Hybrid coronary revascularization versus coronary artery bypass surgery: Systematic review and meta-analysis

Clinical outcomes of different revascularization approaches for patients with multi-vessel coronary artery disease: A network meta-analysis

BACKGROUND

As surgical techniques continue to evolve, the optimal approach for revascularizing multi-vessel coronary artery disease (CAD) remains a matter of ongoing debate. Accordingly, our objective was to compare and contrast various surgical techniques utilized in the management of multi-vessel CAD.

METHODS

A systematic literature review was performed using PubMed, Embase, and Cochrane central register of controlled trials from inception to May 2022. Random-effects network meta-analysis was performed for the primary outcome; target vessel revascularization (TVR), and secondary outcomes; mortality, major adverse cardiac and cerebrovascular events, postoperative myocardial infarction, new-onset atrial fibrillation, stroke, new-onset dialysis, in patients undergoing percutaneous coronary intervention (PCI) with a stent, off-pump coronary bypass graft, on-pump coronary artery bypass graft (ONCABG), hybrid coronary revascularization, minimally-invasive coronary artery bypass, or robot-assisted coronary artery bypass (RCAB) surgeries.

RESULTS

A total of 8841 patients were included from 23 studies. The analysis showed that ONCABG had the highest freedom from TVR, with a mean (SD) absolute risk of 0.027 (0.029); although ONCABG was found to be superior to all other methods, it was only significantly better than first-generation stent PCI. While RCAB did not demonstrate significant superiority over other treatments, it showed a greater probability of preventing postoperative complications. Notably, no significant heterogeneity was calculated for any of the reported outcomes.

CONCLUSIONS

ONCABG shows a better rank probability compared to all other techniques for preventing TVR, while RCAB offers greater freedom from most postoperative complications. However, given the absence of randomized controlled trials, these results should be interpreted with caution.

The Current State of Hybrid Coronary Revascularization

Hybrid coronary revascularization (HCR) combines a minimally invasive surgical approach with percutaneous coronary intervention (PCI) for the treatment of multivessel coronary artery disease. Despite decades of use, widespread acceptance has been limited. In this review, we conduct a comparative assessment of HCR in relation to traditional coronary artery bypass graft surgery and multivessel PCI. Although large-scale randomized data are still lacking, numerous studies have demonstrated that HCR may offer benefits regarding resource utilization and short-term morbidity while delivering comparable mid- and long-term survival compared with traditional bypass surgery. Compared with PCI, HCR may offer similar periprocedural morbidity while mitigating the need for repeat revascularization by providing a surgical arterial bypass graft to the left anterior descending artery.

Maximizing Minimally Invasive Cardiac Surgery With Enhanced Recovery (ERAS)

We convened a group of cardiac surgeons, intensivists, and anesthesiologists with extensive experience in minimally invasive cardiac surgery (MICS) and perioperative care to identify the essential elements of a MICS program and the relationship with Enhanced Recovery After Surgery (ERAS). The MICS incision should minimize tissue invasion without compromising surgical goals. MICS also requires safe management of hemodynamics and preservation of cardiac function, which we have termed myocardial management. Finally, comprehensive perioperative care through an ERAS program should be provided to allow patients to achieve optimal recovery. Therefore, we propose that MICS requires 3 elements: (1) a less invasive surgical incision (non-full sternotomy), (2) optimized myocardial management, and (3) ERAS. We contend that the full benefit of MICS can be achieved only by also utilizing an ERAS platform.

Randomized Clinical Trial of Hybrid vs. Surgical vs. Percutaneous Multivessel Coronary Revascularization: 5‑year Follow-up of HREVS Trial

