Original title: One-Stop Hybrid Coronary Revascularization versus Coronary Artery Bypass Graft and Percutaneous Coronary Intervention for the Treatment of Multivessel Coronary Artery Disease: Three-Year Follow-up Results from A Single Institution. Reference: Liuzhong Shen et al. J Am Coll Cardiol Intv 2013. Article in press. Accepted Manuscript.
A mammary bridge to anterior descending artery (LMCA) with a permeability > 90% at 10 years contributes mainly to the advantage of surgery but, on the other hand, is a relatively high-risk procedure since vein bridges differ in permeability, (up to 25% occlude per year), from other vessels. Angioplasty in patients with multiple vessels is much less invasive but repeat revascularization remains a problem.
The hybrid approach combines the patency advantage of LMCA with minimal invasive angioplasty for other vessel injuries. Both procedures can be performed consecutively in the same act by a multidisciplinary team (Heart Team) in a hybrid room. For this strategy patients with high surgical risk and adverse injuries for angioplasty of anterior descending artery, (i.e. total occlusion, diffuse disease, injury to left main coronary artery), plus favorable lesions in other vessels, were evaluated. Between 2007 and 2010, 141 consecutive patientes were included who all received hybrid revascularization and then compared with those receiving conventional coronary revascularization surgery and multivessel angioplasty matching baseline characteristics of the 3 groups using a propensity score. The primary end point was a composite of death, myocardial infarction, stroke and revascularization (MACCE).
In the hybrid group all patients received LMCA to left anterior descending by mini thoracotomy and angioplasty with drug-eluting stents to other vessels, with an average of 1.9 stents and total stent length of 32.6 mm. The average stents for the PCI group was 2.7 with a total length of 62.8 mm. All surgical group patients received LMCA to left anterior descending and a total mean of 3 of bridges. After 3 years of actuarial survival the hybrid, coronary revascularization surgery and angioplasty groups were 99.3%, 97.2% and 96.5% respectively, (p = 0.34). The combined end point in the hybrid group was significantly lower than in the PCI group, (6.4% versus 22.7%, p <0.001), and similar to the coronary revascularization surgery group, (6.4% versus 13.5%, p = .14). Yet in EuroSCORE tertiles low and medium, the combined end point of the hybrid group was similar to the coronary revascularization surgery and PCI groups. However in EuroSCORE high tertile the hybrid group was superior to coronary revascularization surgery, (p = 0.03), and PCI, (p = 0.006). Regarding the SYNTAX score, for low and middle tertiles the three strategies were similar, however for the last tertile, (score ≥ 30), the hybrid strategy was better than PCI, (p = 0.002), and similar to coronary revascularization surgery, (p = 0.362 ).
Conclusion:
Hybrid revascularization in the same procedure has a favorable evolution for selected patients with multi-vessel lesion, being the most beneficial to those with high surgical risk (EuroSCORE high) or a very challenging anatomy (high SYNTAX score). These initial findings need to be confirmed in larger works.
Comment:
The observed difference between hybrid revascularization and multivessel angioplasty both globally and in the group with high SYNTAX was basically set as expected because of the high revascularization. This increased revascularization was concentrated in the anterior descending artery and was not different to the rest of the vessels. While patients are specially selected, (a multidisciplinary team should be involved in the decision-making), this strategy can offer the benefits of both surgery and angioplasty. The small number of patients and indirect comparison must be considered as a limitation.
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