Long‐term survival in triple‐vessel disease: Hybrid coronary revascularization compared to contemporary revascularization methods

Clinical outcomes of different revascularization approaches for patients with multi-vessel coronary artery disease: A network meta-analysis

BACKGROUND

As surgical techniques continue to evolve, the optimal approach for revascularizing multi-vessel coronary artery disease (CAD) remains a matter of ongoing debate. Accordingly, our objective was to compare and contrast various surgical techniques utilized in the management of multi-vessel CAD.

METHODS

A systematic literature review was performed using PubMed, Embase, and Cochrane central register of controlled trials from inception to May 2022. Random-effects network meta-analysis was performed for the primary outcome; target vessel revascularization (TVR), and secondary outcomes; mortality, major adverse cardiac and cerebrovascular events, postoperative myocardial infarction, new-onset atrial fibrillation, stroke, new-onset dialysis, in patients undergoing percutaneous coronary intervention (PCI) with a stent, off-pump coronary bypass graft, on-pump coronary artery bypass graft (ONCABG), hybrid coronary revascularization, minimally-invasive coronary artery bypass, or robot-assisted coronary artery bypass (RCAB) surgeries.

RESULTS

A total of 8841 patients were included from 23 studies. The analysis showed that ONCABG had the highest freedom from TVR, with a mean (SD) absolute risk of 0.027 (0.029); although ONCABG was found to be superior to all other methods, it was only significantly better than first-generation stent PCI. While RCAB did not demonstrate significant superiority over other treatments, it showed a greater probability of preventing postoperative complications. Notably, no significant heterogeneity was calculated for any of the reported outcomes.

CONCLUSIONS

ONCABG shows a better rank probability compared to all other techniques for preventing TVR, while RCAB offers greater freedom from most postoperative complications. However, given the absence of randomized controlled trials, these results should be interpreted with caution.

The Current State of Hybrid Coronary Revascularization

Hybrid coronary revascularization (HCR) combines a minimally invasive surgical approach with percutaneous coronary intervention (PCI) for the treatment of multivessel coronary artery disease. Despite decades of use, widespread acceptance has been limited. In this review, we conduct a comparative assessment of HCR in relation to traditional coronary artery bypass graft surgery and multivessel PCI. Although large-scale randomized data are still lacking, numerous studies have demonstrated that HCR may offer benefits regarding resource utilization and short-term morbidity while delivering comparable mid- and long-term survival compared with traditional bypass surgery. Compared with PCI, HCR may offer similar periprocedural morbidity while mitigating the need for repeat revascularization by providing a surgical arterial bypass graft to the left anterior descending artery.

Long-Term Outcomes After Hybrid Coronary Revascularization Versus Coronary Artery Bypass Grafting: Meta-Analysis of Kaplan-Meier-Derived Data

Hybrid coronary revascularization (HCR) is an alternative option to conventional coronary artery bypass grafting (CABG), but the long-term outcomes of HCR versus CABG remain unclear. We aimed to analyze the long-term outcomes after HCR and CABG for patients with multivessel coronary artery disease using meta-analysis. A systemic literature search of PubMed and EMBASE was performed from inception to March 2023. Studies reporting Kaplan-Meier curves with follow-up ≥1 year were included. The primary outcome was all-cause mortality, and the secondary outcomes were major adverse cardiac and cerebrovascular events (MACCEs) and repeat revascularization. In total, 13 studies (1 randomized controlled trial and 12 propensity-score matched observational studies) were analyzed. The mean follow-up period was 5.1 ± 3.1 years. HCR was associated with similar overall mortality (hazard ratio [HR] 1.09, 95% confidence interval [CI] 0.87 to 1.36), significantly higher incidence of MACCEs (HR 1.49, 95% CI 1.07 to 2.06), and repeat revascularization (HR 2.01, 95% CI 1.53 to 2.64) compared with CABG. In phase-specific analysis, the mortality rate was similar, and the incidence of repeat revascularization was higher in HCR regardless of phases. The incidence of MACCEs was higher in HCR during the mid-term phase (1 to 5 years), but it was similar during the long-term phase (long-term: ≥5 years). In conclusion, despite the higher incidence of MACCEs and repeat revascularization compared with CABG, HCR offered a similar long-term survival. Even longer-term follow-up and randomized controlled trials with a large population are warranted to investigate the role of HCR for multivessel coronary artery disease.

Minimally Invasive Direct Coronary Artery Bypass: An Evolving Paradigm Over the Past 25 Years

OBJECTIVE

We have routinely utilized minimally invasive direct coronary artery bypass (MIDCAB) for revascularization of the left anterior descending (LAD) coronary artery. We examined how this procedure has evolved.

