Clinical outcomes after hybrid coronary revascularization versus off-pump coronary artery bypass: a prospective evaluation

Is hybrid coronary revascularization really beneficial in the long term?

 

OBJECTIVES

This analysis aimed to compare both short- and long-term outcomes of hybrid coronary revascularization (HCR) with different techniques and coronary artery bypass grafting (CABG).

METHODS

Twenty-three studies were included, covering 10 468 different patients, among whom 2403 patients underwent HCR with either simultaneous or staged method and 8065 patients underwent CABG.

RESULTS

Compared with CABG, HCR had a statistically significant lower risk of stroke [odds ratio (OR) = 0.55, P = 0.049], major adverse cardiac and cerebrovascular events (OR = 0.69, P = 0.024) and blood transfusion (BT) (OR = 0.39, P < 0.001), whereas no significant differences were detected in mortality, myocardial infarction and repeat revascularization. A network meta-analysis showed that simultaneous HCR had significantly better outcomes in stroke (OR = 0.24, P = 0.01) and major adverse cardiac and cerebrovascular events (OR = 0.29, P < 0.001), and staged HCR had a significantly better outcome in BT (OR = 0.31, P < 0.001). According to the frequentist statistic results, simultaneous HCR had the highest probability of being the best treatment in terms of mortality (84%), stroke (97%), myocardial infarction (88%) and major adverse cardiac and cerebrovascular events (99%), whereas staged HCR had the highest probability of being the best in postoperative repeat revascularization (59%) and BT (83%). However, long-term results showed no significant difference between the HCR and CABG techniques.

CONCLUSIONS

HCR appears to be a feasible option for multivessel coronary artery disease patients. Compared to traditional CABG, HCR had lower risk of adverse events in the short term, but in the long term, survival rate and freedom from major adverse cardiac and cerebrovascular events rate were similar between groups.

Review of Contemporary Techniques for Minimally Invasive Coronary Revascularization

Minimally invasive coronary revascularization techniques aim to avoid median sternotomy with its associated complications, while facilitating recovery and maintaining the benefits of surgical revascularization. The 3 most common procedures are minimally invasive coronary artery bypass grafting, totally endoscopic coronary artery bypass, and hybrid coronary revascularization. For a variety of reasons, including cost and technical difficulty, not many centers are routinely performing minimally invasive coronary revascularization. Nevertheless, many studies have assessed the safety and efficacy of each of these procedures in different clinical contexts. Thus far results have been promising, and with the evolution of procedural techniques, these approaches have the potential to redefine coronary revascularization in the future. This review highlights the current state of minimally invasive coronary revascularization techniques by exploring their benefits, identifying barriers to their adoption, and discussing future potential paradigms.

Minimally invasive coronary surgery

Minimally invasive options for coronary artery bypass graft (CABG) surgery progressed dramatically in the last decades. Minimally invasive CABG surgery is presented trough these forms: minimally invasive direct coronary artery bypass (MIDCAB), endoscopic atraumatic coronary artery bypass (EndoACAB), robot-assisted direct coronary artery bypass (RADCAB), total endoscopic coronary artery bypass (TECAB), and hybrid coronary revascularisation (HCR). Unfortunately, these are still limited only to the specialised centres across the world and have not been accepted by the majority of cardiac surgeons. A surgeon who is starting to practice minimally invasive CABG surgery needs to be ready for long duration of the interventions, higher rate of conversions to sternotomy and significant learning curve. Excellent results that have been published on the subject of minimally invasive revascularisation methods support the potential of these alternative approaches to evolve in the near future.

Current landscape of hybrid revascularization: A report from the NCDR CathPCI Registry

BACKGROUND

Hybrid revascularization, combining percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG), may be used differently across hospitals. How outcomes compare with multivessel PCI is unknown.

METHODS

We studied hybrid revascularization use in patients in the National Cardiovascular Data Registry from 2009 to 2017 who underwent PCI for multivessel coronary artery disease (CAD) at 711 hospitals, excluding patients with prior CABG, acute ST-elevation myocardial infarction, emergency/salvage CABG, or PCI without stent placement. In-hospital mortality associated with hybrid revascularization versus multivessel PCI was compared using a multivariable logistic model.

