Simultaneous Hybrid Coronary Revascularization vs Conventional Strategies for Multivessel Coronary Artery Disease: A 10-Year Follow-Up

Long-term benefits of drug-coated balloons for coronary artery revascularization

Percutaneous coronary intervention (PCI) with drug-eluting stents (DES) represents the treatment of choice for the majority of patients with coronary artery disease. While currently available DES, in addition to physiological support, has failed to show the non-inferiority to coronary artery bypass grafting (CABG) in terms of cumulative incidence of clinical events over the short-term follow-up. Studies have also shown that DES is associated with an increased risk of target vessel revascularization compared to CABG after long-term follow-up. Drug-coated balloons (DCB) have been shown to provide clinically significant benefits in the management of in-stent restenosis and diffuse coronary artery disease, as well as small coronary artery lesions. The aim of this review was to describe the inherent technical limitations of DES and highlight the potential advantages of PCI with DCB for long-term outcomes and potentially demonstrate its non-inferiority to CABG. Currently, ongoing studies will provide more information and help to understand if a blended therapy of DCB+DES can match the performance of CABG in the need for revascularization in more complex patients.

Controversy. On pump or off pump: what will I do when I grow up? A narrative systematic review

The transition from the second to the third millennium happened to be a turning point in the history of myocardial revascularization on a beating heart, which moved from technical development to critical evaluation. This article describes how the initial acceptance and spread of off-pump coronary artery bypass grafting (OPCABG) was followed by the general perception that the technique could not fulfill the expectations placed in it and provides some insight on what should we do with the know-how of OPCABG in the present and the future of coronary surgical revascularization.

Clinical efficacy of clopidogrel and ticagrelor in patients undergoing off-pump coronary artery bypass grafting: a retrospective cohort study

BACKGROUND

Ticagrelor is reportedly more effective than clopidogrel in preventing atherothrombotic events in patients with percutaneous coronary intervention. However, the optimal antiplatelet therapy strategy after off-pump coronary artery bypass grafting (OPCABG) is yet to be established.

MATERIALS AND METHODS

This study was performed using the prospectively-maintained database at our institution. Patients who underwent OPCABG were divided into the clopidogrel and the ticagrelor groups. Propensity score matching analysis was performed between the two groups. The clinical outcome was the occurrence of major adverse cardiovascular event (MACE), defined as a composite of vascular death, myocardial infarction, or stroke 1-year after surgery.

RESULTS

In total, 545 patients completed the entire follow-up assessment. After propensity score matching, 232 patients each were included in the clopidogrel and ticagrelor groups. The primary outcome occurred in 7.8 and 4.3% of patients in the clopidogrel and ticagrelor groups, respectively ( P =0.113). CYP2C19 variants (*2, *3, and *17) did not impact the clinical outcomes, regardless of the use of clopidogrel or ticagrelor. The rates of MACE were significantly lower in patients carrying the ABCB1 C3435T CT/TT genotypes in the ticagrelor group than in those carrying the ABCB1 C3435T CC genotype in the clopidogrel group (1.4 vs. 9.1%, adjusted P =0.030), as well as those carrying the ABCB1 C3435T CC genotype in the ticagrelor group (1.4 vs. 8.9%, adjusted P =0.036). The ABCB1 C3435T CC genotype was significantly associated with the incidence of 1-year MACE (HR=1.558, 95% CI: 1.109-2.188, P =0.011). Patients who experienced severe perioperative bleeding exhibited a significantly higher incidence of MACE than those who did not experience severe perioperative bleeding (14.0 vs. 4.9%, adjusted P =0.007).

CONCLUSION

There was no significant difference in the 1-year MACE between patients receiving clopidogrel and those receiving ticagrelor after OPCABG. Notably, The ABCB1 C3435T CC genotype was related to a higher risk of MACE.

Early and late outcomes after minimally invasive direct coronary artery bypass vs. full sternotomy off-pump coronary artery bypass grafting

Objectives

Minimally-invasive direct coronary artery bypass (MIDCAB) is a less-invasive alternative to full sternotomy off-pump coronary artery bypass (FS-OPCAB) revascularization of the left anterior descending artery (LAD). Some studies suggested that MIDCAB is associated with a greater risk of graft occlusion and repeat revascularization than FS-OPCAB LIMA-to-LAD grafting. Data comparing MIDCAB to FS-OPCAB with regard to long-term follow-up is scarce. We compared short- and long-term results of MIDCAB vs. FS-OPCAB revascularization over a maximum follow-up period of 10 years.

