Hybrid coronary revascularization versus off-pump coronary artery bypass grafting and percutaneous coronary intervention for the treatment of two-vessel coronary artery disease with proximal left anterior descending artery stenosis

Alternative Approaches to Coronary Artery Bypass Grafting Versus Percutaneous Coronary Intervention, How Do They Compare?: A Systematic Review and Meta-Analysis

Coronary artery disease (CAD) is a leading cause of mortality worldwide. Severe symptomatic CAD is treated with coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI). Alternative CABG (ACABG) approaches including thoracotomy, off-pump, total endoscopic, and robotic-assisted CABG are increasing in prevalence to address the increased early risk of CABG. This systematic review and meta-analysis aims to review the contemporary literature comparing outcomes after ACABG and PCI. Pubmed, Medline, and Embase were systematically searched by 2 authors for articles comparing the outcomes after ACABG and PCI. A total of 1154 articles were screened, and 11 were included in this review. The RevMan 5.4 software was used to perform a meta-analysis of the pooled data. Individual studies found rates of long-term survival, major adverse cardiovascular and cerebrovascular events (MACCE), myocardial infarction (MI), and repeat revascularization either favored ACABG or did not differ significantly. Pooled estimates of the compiled data identified rates of MACCE, MI, and repeat revascularization favored ACABG. The results of this review demonstrated the favorable rates of long-term mortality, MACCE, MI, and repeat revascularization for ACABG in addition to similar short-term mortality and stroke when compared with PCI. Advancement of both CABG and PCI continues to improve patient outcomes. With the increasing prevalence of ACABG, similar studies will need to be undertaken with further direct comparisons between ACABG and PCI. Finally, hybrid revascularization should continue to be explored for its combined benefits of long-term outcomes, short-term safety, and ability to achieve complete revascularization.

Need for repeat revascularisation in hybrid coronary revascularisation vs. percutaneous coronary intervention

Hybrid coronary revascularisation (HCR), being a treatment path combining both coronary artery bypass grafting and percutaneous coronary intervention (PCI) approaches, offers the advantages of both methods in patients with multi-vessel coronary artery disease. Since available literature provides few studies comparing the need for repeat revascularisation (RR) after HCR in comparison to PCI, our review aimed at summarising the latest data on this topic from the last 5 years (2018-2023). The search was conducted within the PubMed and Embase databases, followed by application of inclusion and exclusion criteria and providing a summary of data and characteristics of eligible studies. On the basis of 7 records included in the final analysis, RR and/or follow-up target vessel revascularisation (TVR) were significantly less frequently required in the case of HCR than in PCI in 3 out of 7 records, whereas the remaining four provided no significant differences in analysed rates between the 2 therapeutic pathways. When it comes to lowering the necessity for follow-up TVR and/or RR in a fraction of instances, HCR demonstrates a significant advantage over PCI. The complexity of outcomes associated with these therapies is emphasised by the fact that no statistically significant differences were observed between the 2 methods in the remaining 4 records.

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.

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

BACKGROUND

Although evidence is sufficient to confirm that hybrid coronary revascularization (HCR) is safe and effective in the short term, its value in the long run is debatable.

OBJECTIVES

This study sought to compare the long-term outcomes of HCR with coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) for multivessel disease.

METHODS

Three groups of patients, 540 each, receiving HCR, CABG, or PCI between June 2007 to September 2018, were matched using propensity score matching. Patients were stratified by EuroSCORE (European System for Cardiac Operative Risk Evaluation) II (low ≤0.9; 0.9 < medium <1.5; high ≥1.5) and SYNTAX (Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery) score (low ≤22; 22 < medium <33; high ≥33). Major adverse cardiac and cerebrovascular events (MACCE) and Seattle Angina Questionnaire (SAQ) scores were compared among the 3 groups.

RESULTS

In terms of MACCE and SAQ, HCR performed similarly to off-pump CABG 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).

CONCLUSIONS

Compared with conventional strategies, HCR provided satisfactory long-term outcomes in MACCE and functional status for multivessel disease.

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.