Aim      To evaluate 5-year results of the HREVS (Hybrid REvascularization Versus Standarts) study.Material and methods  The study included 155 consecutive patients with multivessel coronary artery disease who were randomized into 3 groups: coronary artery bypass grafting (CABG) (n=50), hybrid coronary revascularization (HCR) (n=52) and percutaneous coronary intervention (PCI) (n=53) according to the consensus of the cardiology team on the technical and clinical feasibility of each of the three coronary revascularization strategies. The primary endpoint of the study was residual ischemia 12 months after revascularization according to data of single-photon emission computed tomography (SPECT). Secondary endpoints were major adverse cardiac and cerebrovascular events (MACCE) over 5 years of follow-up, which included all-cause death, myocardial infarction, stroke, and clinically determined repeat myocardial revascularization.Results Baseline characteristics of patients did not differ between study groups. Median residual ischemia determined by SPECT data after 12 months was not statistically significantly different in the CABG, HCR and PCI groups: 6.7 [4.6; 8.8]%, 6.4 [4.3; 8.5]% and 7.9 [5.9; 9.8]%, respectively (p=0.45). Mean follow-up period was 76.5 months (at least 60 months). There were no statistically significant differences in all-cause mortality between the CABG, HCR and PCI groups, 10.6, 12.8 and 8.2 %, respectively (p=0.23). Statistically significant differences between the groups of CABG, HCR and PCI in the incidence of myocardial infarction (12.8; 8.5 and 16.3 %; p=0.12), stroke (4.2; 6.4 and 10.2 % ; p=0.13), repeat revascularization for clinical indications (23.4; 23.4 and 34.7 %; p=0.11) were not observed either. However, the cumulative 5-year MACCE value was similar in the HCR group and the CABG group but significantly lower than in the PCI group (51.1, 51.1 and 69.4 %, respectively; p = 0.03).Conclusion      HCR that combines advantages of PCI and CABG is a promising strategy for coronary revascularization in multivessel coronary artery disease. HCR demonstrates satisfactory long-term results comparable to those of CABG but superior to PCI. To confirm the safety and efficacy of HCR, a large multicenter study is required that would have a sufficient power to evaluate clinical endpoints.

Hybrid coronary revascularization (HCR) versus coronary artery bypass grafting (CABG) in multivessel coronary artery disease (MVCAD): A meta-analysis of 14 studies comprising 4226 patients

OBJECTIVES

To compare the outcomes of hybrid coronary revascularization (HCR) with traditional coronary artery bypass grafting (CABG) in multivessel coronary artery disease (MVCAD).

BACKGROUND

HCR has emerged as an alternative to CABG in patients with MVCAD. Through minimally invasive surgical techniques, HCR carries the potential for faster recovery postoperatively, fewer complications, and lower utilization of resources.

METHODS

Systematic search of electronic databases was conducted up to December 2021 and studies comparing HCR with CABG in the treatment of MVCAD were included in this meta-analysis. Primary outcomes of interest were incidence of 5-year mortality and major adverse cardiac and cerebral event (MACCE).

RESULTS

Fourteen studies (12 observational studies and 2 randomized controlled trials) comprising 4226 patients were included. The rates of 5-year mortality (odds ratios [OR]: 1.55; 95% confidence interval [CI]: 0.92-2.62; I²  = 83.0%) and long-term MACCE (OR: 0.97; 95% CI: 0.47-2.01; I²  = 74.7%) were comparable between HCR and CABG groups. HCR was associated with a significantly lower likelihood of perioperative blood transfusion (OR: 0.36; 95% CI: 0.25-0.51; I²  = 55.9%), shorter mean hospital stay (weighted mean difference: -2.04; 95% CI: -2.60 to -1.47; I²  = 54%), and risk of postoperative acute kidney injury (OR: 0.45; 95% CI: 0.23-0.88; p = 0.02). CABG demonstrated a lower likelihood of requiring long-term repeat revascularization (OR: 1.51; 95% CI: 1.03-2.20; I²  = 18%) over a follow-up duration of 29.14 ± 21.75 months.

CONCLUSION

This meta-analysis suggests that HCR is feasible and safe for the treatment of MVCAD. However, benefits of HCR should be carefully weighed against the increased long-term risk of repeat-revascularization when selecting patients, and further studies evaluating differences in long-term mortality between HCR and CABG are required.

Hybrid coronary revascularization in multivessel coronary artery disease: a systematic review

Aim: Hybrid coronary revascularization (HCR) for multivessel coronary artery disease (CAD) integrates coronary artery bypass grafting (CABG) and percutaneous intervention in a planned revascularization strategy. This systematic review summarizes the state of this art of this technique. Methods: Major databases searched until October 2021. Results: The available literature on HCR includes three randomized trials, ten meta-analysis and 27 retrospective studies. The greatest benefits are observed in patients with low-to-intermediate risk and less complex coronary anatomy; highly complex disease and the presence of risk factors favored conventional CABG in terms of adverse events and survival. Conclusion: HCR is an interesting approach for multivessel CAD but should not be considered a 'one-size-fits-all' procedure. Further studies will specify the subset of patients likely to benefit most from this hybrid approach.

