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Hybrid coronary revascularization versus coronary artery bypass surgery with bilateral or single internal mammary artery grafts

Selected in The Journal of Thoracic and Cardiovascular Surgery by S. Head

References

Authors

Rosenblum JM, Harskamp RE, Hoedemaker N, Walker P, Liberman HA, de Winter RJ, Vassiliades TA, Puskas JD, Halkos ME

Reference

J Thorac Cardiovasc Surg. 2016 Apr;151(4):1081-9

Published

April 2016

Link

Read the abstract

My Comment

Background

The optimal treatment for patients with coronary artery disease has been a matter of debate for many decades. Both coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) are excellent treatment options for selected patients. For some patients, a so-called hybrid revascularization that combines CABG with PCI may be an option to produce a less invasive treatment with the benefits of long-term internal mammary artery anastomoses. However, little data are available and no comparisons to conventional CABG. Therefore, Rosenblum performed a propensity-matched analysis of hybrid revascularization versus CABG with the use of a single internal mammary artery (SIMA) versus CABG with the use of bilateral internal mammary arteries (BIMA).

Results

  • Single-center study performed in the United States
  • Through 2003-2013, 306 consecutive patients underwent hybrid revascularization, and 8254 patients underwent CABG with SIMA (7381; 89.4%) or BIMA (873; 10.6%)
  • There were severe baseline differences between those patients who underwent hybrid revascularization or CABG, and also between patients who underwent SIMA and BIMA
  • After propensity matching, three groups of 306 patients each were available for analysis. The groups were comparable with an age of about 63 years, 35% diabetics, a left ventricular ejection fraction of 55%, about 10% of patients with isolated left main disease, and 35% of patients with three-vessel disease. The STS predicted risk of mortality was about 1.5%.
  • No short-term differences were found in terms of hard clinical endpoints (death, stroke, myocardial revascularization) between any of the groups, although patients who underwent hybrid revascularization did have lower rates of renal failure, prolonged mechanical ventilation, and blood transfusions. The postoperative length of stay was also significantly shorter.
  • After a median follow-up of 2.8 years (IQR 1.2-4.9), 5-year mortality was estimated at 11.5% for hybrid revascularization, 13.6% for SIMA, and 10.1% for BIMA.
  • Propensity-matched adjusted analysis showed that there was no significant difference in all-cause mortality: hybrid versus SIMA HR=0.66 (95% CI 0.32-1.38, p=0.66) and hybrid versus BIMA HR=1.05 (95% CI 0.48-2.29, p=0.91).

My comments

Hybrid revascularization is an exciting ‘new’ treatment option that combines the long-term durability of a CABG procedure with potential for a more minimally invasive surgical procedure because of stenting to non-LAD territories. It is imperative that evidence to support this treatment option is provided. This study is well-designed and provides evidence for superior short-term safety and comparative long-term efficacy when compared to conventional CABG. It should be noted that there were severe differences between the treatment groups and even propensity matching may not adequately balance out the patient populations. Therefore, data from a randomized controlled trial will be required for widespread adoption of hybrid revascularization. Multiple trials such as this one are currently recruiting patients.

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