Hybrid Coronary Revascularization 'Satisfactory' Up to 10 Years

Marilynn Larkin

January 11, 2023

For patients with multivessel disease, hybrid coronary revascularization (HCR) produced "satisfactory" outcomes compared with coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) in a long-term, single-center study.

HCR, which combines minimally invasive CABG to the left anterior descending (LAD) coronary artery and PCI for non-LAD lesions, has been shown to be safe and feasible in selected patients with multivessel coronary disease, write Shengshou Hu, MD, of the State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, Beijing, and colleagues. However, most studies have had small sample sizes with short follow-up.

To fill the gap, the researchers compared long-term outcomes with HCR, CABG, and PCI in a 10-year, single-center retrospective analysis that included 1620 patients.

They found that HCR performed similarly to off-pump CABG (OPCAB) with respect to both adverse cardiac and cerebrovascular events (MACCE) and Seattle Angina Questionnaire (SAQ) scores and that it outperformed PCI.

The study was published online on January 9 in JACC: Cardiovascular Interventions.

HCR Revascularization Rate Higher

Across the three groups (540 in each), the mean age of the patients, who were propensity score–matched, was 61 years, and about 83% were men. They received HCR, CABG, or PCI between 2007 and 2018.

Patients were stratified using EuroSCORE (European System for Cardiac Operative Risk Evaluation) II (low < 0.9; medium 0.9 - < 1.5; high > 1.5), and SYNTAX (Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery) score (low < 22; medium 22 - < 33; high > 33).

To minimize the confounding effects of the learning curve, they note, analyses were restricted to HCR interventions performed by three experienced surgeons and excluded each surgeon's first 10 procedures. To reduce selection bias, patients in the CABG group were restricted to those receiving OPCAB.

The main endpoints were MACCE, all-cause mortality, and functional status during follow-up. MACCE was defined as a composite of cardiac mortality, myocardial infarction, stroke, and repeat revascularization.

In the OPCAB group, 533 (98.7%) left internal mammary artery (LIMA) pedicles, three (0.6%) right internal mammary artery pedicles, and four (0.7%) radial artery grafts were bypassed to LAD. In addition, 1011 saphenous vein grafts were bypassed to non-LAD.

In the HCR group, 539 (99.8%) patients received a LIMA–LAD bypass, and one (0.2% received a right internal mammary artery–LAD bypass. All received stents for non-LAD lesions.

At 8 years' follow-up, completion rates were 95.7% for HCR, 96.9% for OPCAB, and 96.5% for PCI.

HCR performed similarly to off-pump CABG but significantly outperformed PCI with respect to MACCE and SAQ. 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 group (EuroSCORE II: low, 30.7% vs 41.2%; medium, 31.3% vs 41.7%; SYNTAX score: medium, 27.6% vs 41.2%; high, 32.4% vs 52.7%).

In the high EuroSCORE II stratum, HCR had a lower MACCE rate than both CABG (31.9% vs 47.0%) and PCI (31.9% vs 53.7%).

The 10-year cumulative MACCE rate after HCR was similar to that of OPCAB (28.7% vs 23.9%), significantly lower than after PCI (28.7% vs 45.3%).

No significant differences were seen in cumulative all-cause mortality among the HCR, OPCAB, and PCI groups (12.7% vs 9.7% vs 15.6%, respectively).

The HCR group scored similarly to the OPCAB group on SAQ scores but scored significantly higher on all domains (physical limitation, angina stability, angina frequency, treatment satisfaction, and quality of life) than the PCI group.

However, among patients who underwent HCR, the incidence of cardiac rehospitalization was higher compared to those who underwent OPCAB (28.5% vs 19.7%) but was lower compared to those who underwent PCI (28.5% vs 50.5%).

"It is noticeable that the residual SYNTAX score, with high points indicating incomplete revascularization, was higher in the HCR group than in the OPCAB group and that patients receiving HCR had a significantly higher cardiac readmission rate, mainly driven by repeated revascularization, when compared with those receiving OPCAB," the authors write. "The noticeable increase...should not be ignored."

Centers Ill-Equipped for HCR

Wayne B. Batchelor, MD, chair of the American College of Cardiology's Interventional Section and director of interventional cardiology and interventional cardiology research at Inova Medical Group in Fairfax, Virginia, commented on the study for theheart.org | Medscape Cardiology.

"Centers that have done HCR have shown that it can be done, it's feasible, and can be done quite safely and effectively," he said. "The problem is, most centers don't have the expertise to do this. They don't have the protocols. They don't have a hybrid lab. You need to be able to coordinate such that the patient gets surgery and then ideally gets PCI the same day. The logistics are difficult."

The combination of a lack of prospective trials and feasibility issues have limited use of this technique in the United States, where only about one half of 1% of procedures are performed as hybrids, he said.

He added, "although the study looked at 10-year outcomes, it was still a retrospective, single-center. nonrandomized study done in China. When you look at the total number of hybrids they did over the study period, it was less than 1% of their procedures. So, this is an extremely selected group."

Overall, Batchelor said, the study is "thought-provocative. It pushes us to consider if we can somehow do a properly performed prospective randomized trial. Historically, when we've tried to do these trials, enrollment has been very difficult, and in order to address our clinical endpoints, you'd need a good-sized trial. So it might take too long and just not be feasible."

Mateusz Tajstra, MD, PhD, of Silesian Center for Heart Diseases in Zabrze, Poland, and colleagues write in a related editorial, "The entire cardiovascular community should become united, following the experience of, for example, oncologists, who have shown that different subspecialties can cooperate and eliminate all barriers in pursuing a common goal: the optimization of treatment.

"It is becoming particularly important now, in light of the data that cast a shadow on the validity of revascularization in general and additionally to support [this] important research...showing that HCR is not merely a technique suitable for a small percentage of patients used by a handful of enthusiasts," they conclude.

The study was was supported by grants from the National Key R&D program. No relevant financial relationships were reported.

JACC: Cardiovasc Interv. Published online January 9, 2022. Abstract, Editorial

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