A Practical Approach to Hybrid Coronary Revascularization

Combined surgical and percutaneous coronary revascularization, ie, hybrid coronary revascularization (HCR) consists of surgical left internal mammary artery (LIMA) bypass to the left anterior descending artery (LAD) and percutaneous revascularization of other diseased coronary arteries. Developed as a 1-stage procedure, HCR has not been widely adopted by the cardiovascular community. The recommended minimally invasive approach through a small left thoracotomy incision is technically demanding, and same-day percutaneous revascularization requires a hybrid operating room that is not available in most hospitals. In this review, we consider present HCR protocols, barriers to widespread adoption of HCR, and we give special attention to the surgical approach for the LIMA graft to the LAD and the timing of percutaneous revascularization. We conclude that grafting the LIMA to the LAD through a median sternotomy approach and delaying the percutaneous revascularization may facilitate the widespread use of HCR in patients with multivessel coronary artery disease and a low to intermediate Synergy between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery score.

Advances in revascularization of the left coronary artery

Ischaemic heart disease is the most common cardiovascular disease worldwide, and it contributes to a significant source of morbidity and mortality internationally. It can be asymptomatic for many years and present suddenly with acute coronary syndrome or can be progressive with angina and eventual acute myocardial infarction. Diseases of the left coronary system can be drastic and fatal if not managed correctly. With ongoing increase in the practice of percutaneous intervention; patient demographics for conventional coronary artery bypass grafting surgery have more risk factors than before. Conventional bypass surgery has also evolved to include minimally invasive and hybrid techniques. Although some evidence supports each approach, controversies remain.

Hybrid coronary revascularization vs. percutaneous coronary interventions for multivessel coronary artery disease

OBJECTIVE

Hybrid coronary revascularization (HCR) combines a minimally invasive surgical approach to the left anterior descending (LAD) artery with percutaneous coronary intervention (PCI) for non-LAD diseased coronary arteries. It is associated with shorter hospital lengths of stay and recovery times than conventional coronary artery bypass surgery, but there is little information comparing it to isolated PCI for multivessel disease. Our objective is to compare long-term outcomes of HCR and PCI for patients with multivessel disease.

METHODS

This cohort study used data from New York's cardiac surgery and PCI registries in 2010-2016 to examine mortality and repeat revascularization rates for patients with multivessel coronary artery disease who underwent HCR and PCI. Cox proportional hazards methods were used to reduce selection bias. Patients were followed for a median of four years.

RESULTS

There was a total of 335 HCR patients (1.2%) and 25,557 PCI patients (98.8%) after exclusions. There was no difference in 6-year risk adjusted survival between HCR and PCI patients (83.17% vs. 81.65%, adjusted hazard ratio (aHR) = 0.90 (95% CI: 0.67-1.20). However, HCR patients were more likely to be free from repeat revascularization in the LAD artery (91.13% vs. 83.59%, aHR = 0.51 (95% CI: 0.34-0.77)).

CONCLUSIONS

For patients with multi-vessel coronary artery disease, HCR is rarely performed. There are no differences in mortality rates after four years, but HCR is associated with lower repeat revascularization rates in the LAD artery, presumably due to better longevity in left arterial mammary grafts.

Hybrid Coronary Revascularization Versus Conventional Coronary Artery Bypass Surgery: Utilization and Comparative Outcomes

BACKGROUND

Hybrid coronary revascularization (HCR) treats multivessel coronary artery disease by combining a minimally invasive surgical approach to the left anterior descending artery with percutaneous coronary intervention for non-left anterior descending diseased coronary arteries. The objective of this study is to compare HCR and conventional coronary artery bypass graft (CABG) surgery medium-term outcomes.

METHODS

Data from multivessel disease patients in New York's cardiac surgery and percutaneous coronary intervention registries in 2010 to 2016 were used to compare mortality and repeat revascularization rates for HCR and conventional CABG after using propensity matching to reduce selection bias.

RESULTS

There was a total of 303 HCR (0.80%) patients and 37 556 conventional CABG patients after exclusions. After propensity matching, the respective median follow-up times were 3.72 years and 3.76 years. There was no difference between HCR and conventional CABG in survival at 6 years (80.9% versus 85.8%%, adjusted hazard ratio, 1.44 [0.90-2.31]), but HCR had higher mortality excluding deaths during the first year (adjusted hazard ratio, 1.88 [1.10-3.23]). Conventional CABG patients were more likely to be free from repeat revascularization at 6 years than HCR patients (88.2% versus 76.6%; hazard ratio, 2.22 [1.44-3.42]).

CONCLUSIONS

HCR is rarely performed for patients with multivessel coronary artery disease. HCR and conventional CABG had no different 6-year mortality rates, but HCR had higher mortality after 1 year and higher rates of subsequent revascularization that were caused by both the need for repeat revascularization in the left anterior descending artery where minimally invasive CABG was performed, and in the coronary arteries where percutaneous coronary intervention was performed. Graphic Abstract: A graphic abstract is available for this article.

