group. In the high EuroSCORE II stratum, HCR had a lower MACCE rate than CABG (31.9% vs 47.0%; P = 0.041) and PCI (31.9% vs 53.7%; P = 0.015).
Most clinical and functional status results followed the same pattern: the outcomes of HCR were similar to OPCAB but superior to PCI.
Ding, Yuan and colleagues wrote that simultaneous HCR has established advantages over CABG, such as instant confirmation of instant left internal mammary artery (LIMA)–LAD graft patency, avoidance of aortic manipulation, standardized dual antiplatelet therapy, and the superiority of contemporary drug-eluting stents over saphenous vein grafts in terms of long-term patency.
Compared to PCI, they wrote, there is a satisfactory long-term patency rate of LIMA–LAD over PCI of the LAD.
The writers believe that one of the crucial advantages of HCR lies in genuinely patient-centered comprehensive care organized under the collaboration of the multidisciplinary HCR team, and the individual patient is genuinely benefit from such a decision-making strategy.
In an accompanying editorial comment, Mateusz Tajstra, MD, PhD, and colleagues from the
Silesian Center for Heart Diseases, Zabrze, Poland, wrote that HCR is a very advantageous option for revascularization of patients with multivessel coronary artery disease, but this has not been implemented into daily practice.
The reason for this might be the lack of large, multicenter randomized controlled (RCT) trials comparing HCR with other revascularization options. This may result in a kind of vicious circle: no wider implementation because of lack of RCTs and no RCTs because of the problem with a wider implementation.
The editorial comment suggests that is important to support the research of Ding, Yuan and colleagues showing that HCR is not merely a technique suitable for a small percentage of patients used by a handful of enthusiasts.
The study was supported by grants from the National Key R&D program.
Ding T, Yuan X, Chen K, et al. Simultaneous Hybrid Coronary Revascularization vs Conventional Strategies for Multivessel Coronary Artery Disease: A 10-Year Follow-Up. JACC Cardiovasc Interv 2023;16:50–60.
Tajstra M, Wilczek K, Gasior M. Hybrid Coronary Revascularization: Best of 2 Worlds in the Environment Where Revascularization Is in Reverse. JACC Cardiovasc Interv 2023;16:61–63.
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