Long-Term Evolution of Hybrid Coronary Revascularization

Currently, myocardial revascularization surgery (MRS) and percutaneous coronary intervention (PCI) are the available strategies for multivessel coronary artery disease. However, an alternative strategy has long been developed, called hybrid coronary revascularization (HCR), where the anterior descending artery is bypassed with a graft from the mammary artery and the rest of the lesions are treated by PCI.

Evolución a largo plazo de la estrategia de revascularización coronaria híbrida

Different analyses and some randomized studies have been performed using this strategy, all of them with small cohorts and a short follow-up of under 5 years.

An analysis was conducted with patients treated from 2007 to 2018. In total, 70,205 coronary revascularizations were recorded, of which 585 corresponded to patients who received simultaneous HCR (0.83%), 15,118 corresponded to off-pump coronary artery bypass grafting (OP CAB) (21.53%), and 54,502 were cases of PCI (77.63%).

Populations were different, so they were propensity score matched, leaving 540 patients in each group.

Mean patient age was 61 years old, and 80% of subjects were male. Sixty percent of patients had hypertension, 30% had diabetes, 2% had COPD, 0.4% had impaired renal function, 12% had peripheral vascular disease, and 1.7% had atrial fibrillation; 14% had experienced a stroke, 23%, an infarction, and 5.2% had undergone previous PCI.

Ejection fraction was preserved; 38% of patients had LMCA lesions, 62% had 3-vessel lesions, and 26% had 2-vessel lesions.

The Society of Thoracic Surgeons (SYNTAX) mortality score was 28 and the EuroSCORE II was 1.2%.

The stents used were DES of different generations, although some patients received drug-free stents.

The number of vessels revascularized with HCR was lower than with OP CAB (2.1 ± 0.4 vs. 2.5 ± 0.7; p < 0.001), but higher than with PCI (2.1 ± 0.4 vs. 1.4 ± 0.6; p < 0.001).

Residual SYNTAX was higher with HCR than with OP CAB (11.1 ± 6.1 vs. 6.9 ± 7.2; p < 0.001), but lower than with PCI (11.1 ± 6.1 vs. 13.1 ± 7.9; p < 0.001).

The 10-year cumulative major adverse cardiovascular and cerebrovascular events (MACCE) in HCR was similar to OP CAB (28.7% vs. 23.9%; p = 0.15), but significantly lower than for PCI (28.7% vs. 45.3%; p < 0.001). Quality of life was superior in those who underwent HCR and OP CAB compared with those who underwent PCI.

At follow-up, cardiac mortality, all-cause mortality, infarction, and stroke were similar in the 3 groups.

Hospitalizations and reinterventions were higher for those who underwent HCR compared with OP CAB, but lower than in the PCI group.

Patients with low or intermediate EuroSCORE HCR and OP CAB had similar MACCE rates, which were lower than those for patients in the PCI group. In patients with a high EuroSCORE who underwent HCR, the rates for MACCE were lower compared with patients who received the other two strategies.

In those with SYNTAX Score, there was no difference in MACCE, but in the intermediate and high segment the hybrid strategy was similar to OP CAB, though significantly lower than for those who underwent PCI.

Conclusion

Compared with conventional strategies, HCR showed satisfactory evolution during a long-term follow-up in MACCE and in quality of life in multivessel coronary artery disease.