Hybrid coronary revascularization versus conventional coronary artery bypass grafting: Systematic review and meta-analysis

BACKGROUND

Hybrid coronary revascularization (HCR) combining minimally invasive grafting of the left internal mammary artery to the left anterior descending artery with percutaneous coronary intervention has become a viable option for treating coronary artery disease. The aim of this meta-analysis was to compare HCR with conventional coronary artery bypass grafting (CABG) in a range of clinical outcomes and hospital costs.

METHODS

To identify potential studies, systematic searches were carried out in various databases. The key search terms included "hybrid revascularization" AND "coronary artery bypass grafting" OR "HCR" OR "CABG." This was followed by a meta-analysis investigating the need for blood transfusion, hospital costs, ventilation time, hospital stay, cerebrovascular accident, myocardial infarction, mortality, postoperative atrial fibrillation, renal failure, operation duration, and ICU stay.

RESULTS

The requirement for blood transfusion was significantly lower for HCR: odds ratio 0.38 (95% confidence intervals [CIs] 0.31-0.46, P < .00001) as was the hospital stay: mean difference (MD) -1.48 days (95% CI, -2.61 to -0.36, P = 0.01) and the ventilation time: MD -8.99 hours (95% CI, -15.85 to -2.13, P = .01). On the contrary, hospital costs were more expensive for HCR: MD $3970 (95% CI, 2570-5370, P < .00001). All other comparisons were insignificant.

CONCLUSIONS

In the short-term, HCR is as safe as conventional CABG and may offer certain benefits such as a lower requirement for blood transfusion and shorter hospital stays. However, HCR is more expensive than conventional CABG.

Hybrid Revascularization: A Review

Hybrid coronary revascularization (HCR) combines surgical bypass with percutaneous coronary intervention (PCI) performed either during the same procedure or in a staged approach within 60 days. Coronary artery bypass grafting using the left internal mammary artery (LIMA) has shown excellent long-term patency with improved patient survival. It remains the gold standard treatment for the majority of patients with multivessel coronary artery disease. However, saphenous vein grafts have poor long-term patency. Advances in stent technology have resulted in reduced rates of thrombosis and restenosis, making PCI a viable alternative to coronary surgery in selected patients. HCR is attractive as a less invasive method of coronary revascularization which preserves the benefits of the LIMA performed with less invasive surgical techniques with the efficacy of newer generation stents.

Mid-Term Follow-up of Minimally Invasive Multivessel Coronary Artery Bypass Grafting: Is the Early Learning Phase Detrimental?

OBJECTIVE

Minimally invasive coronary artery bypass grafting (MICS CABG) through a small left thoracotomy is a novel technique for surgical coronary revascularization, which is increasingly being adopted around the world. This study aimed to describe the characteristics and mid-term outcomes of a series of MICS CABG to identify areas for improvement.

METHODS

A prospective longitudinal study was performed on the 306 MICS CABG patients operated on by a single surgeon from 2005 to 2015. Minimally invasive coronary artery bypass grafting used a small left thoracotomy to enable coronary revascularization with a similar configuration to an open sternotomy technique, with left internal thoracic artery harvesting, and hand-sewn proximal radial/saphenous and distal anastomoses, under direct visualization. We compared patients who were operated on during the first and second halves of the series to ascertain the impact of a learning curve on outcomes.

RESULTS

The mean ± SD age was 62 ± 9 years, 87% were male, and 23% had three-vessel disease. Off-pump coronary artery bypass was performed in 80%, and the median number of grafts was 2 (range 1-4). Sternotomy conversion occurred in 3.3%, reoperation for bleeding in 2%, and unplanned, emergency CPB conversion in 1%. Superficial thoracotomy infection, atrial fibrillation, and left-sided pleural effusion requiring drainage were encountered in 2%, 4%, and 4%, respectively. There were no perioperative stroke, myocardial infarction, or death. At a mean ± SD follow-up of 2.8 ± 2.5 years, 97.4% of patients were free from major adverse cardiac and cerebrovascular events. Between the first and latter half of the series, there was a decrease in the rate of conversion to sternotomy (5.2%-1.3%, P = 0.05) and in the mid-term need for repeat revascularization (11% vs 2.6%, P = 0.03). Overall repeat revascularization rate was 2.5% per year. The intensive care unit and hospital lengths of stay (1.6 ± 1.5 vs 1.4 ± 0.9, P = 0.2, and 6.1 ± 2.6 vs 5.6 ± 1.8, P = 0.4) were not statistically different.