Comparison of hybrid coronary revascularization versus coronary artery bypass grafting in patients with multivessel coronary artery disease: a meta-analysis

BACKGROUND

Percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) are widely used in the treatment of coronary heart disease, but the best revascularization method for multivessel coronary artery disease (MVD) patients is still controversial. Hybrid coronary revascularization (HCR), together with CABG and PCI, have been proved to be feasible methods, but the long-term effect of HCR is not as clear as CABG.

METHOD

By October 2020, we retrieved articles from PubMed, Web of science, EMBASE and Cochrane library databases. The main results are based on major adverse cardiovascular and cerebral events (MACCE).

RESULT

A total of 18 articles (3 randomized controlled trials (RCTs) and 15 observational studies) were included in this meta-analysis. The outcomes of MACCE in the HCR group at perioperative, short-term (30 days to 1 year), medium-term (1 year to 5 years) and long-term (5 years and above) follow-up period were similar to those in the CABG group. The mortality rates of patients in perioperative, short-term and medium-term follow-up were similar to those in the CABG group, but lower than that in the CABG group at long-term follow-up (OR = 0.35, 95% CI 0.18-0.69, p = 0.002). The revascularization rate was higher in the HCR group during the perioperative period (OR = 3.50, 95% CI 2.07-5.94, p < 0.001), short-term (OR = 3.28, 95% CI 1.62-6.64, p < 0.001) and mid-term follow-up (OR = 2.84, 95% CI 1.64-4.92, p < 0.001).

CONCLUSION

Our results reveal that HCR is a safe and therapeutically effective alternative in treatments for MVD patients. It has not only less short-term adverse effect, but also better long-term effect, especially in death.

Hybrid revascularization vs. coronary bypass for coronary artery disease: a systematic review and meta-analysis

INTRODUCTION

Coronary artery bypass graft is the mainstay of treatment for multivessel coronary artery disease and is superior to percutaneous coronary intervention. Combined approaches such as hybrid coronary revascularization integrate coronary artery bypass grafting with percutaneous coronary intervention during the same procedure or weeks apart. These attempt to improve surgical morbidity and long-term outcomes.

EVIDENCE ACQUISITION

Per PRISMA criteria, a systematic review of keywords "Hybrid Revascularization," "Hybrid Coronary Revascularization," "Surgical," "Surgery," "Treatment," "CABG," "HCR" and "PCI" was conducted in PubMed, EMBASE and SCOPUS. Studies comparing this technique's performance on either single or two-stage approach against traditional multiple vessel coronary artery bypass grafting were screened and analyzed for our review.

EVIDENCE SYNTHESIS

Twenty-two studies totaling 6981 participants were ultimately included for analysis. Mean differences in operative time, bleeding, ventilator time and length of stay were significantly lower in the hybrid coronary revascularization group. Odds ratios in transfusions and in-hospital myocardial infarction were also lower in the hybrid coronary revascularization group. Results for in-hospital and all-cause mortality, major adverse cardiac events (MACE), stroke, reintervention, and complete revascularization were not significantly different.

CONCLUSIONS

Our analysis shows hybrid coronary revascularization is a feasible alternative to traditional coronary artery bypass grafting. Short-and long-term outcomes including mortality, MACE, and postoperative morbidity are similar between both groups, while hybrid approaches are associated with decreased perioperative morbidity.

Hybrid coronary revascularization versus percutaneous coronary intervention: A systematic review and meta-analysis

BACKGROUND

Hybrid coronary revascularization (HCR) is an emerging approach for multivessel coronary artery disease (MVD) which combines the excellent long-term outcomes of surgery with the early recovery and reduced short-term complications of percutaneous coronary intervention (PCI). Here, we evaluated the effectiveness of HCR compared to PCI in patients with MVD.

METHODS

A systematic database search in PubMed/MEDLINE, Embase, Scopus, and CENTRAL/CCTR was conducted by June 2021. Random-effects meta-analysis was performed, comparing major adverse cardiac and cerebrovascular events (MACCE) at 30 days and at latest follow-up between patients undergoing HCR versus PCI.

RESULTS

A total of 27,041 patients (HCR: 939 patients, PCI: 26,102 patients) were included from seven studies published between 2013 and 2021. At latest follow-up, HCR was associated with lower rates of myocardial infarction (OR 0.40, 95% CI 0.20-0.80, p = 0.010) and target vessel revascularization (OR 0.49, 95% CI 0.37-0.64, p < 0.001), while the difference for MACCE did not reach statistical significance (OR 0.46, 95% CI 0.20-1.05, p = 0.061). No differences were observed in terms of 30-day outcomes, nor rates of mortality or stroke at latest follow-up.