RESULTS

Among 775,000 patients with multivessel CAD, 1,126 (0.2%) underwent hybrid revascularization and 256,865 (33%) were treated with multivessel PCI. Although 358 (50.4%) hospitals performed hybrid revascularizations, most (97.3%) performed <1 per year. Most patients (68.7%) treated with hybrid revascularization underwent CABG after PCI; only 79.4% of these patients were discharged on P2Y12 inhibitors. Patients who underwent hybrid revascularization were younger and more likely to have significant left main or proximal left anterior descending disease. Unadjusted in-hospital mortality rates were higher among patients treated with hybrid revascularization than multivessel PCI (1.5% vs 0.9%, P = .02), a difference that was not significant after multivariable adjustment (odds ratio = 1.54, 95% CI = 0.92-2.59).

CONCLUSIONS

Hybrid revascularization remains an infrequently used treatment modality for multivessel CAD. Risk-adjusted in-hospital mortality was no different between hybrid revascularization and multivessel PCI; however, patients who underwent hybrid revascularization were less likely to be discharged on P2Y12 inhibitor therapy despite stent implantation.

Hybrid myocardial revascularization

Background

In patients with advanced coronary artery disease (CAD), coronary artery bypass grafting (CABG) is associated with improved long-term outcomes while percutaneous coronary intervention (PCI) is associated with lower periprocedural complications. A new approach has emerged in the last decade that attempts to reap the benefits of bypass surgery and stenting while minimizing the shortcomings of each approach, hybrid myocardial revascularization (HMR).Three strategies for timing of the hybrid revascularization exists, each with their own inherent advantages and shortcomings: (1) CABG followed by PCI, (2) PCI followed by CABG, or (3) simultaneous CABG + PCI in a hybrid suite.

Studies

The results of the first randomized control trial comparing HMR (CABG first) and standard CABG, POL-MIDES (Prospective Randomized PilOt Study EvaLuating the Safety and Efficacy of Hybrid Revascularization in MultIvessel Coronary Artery DisEaSe), show HMR was feasible for 93.9% of patients whereas conversion to standard CABG was required for 6.1%. At 1 year, both groups had similar all-cause mortality (CABG 2.9% vs. HMR 2%) and major adverse clinical event (MACE)-free survival rates (CABG 92.2% vs. HMR 89.8%). Results of observational and comparative studies show that minimally invasive HMR procedures in patients with multivessel CAD carry minimal perioperative mortality risk and low morbidity and do not increase the risk of postoperative bleeding. The advantage they offer in comparison to classical surgical revascularization is indeed faster rehabilitation and patient's return to normal life.

Conclusion

Hybrid myocardial revascularization has been developed as a promising technique for the treatment of high-risk patients with CAD. Hybrid revascularization using minimally invasive surgical techniques combined with PCI offers to a part of patients an advantage of optimal revascularization of the most important artery of the heart, together with adequate myocardial revascularization in a relatively delicate way. Indeed, to patients with high operative risk of standard surgery, it offers an alternative which should be considered carefully.

Is There a Role for Diagonal Coronary Artery Stenting in Patients Undergoing Robotic Coronary Artery Bypass Graft Surgery?

Background

The efficacy of diagonal coronary artery stenting in patients undergoing robotic left internal thoracic artery-to-left anterior descending (LITA-to-LAD) anastomosis is not well defined. The objective of this study was to assess graft and stent patency in a single-stage hybrid revascularization with LITA-to-LAD anastomosis and PCI to a diagonal coronary artery.

Methods

From 2004 to 2014, a total of 25 patients consented to robotic-assisted LITA harvesting and a small left anterior thoracotomy for off-pump coronary artery bypass anastomosis onto the LAD along with concomitant PCI to the diagonal coronary artery. PCI to the diagonal coronary artery was performed in the same fluoroscopy-equipped hybrid operating room.

Results

Patients were on average 66 ± 11 years with 32% female. Pre-operative characteristics of these patients included 8% with a grade 3 or 4 left ventricle, 16% with a recent MI, and 92% with CCS III/IV symptoms. There were no death, one patient required an intra-aortic balloon pump, and one patient required re-operation for bleeding. The average ICU stay was 1.1 ± 0.53 days, and the average hospital stay was 4.6 ± 2.4 days. Fitzgibbon Grade A LITA-to-LAD patency at 6-month follow-up was 100%. As well, at 6-month follow-up the DES to the diagonal coronary artery had a patency rate of 96%.