CONCLUSIONS

Minimally invasive coronary artery bypass grafting can be safely initiated as a minimally invasive, multivessel alternative to open surgical coronary revascularization, with excellent mid-term results. Learning phase effects were not observed with regard to overall procedural safety, but rather in terms of improved freedom from conversion to sternotomy and from repeat revascularization.

Minimally Invasive Multivessel Coronary Surgery and Hybrid Coronary Revascularization: Can We Routinely Achieve Less Invasive Coronary Surgery?

Coronary artery bypass grafting (CABG) is the gold standard in managing severe coronary artery disease. However, it is associated with prolonged recovery and potential complications, in part due to the invasiveness of the procedure. Less invasive CABG techniques attempt to improve the quality and quantity of life in the same way as surgical revascularization but with fewer complications. Minimally invasive coronary surgery (MICS) through a small thoracotomy allows for complete revascularization with good results in graft patency. Perioperative mortality is low, and there is decreased need for blood transfusion, lower surgical site infection rates, and an earlier return to full physical function. Hybrid coronary revascularization (HCR) attempts to combine the advantages of coronary artery bypass grafting with those of percutaneous coronary intervention. Several studies have shown that HCR provides better short-term outcomes with regard to decreased ventilation and ICU time, reduced need for blood transfusion, and shortened hospital stay. However, the rates for major adverse cardiovascular events and mortality are comparable to conventional CABG, except for patients with a high SYNTAX score who displayed increased mortality rates. There is also strong evidence of a higher need for repeat revascularization with HCR compared to CABG. Overall, MICS and HCR appear to be viable alternatives to conventional CABG, offering a less invasive approach to coronary revascularization, which may be especially beneficial to high-risk patients. This article discusses approaches that deliver the advantages of minimally invasive surgical revascularization that can be adapted by surgeons with minimal investment with regards to training and infrastructure.

Clinical Outcomes of Revascularization Strategies for Patients With MVD/LMCA Disease: A Systematic Review and Network Meta-Analysis

Hybrid coronary revascularization (HCR), a new minimally invasive procedure for patients requiring revascularization for multivessel coronary lesions, combines coronary artery bypass grafting (CABG) for left anterior descending (LAD) lesions and percutaneous coronary intervention (PCI) for non-LAD coronary lesions. However, available data related to outcomes comparing the 3 revascularization therapies is limited to small studies.We conducted a search in MEDLINE, EMBASE, and the Cochrane Library of Controlled Trials up to December 31, 2014, without language restriction. A total of 16 randomized trials (n=4858 patients) comparing HCR versus PCI or off-pump CABG (OPCAB) were included in this meta-analysis. The primary outcomes were major adverse cardiac and cerebrovascular events (MACCE), all-cause death, myocardial infarction (MI), cerebrovascular events (CVE), and target vessel revascularization (TVR). Odds ratios (OR) and 95% confidence intervals (CI) were calculated using random-effect and fixed-effect models. Ranking probabilities were used to calculate a summary numerical value: the surface under the cumulative ranking (SUCRA) curve.No significant differences were seen between the HCR and PCI in short term (in hospital and 30 days) with regard to MACCE (odds ratio [OR] = 0.51, 95% confidence interval [CI] 0.00-2.35), all-cause death (OR = 2.09, 95% CI 0.34-7.66), MI (OR = 1.02, 95% CI 0.19-2.95), CVE (OR = 4.45, 95% CI 0.39-19.16), and TVR (OR = 6.99, 95% CI 0.17-39.39). However, OPCAB had lower MACCE than HCR (OR = 0.19, 95% CI 0.00-0.95). In midterm (1 year and 3 year), in comparison with HCR, PCI had higher all-cause death (OR = 5.66, 95% CI 0.00-13.88) and CVE (OR = 4.40, 95% CI 0.01-5.68), and lower MI (OR = 0.51, 95% CI 0.00-2.86), TVR (OR = 0.53, 95% CI 0.05-2.26), and thus the MACCE (OR = 0.51, 95% CI 0.00-2.35). Off-pump CABG presented a better outcome than HCR with significant lower MACCE (OR = 0.17, 95% CI 0.01-0.68). Surface under the cumulative ranking probabilities showed that HCR may be the superior strategy for MVD and LMCA disease when regarded to MACCE (SUCRA = 0.84), MI (SUCRA = 0.76) in short term, and regarded to MACCE (SUCRA = 0.99), MI (SUCRA = 0.94), and CVE (SUCRA = 0.92) in midterm.Hybrid coronary revascularization seemed to be a feasible and acceptable option for treatment of LMCA disease and MVD. More powerful evidences are required to precisely evaluate risks and benefits of the 3 therapies for patients who have different clinical characteristics.