Hybrid Coronary Revascularization as a Safe, Feasible, and Viable Alternative to Conventional Coronary Artery Bypass Grafting: What Is the Current Evidence?

Abstract

The “hybrid” approach to multivessel coronary artery disease combines surgical left internal thoracic artery (LITA) to left anterior descending coronary artery (LAD) bypass grafting and percutaneous coronary intervention of the remaining lesions. Ideally, the LITA to LAD bypass graft is performed in a minimally invasive fashion. This review aims to clarify the place of hybrid coronary revascularization (HCR) in the current therapeutic armamentarium against multivessel coronary artery disease. Eighteen studies including 970 patients were included for analysis. The postoperative LITA patency varied between 93.0% and 100.0%. The mean overall survival rate in hybrid treated patients was 98.1%. Hybrid treated patients showed statistically significant shorter hospital length of stay (LOS), intensive care unit (ICU) LOS, and intubation time, less packed red blood cell (PRBC) transfusion requirements, and lower in-hospital major adverse cardiac and cerebrovascular event (MACCE) rates compared with patients treated by on-pump and off-pump coronary artery bypass grafting (CABG). This resulted in a significant reduction in costs for hybrid treated patients in the postoperative period. In studies completed to date, HCR appears to be a promising and cost-effective alternative for CABG in the treatment of multivessel coronary artery disease in a selected patient population.

One-year clinical and angiographic results of hybrid coronary revascularization

“…6,12 During the past 2 decades, the concept of HCR has been assessed in numerous case series and registry studies, mainly retrospective and including selected patients. 13 Most studies on HCR applied minimally invasive direct CABG, performing the LIMA-to-LAD graft off-pump through an anterolateral mini-thoracotomy. Most of the initial series harvested the LIMA under direct vision, whereas recent series used thoracoscopic or robotic techniques.…”

Respite for hybrid coronary revascularization

“…It should be noted that definitions of graft failure varied between the different studies; 6 10-year data from a multicenter European randomized trial, which used pre-planned repeat angiography to reassess in-stent restenosis [86] ; 7,8 rates of SVG and LIMA-LAD were determined via angiography in their respective studies [15,87] not require a hybrid OR. When patients have critical lesions of non-LAD arteries, PCI with endovascular implantation of 2nd generation DES in diseased non-LAD arteries can be first performed to avoid complications (hypotension and hemodynamic compromise) at the times of thoracotomy and the LIMA graft to the LAD [77] . The PCI endovascular revascularization first approach increases the risk of bleeding as CABG surgery is then performed in patients who are receiving dual anti-platelet therapy [77] .…”

“…When patients have critical lesions of non-LAD arteries, PCI with endovascular implantation of 2nd generation DES in diseased non-LAD arteries can be first performed to avoid complications (hypotension and hemodynamic compromise) at the times of thoracotomy and the LIMA graft to the LAD [77] . The PCI endovascular revascularization first approach increases the risk of bleeding as CABG surgery is then performed in patients who are receiving dual anti-platelet therapy [77] .…”

Collaboration between Interventional Cardiologists and Cardiac Surgeons in the Era of Heart Team Approach

“…On the other hand, there is a couple of situations where HCR is not suitable, such as left subclavian artery stenosis, nonusable LIMA graft due to prior radiation to the left chest, intramyocardial LAD, previous stent to the target lesions, and extensive calcification on LAD [27,29].…”

“…A one-staged HCR is defined as PCI and CABG performed in a hybrid-operating room in one operative setting. The advantages of one-staged HCR include complete revascularization with minimal patient discomfort, intraoperative confirmation of LIMA-to-LAD anastomosis, and easy conversion to conventional CABG if needed [29]. However, bleeding concerns due to dual antiplatelet therapy and incomplete heparin reversal, as well as acute stent thrombosis possibility are disadvantages of one-staged HCR [11].…”