Hybrid Coronary Revascularization versus Conventional Bypass Surgery in Left Main Coronary Artery Disease

Significant left main coronary artery (LMCA) disease continues to represent a therapeutic challenge, particularly in patients with complex multivessel disease and high SYNTAX scores, in whom coronary artery bypass grafting (CABG) retains a class I recommendation in current guidelines.

Hybrid coronary revascularization (HCR), which combines minimally invasive bypass surgery using the left internal mammary artery to the left anterior descending artery with image-guided percutaneous coronary intervention for the remaining coronary anatomy, has emerged as a less invasive alternative that preserves the prognostic benefit of the mammary graft. The aim of this study was to compare the clinical outcomes of both strategies in patients with LMCA disease treated at a high-volume center.

A single-center, retrospective, observational study was conducted including 761 consecutive patients with significant LMCA stenosis treated between 2019 and 2023 at Emory University (Atlanta, United States). After 1:1 propensity score matching, 118 patients were analyzed (59 HCR and 59 CABG). The mean age of the population was 69 ± 11 years, with a predominance of male patients (83.1%). Left ventricular ejection fraction was preserved (≈55–56%). Most patients had three-vessel disease (69.5% in the HCR group and 74.6% in the CABG group), while the remainder had two-vessel disease associated with LMCA involvement. 

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The mean SYNTAX score was significantly higher in the CABG group (38.8 ± 14.6 vs 31.8 ± 10.8; p = 0.003). Surgical risk scores were low and comparable between groups, with a mean STS score of 1.65 ± 1.67 in the CABG group and 1.71 ± 1.60 in the HCR group (p = 0.73). In the hybrid strategy, all patients underwent minimally invasive robotic LIMA–LAD bypass, followed during the same hospitalization by percutaneous coronary intervention—usually on the following day—systematically performed under intravascular imaging guidance.

The primary endpoint was the incidence of major adverse cardiovascular events (MACE: all-cause mortality, myocardial infarction, repeat revascularization, and stroke), assessed at discharge, 30 days, 6 months, and 1 year. Secondary endpoints included the individual components of MACE, hospital readmissions, the need for mechanical circulatory support devices, transfusion requirements, and length of hospital stay.

Clinical outcomes of hybrid coronary revascularization versus conventional bypass surgery in left main coronary artery disease

The results demonstrated a lower incidence of MACE in the HCR group across all evaluated time points. At 30 days, the MACE rate was 0% in the HCR group compared with 10.2% in the CABG group (p = 0.014); at 6 months, 0% versus 17% (p = 0.002); and at 1 year, 2.4% versus 20.5%, respectively (p = 0.010). One-year MACE-free survival significantly favored the hybrid strategy (p = 0.007), with an unadjusted hazard ratio of 0.10 (95% CI: 0.012–0.797; p = 0.03). 

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No statistically significant differences were observed in mortality, myocardial infarction, or stroke during follow-up, although repeat revascularization at 6 months was lower in the HCR group (0% vs 10.9%; p = 0.024). In addition, patients treated with HCR showed lower rates of periprocedural mechanical circulatory support use (1.7% vs 16.9%; p = 0.002), reduced need for intraoperative transfusions (1.7% vs 19%; p = 0.002), fewer overall postoperative events (32.2% vs 50.8%; p = 0.031), and a significantly shorter hospital stay (4.1 ± 1.2 days vs 7.6 ± 7.7 days; p < 0.001).

Lower incidence of MACE and reduced morbidity with hybrid coronary revascularization in left main coronary artery disease

In conclusion, in this single-center retrospective analysis, hybrid coronary revascularization was associated with a significant reduction in major adverse cardiovascular events, lower periprocedural morbidity, and shorter hospitalization compared with conventional coronary artery bypass surgery in patients with left main coronary artery disease. Although these findings support hybrid revascularization as an effective strategy, the lack of randomization and the limited sample size underscore the need for multicenter randomized clinical trials to more precisely define its role in this high-risk population.

Original Title: Hybrid coronary revascularization versus traditional coronary artery bypass grafting for left main coronary artery disease.

Reference: Elsa Hebbo, MD; Madeleine Barker, MD; Daniel A. Gold, MD; Malika Elhage Hassan, MD; Mariem Sawan, MD; Tanveer Rab, MD; William J. Nicholson, MD; Michael E. Halkos, MD; Wissam A. Jaber, MD; Pratik B. Sandesara, MD. Cardiovascular Revascularization Medicine, Volumen 81, páginas 11–15, 2025.