Hybrid coronary revascularization vs. percutaneous coronary interventions for multivessel coronary artery disease

OBJECTIVEHybrid coronary revascularization (HCR) combines a minimally invasive surgical approach to the left anterior descending (LAD) artery with percutaneous coronary intervention (PCI) for non-LAD diseased coronary arteries. It is associated with shorter hospital lengths of stay and recovery times than conventional coronary artery bypass surgery, but there is little information comparing it to isolated PCI for multivessel disease. Our objective is to compare long-term outcomes of HCR and PCI for patients with multivessel disease.METHODSThis cohort study used data from New York’s cardiac surgery and PCI registries in 2010−2016 to examine mortality and repeat revascularization rates for patients with multivessel coronary artery disease who underwent HCR and PCI. Cox proportional hazards methods were used to reduce selection bias. Patients were followed for a median of four years.RESULTSThere was a total of 335 HCR patients (1.2%) and 25,557 PCI patients (98.8%) after exclusions. There was no difference in 6-year risk adjusted survival between HCR and PCI patients (83.17% vs. 81.65%, adjusted hazard ratio (aHR) = 0.90 (95% CI: 0.67−1.20). However, HCR patients were more likely to be free from repeat revascularization in the LAD artery (91.13% vs. 83.59%, aHR = 0.51 (95% CI: 0.34−0.77)). CONCLUSIONSFor patients with multi-vessel coronary artery disease, HCR is rarely performed. There are no differences in mortality rates after four years, but HCR is associated with lower repeat revascularization rates in the LAD artery, presumably due to better longevity in left arterial mammary grafts.

For most patients with multivessel disease coronary artery disease, either coronary artery bypass graft (CABG) surgery or percutaneous coronary intervention (PCI) is the recommended option. The advantage of CABG surgery is generally the durability of the bypass grafts, and CABG surgery is recommended especially among the highest risk patients (e.g., three vessel disease, left main (LM) disease, multivessel disease with proximal left anterior descending artery (LAD) disease).^[1-4] Nevertheless, an advantage of CABG surgery is the superior outcomes achieved with left internal mammary artery (LIMA) grafts to the LAD for patients with LAD disease.^[5-7]Hybrid coronary revascularization (HCR) is an approach that has been developed to combine the main advantages of both CABG surgery and PCI. It consists of using a LIMA anastomosis to the LAD via a minimally invasive CABG surgery approach (no sternotomy) in addition to PCI for other diseased coronary arteries. The rationale for using this approach in lieu of using PCI for all diseased coronary arteries is the potential for more durability of the LAD revascularization as a result of the LIMA to LAD anastomosis. Several studies have compared HCR to CABG surgery, but they are limited with respect to sample size, number of institutions represented, duration, and inability to capture population-based practice.^[8-24] Multi-center studies comparing HCR with PCI, which are arguably more relevant since these two alternatives are the least invasive ones, are extremely limited.^[25,26]The purposes of this study are to: (1) describe the use of HCR and the characteristics of patients undergoing HCR vs. PCI in a population-based setting, and (2) compare short- and medium-term outcomes for HCR and PCI for patients with multi-vessel coronary artery disease accompanied by LAD disease using New York’s clinical cardiac registries.