Conclusions

Single-stage hybrid revascularization strategy for bifurcating lesions of the LAD and diagonal coronary arteries with LITA-to-LAD anastomosis and PCI to a diagonal coronary artery appears to have acceptable clinical results with excellent 6-month angiographic patency results.

Short-Term and Mid-Term Clinical Outcomes Following Hybrid Coronary Revascularization Versus Off-Pump Coronary Artery Bypass: A Meta-Analysis

BACKGROUND

Off-pump coronary artery bypass grafting (OPCAB) is one of the standard treatments for coronary artery disease (CAD) while hybrid coronary revascularization (HCR) represents an evolving revascularization strategy. However, the difference in outcomes between them remains unclear.

OBJECTIVE

We performed a meta-analysis to compare the short-term and mid-term outcomes of HCR versus OPCAB for the treatment of multivessel or left main CAD.

METHODS

We searched the PubMed, EMBASE, Web of Science and Cochrane databases to identify related studies and a routine meta-analysis was conducted.

RESULTS

Nine studies with 6121 patients were included in the analysis. There was no significant difference in short-term major adverse cardiac and cerebrovascular event (MACCE) rate (RR: 0.55, 95% CI: 0.30-1.03, p = 0.06) or mortality (RR: 0.51, 95% CI: 0.17-1.48, p = 0.22). HCR required less ventilator time (SMD: -0.36, 95% CI: -0.55- -0.16, p < 0.001), ICU stay (SMD: -0.35, 95% CI: -0.58 - -0.13, p < 0.01), hospital stay (SMD: -0.29, 95% CI: -0.50- -0.07, p < 0.05) and blood transfusion rate (RR: 0.57, 95% CI: 0.49-0.67, p < 0.001), but needed more operation time (SMD: 1.29, 95% CI: 0.54-2.05, p < 0.001) and hospitalization costs (SMD: 1.06, 95% CI: 0.45-1.66, p < 0.001). The HCR group had lower mid-term MACCE rate (RR: 0.49, 95% CI: 0.26-0.92, p < 0.05) but higher rate in mid-term target vessel revascularization (TVR, RR: 2.20, 95% CI: 1.32-3.67, p < 0.01).

CONCLUSIONS

HCR had similar short-term mortality and morbidity comparing to OPCAB. HCR decreased the ventilator time, ICU stay, hospital stay, blood transfusion rate and increased operation time and hospitalization costs. HCR has a lower mid-term MACCE rate while OPCAB shows better in mid-term TVR.

The future of off-pump coronary artery bypass grafting: a North American perspective

Off-pump coronary artery bypass graft (OPCAB) is currently performed routinely in a minority of specialized centers and in many more centers, utilized only when a porcelain aorta mandates a no-touch aortic technique. The OPCAB literature can be summarized as follows: (I) large-scale randomized trials in relatively low risk patients that include surgeons with a range of experience demonstrating no consistent beneficial differences in major cardiovascular and cerebrovascular outcomes but lower transfusion rates and shorter length of stay, tempered by some reports of higher rates of incomplete revascularization and lower rates of long term graft patency; (II) smaller randomized controlled trials (RCTs) from highly specialized programs demonstrating equivalent or superior outcomes with OPCAB and similar completeness of revascularization and graft patency; and (III) observational data from large databases demonstrating a consistent benefit of OPCAB, especially in higher-risk patient subsets. Our rationale for OPCAB remains that if complete and precise revascularization can be safely and routinely accomplished, then the patient should benefit by avoiding the morbidities that can be attributed to aortic cannulation/clamping, cardiopulmonary bypass (CPB), hemodilution, hypothermia and global myocardial ischemia/cardioplegia. We further believe that OPCAB procedures should emphasize the use of arterial grafts to optimize long term patency and minimize aortic manipulation to limit the risk of stroke. Moving forward, the off-pump surgical community and specialty societies must address the challenge of training surgeons and their teams to master this technically demanding procedure. Furthermore, OPCAB opens the door to minimally-invasive surgical revascularization via hybrid coronary revascularization (HCR). A large NIH-funded RCT is currently underway to determine whether hybrid revascularization can offer a superior alternative to multi-vessel percutaneous coronary intervention for patients with low SYNTAX score and proximal LAD disease.