Patients and methods

From December 2009 to June 2020, 388 elective patients were included in our retrospective study. 229 underwent MIDCAB, and 159 underwent FS-OPCAB LIMA-to-LAD grafting. Inverse probability of treatment weighting (IPTW) was used to adjust for selection bias and to estimate treatment effects on short- and long-term outcomes. IPTW-adjusted Kaplan-Meier estimates by study group were calculated for all-cause mortality, stroke, the risk of repeat revascularization and myocardial infarction up to a maximum follow-up of 10 years.

Results

MIDCAB patients had less rethoracotomies (n = 13/3.6% vs. n = 30/8.0%, p = 0.012), fewer transfusions (0.93 units ± 1.83 vs. 1.61 units ± 2.52, p < 0.001), shorter mechanical ventilation time (7.6 ± 4.7 h vs. 12.1 ± 26.4 h, p = 0.005), and needed less hemofiltration (n = 0/0% vs. n = 8/2.4%, p = 0.004). Thirty-day mortality did not differ significantly between the two groups (n = 0/0% vs. n = 3/0.8%, p = 0.25). Long-term outcomes did not differ significantly between study groups. In the FS-OPCAB group, the probability of survival at 1, 5, and 10 years was 98.4%, 87.8%, and 71.7%, respectively. In the MIDCAB group, the corresponding values were 98.4%, 87.7%, and 68.7%, respectively (RR1.24, CI0.87-1.86, p = 0.7). In the FS group, the freedom from stroke at 1, 5, and 10 years was 97.0%, 93.0%, and 93.0%, respectively. In the MIDCAB group, the corresponding values were 98.5%, 96.9%, and 94.3%, respectively (RR0.52, CI0.25-1.09, p = 0.06). Freedom from repeat revascularization at 1, 5, and 10 years in the FS-OPCAB group was 92.2%, 84.7%, and 79.5%, respectively. In the MIDCAB group, the corresponding values were 94.8%, 90.2%, and 81.7%, respectively (RR0.73, CI0.47-1.16, p = 0.22).

Conclusion

MIDCAB is a safe and efficacious technique and offers comparable long-term results regarding mortality, stroke, repeat revascularization, and freedom from myocardial infarction when compared to FS-OPCAB.

Long-Term Outcomes After Hybrid Coronary Revascularization Versus Coronary Artery Bypass Grafting: Meta-Analysis of Kaplan-Meier-Derived Data

Hybrid coronary revascularization (HCR) is an alternative option to conventional coronary artery bypass grafting (CABG), but the long-term outcomes of HCR versus CABG remain unclear. We aimed to analyze the long-term outcomes after HCR and CABG for patients with multivessel coronary artery disease using meta-analysis. A systemic literature search of PubMed and EMBASE was performed from inception to March 2023. Studies reporting Kaplan-Meier curves with follow-up ≥1 year were included. The primary outcome was all-cause mortality, and the secondary outcomes were major adverse cardiac and cerebrovascular events (MACCEs) and repeat revascularization. In total, 13 studies (1 randomized controlled trial and 12 propensity-score matched observational studies) were analyzed. The mean follow-up period was 5.1 ± 3.1 years. HCR was associated with similar overall mortality (hazard ratio [HR] 1.09, 95% confidence interval [CI] 0.87 to 1.36), significantly higher incidence of MACCEs (HR 1.49, 95% CI 1.07 to 2.06), and repeat revascularization (HR 2.01, 95% CI 1.53 to 2.64) compared with CABG. In phase-specific analysis, the mortality rate was similar, and the incidence of repeat revascularization was higher in HCR regardless of phases. The incidence of MACCEs was higher in HCR during the mid-term phase (1 to 5 years), but it was similar during the long-term phase (long-term: ≥5 years). In conclusion, despite the higher incidence of MACCEs and repeat revascularization compared with CABG, HCR offered a similar long-term survival. Even longer-term follow-up and randomized controlled trials with a large population are warranted to investigate the role of HCR for multivessel coronary artery disease.