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Aim. Optimal revascularization strategy in multivessel (MV) coronary artery disease (CAD) eligible for percutaneous management (PCI) and surgery remains unresolved. We evaluated, in a randomized clinical trial, residual myocardial ischemia (RI) and clinical outcomes of MV-CAD revascularization using coronary artery bypass grafting (CABG), hybrid coronary revascularization (HCR), or MV-PCI. Methods. Consecutive MV-CAD patients (n = 155) were randomized (1 : 1 : 1) to conventional CABG (LIMA-LAD plus venous grafts) or HCR (MIDCAB LIMA-LAD followed by PCI for remaining vessels) or MV-PCI (everolimus-eluting CoCr stents) under Heart Team agreement on equal technical and clinical feasibility of each strategy. SPECT at 12 months (primary endpoint of RI that the trial was powered for; a measure of revascularization midterm efficacy and an independent predictor of long-term prognosis) preceded routine angiographic control. Results. Data are given, respectively, for the CABG, HCR, and MV-PCI arms. Incomplete revascularization rate was 8.0% vs. 7.7% vs. 5.7% (p=0.71). Hospital stay was 13.8 vs. 13.5 vs. 4.5 days (p<0.001), and sick-leave duration was 23 vs. 16 vs. 8 weeks (p<0.001). At 12 months, RI was 5 (2, 9)% vs. 5 (3, 7)% vs. 6 (3, 10)% (median; Q1, Q3) with noninferiority p values of 0.0006 (HCR vs. CABG) and 0.016 (MV-PCI vs. CABG). Rates of angiographic graft stenosis/occlusion or in-segment restenosis were 20.4% vs. 8.2% vs. 5.9% (p=0.05). Clinical target vessel/graft failure occurred in 12.0% vs. 11.5% vs. 11.3% (p=0.62). Major adverse cardiac and cerebral event (MACCE) rate was similar (12% vs. 13.4% vs. 13.2%; p=0.83). Conclusion. In this first randomized controlled study comparing CABG, HCR, and MV-PCI, residual myocardial ischemia and MACCE were similar at 12 months. There was no midterm indication of any added value of HCR. Hospital stay and sick-leave duration were shortest with MV-PCI. While longer-term follow-up is warranted, these findings may impact patient and physician choices and healthcare resources utilization. This trial is registered with NCT01699048.

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В. И. ГАНЮКОВ, Р. С. ТАРАСОВ, А. А. ШИЛОВ, Н. А. КОЧЕРГИН, Л. С. БАРБАРАШФедеральное государственное бюджетное научное учреждение «Научно-исследовательский институт комплексных проблем сердечно-сосудистых заболеваний», лаборатория интервенционных методов диагностики и лечения атеросклероза. Кемерово, Россия В данной статье приводится обзор литературы по проблеме малоинвазивной гибридной реваскуляризации миокарда у па-циентов со стабильной ИБС при многососудистом поражении коронарного русла. Анонсируется дизайн собственного рандомизи-рованного исследования HREVS (Hybrid REvascularization Vs Surgery), сравнивающего результаты реваскуляризации миокарда с применением трех стратегий: 1) гибридной реваскуляризации (шунтирование передней нисходящей артерии из мини-доступа на работающем сердце и стентирование других коронарных артерий с использованием стентов с лекарственным покрытием); 2) стан-дартного коронарного шунтирования в условиях искусственного кровообращения; 3) многососудистого стентирования коронарных артерий с применением стентов с лекарственным покрытием.Ключевые слова: гибридная реваскуляризация миокарда, чрескожное коронарное вмешательство, коронарное шунтиро-вание. this article provides an overview of the literature on the issue of minimally invasive hybrid revascularization in patients with stable multivessel coronary artery disease. It is announced design of randomized study HREVS (Hybrid REvascularization Vs Surgery), to compare the results of myocardial revascularization using three strategies: 1) hybrid revascularization minimally invasive on pump coronary artery bypass surgery LIMA to LAd (MId CAB) and stenting of other coronary arteries using drug-eluting stents); 2) coronary artery bypass grafting with cardiopulmonary bypass; 3) multivessel coronary stenting with drug-eluting stents. HYBRID MINIMALLY INVASIVE MYOCARDIAL REVASCULARIZATION

Background. Acute coronary syndrome remains the leading cause of death worldwide. The rupture of vulnerable atherosclerotic plaque in the coronary artery is a common pathogenetic mechanism contributing to the onset of acute coronary syndrome. Therefore, one of the main goals of the practical cardiology is to ensure the development of sensitive early diagnostic methods and set preventive and treatment strategies for acute coronary event. Aim To evaluate the incidence of vulnerable plaques in the non-target coronary arteries in patients with stable coronary artery disease.Methods. 58 patients with stable coronary artery disease were included in a prospective observational cohort study. After the target vessel had been stented, virtual histology intravascular ultrasound (VH-IVUS) of the proximal and middle segments (6–8 cm) of one non-target artery (i.e. without any significant stenotic lesions on coronary angiography) was performed.Results. The mean age of patients was 60.4±6.6 years. In addition to the targeted hemodynamically significant lesions subjected to stenting, 56 patients had 58 lesions (96.5%) in the non-target coronary arteries. Of them, 5 lesions (8.6%) were with >70% luminal stenosis (including >70% luminal stenosis + lumen area <4 mm2 in 4 cases), 10 lesions (17.2%) – with minimum lumine area <4 mm2 and without any other signs of vulnerable plaque, 12 lesions (20.7%) – with a large necrotic core and a thin cap (including thin-cap fibroatheroma + >70% luminal stenosis in 2 patients; thin-cap fibroatheroma + lumen area <4 mm2 – 2 cases, thin-cap fibroatheroma + >70% luminal stenosis + lumen area <4 mm2 – 2 cases).Conclusion. In vivo evaluation of the plaques in the non-target vessels ensures the detection of vulnerable plaques in stable patients. The long-term follow-up of the study group allows assessing the risk of developing adverse cardiovascular events in those patients who have vulnerable coronary plaques.