CONCLUSIONS

HCR might be a valid alternative to multivessel PCI, demonstrating a lower incidence of MI and TVR. Center experience, well-coordinated heart team discussions, and good patient selection likely remain essential to ensure optimal outcomes. Future comparative studies are required to define the optimal target population.

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.

In patients with multi-vessel coronary artery diseases, does hybrid revascularization provide similar outcomes to conventional coronary artery bypass grafting?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: In [patients with multivessel coronary artery diseases (CAD)] is [hybrid revascularization (HCR)] equal to [coronary artery bypass grafting (CABG)] in regard to [mortality, myocardial infarction, stroke and target vessel revascularization (TVR)]? Three-hundred and fifty-five papers were found using the reported search, of which 8 represented the best evidence to answer the question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. The studies included 4 observational studies, 3 randomized controlled trials (RCTs) and 1 meta-analysis. The meta-analysis consisted of predominantly observational data with 1 randomized controlled trial and suggested non-significant differences in all major clinical outcomes. The observational studies generally cited benefit towards hybrid revascularization on the basis of equivalent major clinical outcomes rates compared to coronary artery bypass grafting, yet favourable in-hospital outcomes. One randomized controlled trial provided robust evidence of equivalent 5-year outcomes; however, the others were insufficiently powered for an effective comparison. There is a paucity of robustly designed studies to answer our clinical question effectively, given hybrid procedures are not routine in clinical practice. On the basis of mostly observational and small randomized cohorts with relatively short follow-up intervals, we conclude that current evidence suggests similar mid-term rates of major clinical outcomes after hybrid revascularization and coronary artery bypass grafting. However, without longer-term follow-up, the comparison of the two techniques, particularly relating to repeat revascularization, is still very much uncertain.

Hybrid coronary revascularization versus total arterial revascularization for the treatment of left main coronary artery disease

BACKGROUND

Hybrid coronary revascularization (HCR) has a similar clinical outcome to coronary artery bypass grafting (CABG) in treating multivessel disease. However, the outcome of HCR in treating left main coronary artery (LM) disease is unclear. This study sought to compare the clinical outcome of HCR with total arterial revascularization (TAR) for treating LM disease.

METHODS

Patients who underwent treatment for LM disease in our center between January 2009 and December 2019 were selected. Of these, 33 patients underwent HCR, and 70 patients underwent TAR. The primary efficacy outcome of this study was mid-term major adverse cardiac and cerebrovascular events (MACCE). The primary safety outcome was perioperative MACCE.

RESULTS

The incidence of postoperative outcomes was comparable between the two groups after adjustment with inverse probability weighting (IPW) (P>0.05). The median follow-up time was 47 (interquartile range, 20 to 85) months. There was no significant difference in the incidence of all mid-term outcomes and the freedom of MACCE between the two groups after adjustment (P>0.05). The Cox proportional hazard model demonstrated that HCR was not a significant determinant for MACCE [hazard ratio (HR) =3.516, 95% confidence interval (CI): 0.835 to 14.813].

CONCLUSIONS

HCR may be safe and effective for the treatment of LM disease compared with TAR.

Hybrid coronary revascularization: are we there yet?

PURPOSE OF REVIEW

With advances in minimally invasive surgical and percutaneous coronary therapies, hybrid coronary revascularization (HCR) is well positioned to be an ideal strategy for revascularization in selected patients with multivessel coronary artery disease (CAD). The purpose of this review is to highlight recent outcomes and comparative effectiveness studies of HCR.

RECENT FINDINGS

Patients undergoing HCR have comparable outcomes compared with coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI). The major benefits compared with CABG appear to be related to short-term morbidity and resource utilization. Compared with PCI, HCR may decrease repeat revascularization rates by decreasing reintervention of the left anterior descending coronary artery.

SUMMARY

Although HCR is associated with a significant learning curve, specifically with minimally invasive CABG techniques, the early outcomes remain promising and should be considered as a viable option for revascularization in select patients with multivessel CAD.