Short-term clinical outcomes after hybrid coronary revascularization versus off-pump coronary artery bypass for the treatment of multivessel or left main coronary artery disease: a meta-analysis

Background

Hybrid coronary revascularization (HCR) and off-pump coronary artery bypass grafting (OPCABG) are both feasible, less invasive techniques for coronary revascularization. Although both techniques utilize the left internal mammary artery to left anterior descending artery graft, HCR uses drug-eluting stents instead of saphenous vein bypass. It remains unclear whether HCR is equal to, better or worse than OPCABG.

Methods and results

A meta-analysis was carried out using a random-effects model. Seven observational studies were included. There was no significant difference either in in-hospital mortality [relative risk (RR) 0.57, 95% confidence interval (CI) 0.13–2.59, P=0.47] or in the MACCE rate (RR 0.63, 95% CI 0.24–1.64, P=0.34) between the HCR group and the OPCABG group. A significant difference was observed between the two groups in the length of hospitalization (RR 0.55, 95% CI 0.13–0.97, P=0.01), length of ICU stay (RR 0.45, 95% CI 0.10–0.80, P<0.05), intubation time (RR 0.48, 95% CI 0.13–0.84, P<0.01), need for red blood transfusion (RR 0.67, 95% CI 0.56–0.82, P<0.001), and total in-hospital costs (RR 0.90, 95% CI 0.39–1.42, P<0.01).

Conclusion

Compared with OPCABG, HCR did not improve early survival but decreased the length of hospitalization, length of ICU stay, intubation time, and need for red blood transfusion, and increased total in-hospitalcosts.

Hybrid coronary revascularization: a systematic review

The hybrid approach to coronary revascularization is an evolving technique that is being used as an alternative to the traditional median sternotomy coronary artery bypass graft surgery. It combines a minimally invasive approach to bypass the left anterior descending coronary artery with a percutaneous approach to revascularize the other coronary arteries. A systematic review of the available literature was conducted to evaluate the benefits, and the short- and long-term outcomes of this procedure.

Hybrid coronary revascularization versus coronary artery bypass grafting for multivessel coronary artery disease: systematic review and meta-analysis

BACKGROUND

The concept of hybrid coronary revascularization (HCR) combines the left internal mammary artery (LIMA)-left anterior descending (LAD) graft and percutaneous coronary intervention (PCI) to non-LAD vessels. Multiple comparative studies have evaluated the safety and feasibility of HCR and coronary artery bypass grafting (CABG) for multivessel coronary artery disease (MCAD). However, the sample size of each study was small, and evidences based on single-institutional experience. The purpose of this meta-analysis was to compare the short-term outcomes of HCR with those of CABG for MCAD.

METHOD

PubMed, EMBASE and Cochrane Library databases, as well as conference proceedings, were searched for eligible studies published up to March 2014. We calculated summary odds ratios (OR) for primary endpoints (death, stroke; myocardial infarction (MI); target vessel revascularization (TVR); major adverse cardiac or cerebrovascular events (MACCEs)) and secondary endpoints (atrial fibrillation (AF); renal failure; length of stay in the intensive care unit (LoS in ICU); length of stay in hospital (LoS in hospital); red blood cell (RBC) transfusion). Data from 6176 participants were derived from ten cohort studies.

RESULTS

HCR was non-inferior to CABG in terms of MACCEs during hospitalization (odds ratio (OR), 0.68, 95% confidence interval (CI), 0.34-1.33)and at one-year follow-up(0.32, 0.05-1.89) , and no significant difference was found between HCR and CABG groups in in-hospital and one-year follow-up outcomes of death, MI, stroke, the prevalence of AF and renal failure, whereas HCR was associated with a lower requirement of RBC transfusion and shorter LoS in ICU and LoS in hospital than CABG (weighted mean difference (WMD) -1.25, 95% CI, -1.62 to -0.88; -17.47, -31.01 to -3.93; -1.77, -3.07 to -0.46; respectively).

CONCLUSION

Our meta-analysis indicates that HCR is feasible, safe and effective for the treatment of MCAD, with similar in-hospital and one-year follow-up outcome, significantly lower requirement of RBC transfusion, and faster recovery compared with CABG.

Status quo of hybrid coronary revascularization for multi-vessel coronary artery disease

Hybrid coronary revascularization (HCR) combines bypass grafting of the left anterior descending (LAD) coronary artery with percutaneous coronary intervention (PCI) of non-LAD vessels. HCR has been performed as an alternative to CABG or multi-vessel PCI in thousands of patients since the late 1990s. In this review article, we provide an overview on patient selection, procedural sequence and timing, use of surgical techniques and anti-platelet agents. Additionally, patient recovery, satisfaction, costs and clinical outcomes of individual studies after HCR are evaluated. Future directions are also discussed, including the need for adequately powered randomized trials.

Effect of one-stop hybrid coronary revascularization on postoperative renal function and bleeding: a comparison study with off-pump coronary artery bypass grafting surgery

OBJECTIVES

Although 1-stop hybrid coronary revascularization offers potential benefits for selected patients with multivessel coronary artery disease, the exposure to contrast dye and potent antiplatelet drugs could increase the risk of postoperative acute kidney injury and coagulopathy. The goal of the present study was to compare the measures of renal function, postoperative bleeding, and transfusion requirements in patients undergoing hybrid revascularization compared with off-pump coronary artery bypass grafting (CABG).

METHODS

We retrospectively analyzed the data from 141 consecutive patients who had undergone 1-stop hybrid coronary revascularization from June 2007 to January 2011. Propensity score matching with 141 off-pump CABG patients from our surgical database was performed for comparison. The change in renal function, cumulative chest tube drainage, and clinical outcome parameters were compared between the 2 groups.

RESULTS

Compared with off-pump CABG, patients undergoing hybrid revascularization had significantly less chest tube drainage at 12 hours after surgery (P = .04) and for the total amount during the postoperative period (P < .001) and required fewer blood transfusions (P = .001). The hybrid group had a higher incidence of acute kidney injury, but this did not reach statistical significance (25.2% vs 17.6%, P = .13). The hybrid group required less inotropic and vasoactive support, had fewer respiratory complications, required a shorter time of mechanical support, and had a decreased length of intensive care unit stay.

CONCLUSIONS

Compared with off-pump CABG, 1-stop hybrid coronary revascularization was associated with benefits such as less postoperative bleeding and blood transfusion requirements without significantly increasing the additional risk of acute kidney injury.

Perioperative outcomes in hybrid versus conventional surgical coronary artery revascularisation

A best evidence topic was written on perioperative outcomes in hybrid coronary revascularisation according to a structured protocol. The question addressed was 'In patients with stable multivessel coronary artery disease, does the use of hybrid coronary revascularisation compared to conventional and off-pump coronary artery bypass grafting (CABG) reduce perioperative morbidity and mortality?' Six hundred and twenty-three papers were found in the literature search. From these results, six comparative studies and one review paper appeared to be relevant. The authors, journal, date and country of publication, patient group studied, study type, relevant results and weaknesses of these papers were compiled and tabulated. Critical appraisal ruled out three of the six comparative studies identified by the search. Therefore, the following papers constituted best evidence. de Cannière et al. reported a non-randomised retrospective comparison of staged hybrid revascularisation with conventional CABG, showing an association with shorter intensive care unit and total hospital stays, as well as shorter time to return to work. Kon et al. reported a non-randomised retrospective comparison of simultaneous hybrid revascularisation with off-pump CABG, showing that fewer blood transfusions were required in addition to shorter intensive care and hospital stays. Vassiliades et al. reported a non-randomised retrospective comparison of staged hybrid revascularisation with off-pump CABG, which failed to show a difference between 30-day major adverse cardiac events in the two patient groups. DeRose reviewed 13 published series of hybrid revascularisation cases, concluding that experienced centres should consider hybrid revascularisation as an appropriate alternative to conventional CABG for selected patients. In summary, these papers provide limited evidence of improved perioperative outcomes in both staged and simultaneous hybrid revascularisation compared to CABG. Weaknesses of the comparative studies include the lack of mid-term and long-term follow-up and the difficulty of generalising results from specialist units to general cardiac surgical practice. A large randomised control trial comparing hybrid revascularisation and coronary artery bypass with mid-term follow-up will be required to establish the clinical effectiveness of this procedure.