METHODS

A retrospective review was undertaken of 2,283 consecutive patients who underwent MIDCAB between 1997 and 2021. Patients were divided into 3 groups: group A from 1997 to 2002 (n = 751, 32.9%), group B from 2003 to 2009 (n = 452, 19.8%), and group C from 2009 to 2021 (n = 1,080, 47.3%). Risk profiles and short-term outcomes were analyzed for the entire cohort and for 293 propensity-matched patients drawn from each group.

RESULTS

The left internal mammary artery was harvested open in group A but with robotic assistance in group C. Thirty-day mortality was higher in group A versus group C (12 deaths, 1.6% vs 5 deaths, 0.5%, P = 0.044); this difference was negated after propensity matching. Group A had more comorbidities than group C, including peripheral vascular disease (17.7% vs 10.0%, P < 0.001), congestive heart failure (39.6% vs 18.0%, P < 0.001), and a history of stroke (17.9% vs 10.0%, P < 0.001), although diabetes mellitus was more common in group C (51.4% vs 31.0%, P < 0.001). Stroke was greater in group A (1.2% vs 0.0% vs 0.2%, respectively, P = 0.004), as was the need for prolonged ventilation (3.6% vs 0.2% vs 0.9%, respectively, P < 0.001), before and after propensity matching.

CONCLUSIONS

MIDCAB patients had less comorbidities than in the past. Robot-assisted MIDCAB was associated with lower stroke risk.

Hybrid Coronary Revascularization: Early Outcomes and Midterm Follow-Up in Patients Undergoing Single or Multivessel Robotic TECAB and PCI

OBJECTIVE

Hybrid coronary revascularization (HCR) is the integration of sternal-sparing coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) in patients with multivessel coronary artery disease (CAD). It is traditionally performed with single-vessel bypass (left internal mammary artery [LIMA] to left anterior descending artery [LAD]) and PCI but can also be accomplished with multiple arterial grafts using bilateral IMA conduits. We sought to review our HCR experience over an 8-year period with robotic totally endoscopic coronary artery bypass (TECAB) and PCI.

METHODS

Of 694 patients undergoing beating-heart TECAB from August 2013 to June 2022, 306 patients were designated as intention-to-treat HCR candidates. Patients underwent PCI prior to, the same day as, or following TECAB, performed using single or bilateral IMA grafts. We retrospectively reviewed early and midterm outcomes up to 8 years in this cohort of patients.

RESULTS

The mean Society of Thoracic Surgeons predicted risk of mortality was 1.5% ± 2.5%. There were 44 patients (14%) who had ≥70% left main disease and 218 patients (71%) who had triple-vessel disease. A total of 193 patients (63%) underwent multivessel grafting (advanced HCR), with 83% bilateral IMA use. Mean operative time was 263 ± 80 min, and mean length of stay was 2.6 days. The mean number of vessels bypassed per patient was 1.7 ± 0.6. The mean number of vessels stented was 1.2 ± 0.5. Of the patients, 84% underwent TECAB first, 14% PCI first, and 2% same-day TECAB/PCI. Mortality was 0.6% (observed to expected ratio: 0.42). Early graft patency was 97% (328 of 339 grafts); LIMA-LAD patency was 98%. At 8-year follow-up (mean 37 ± 26 months), all-cause and cardiac-related mortality were 13% and 2.6%, respectively. Freedom from major adverse cardiac and cerebrovascular events was 92%.

CONCLUSIONS

In patients with multivessel CAD, integrating robotic single and multivessel TECAB with PCI resulted in excellent early and midterm outcomes. In experienced hands, the robotic endoscopic approach allows the routine use of multiple arterial grafting during HCR.

Comparison of hybrid coronary revascularization versus coronary artery bypass grafting in patients with multivessel coronary artery disease: a meta-analysis

BACKGROUND

Percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) are widely used in the treatment of coronary heart disease, but the best revascularization method for multivessel coronary artery disease (MVD) patients is still controversial. Hybrid coronary revascularization (HCR), together with CABG and PCI, have been proved to be feasible methods, but the long-term effect of HCR is not as clear as CABG.

METHOD

By October 2020, we retrieved articles from PubMed, Web of science, EMBASE and Cochrane library databases. The main results are based on major adverse cardiovascular and cerebral events (MACCE).

RESULT

A total of 18 articles (3 randomized controlled trials (RCTs) and 15 observational studies) were included in this meta-analysis. The outcomes of MACCE in the HCR group at perioperative, short-term (30 days to 1 year), medium-term (1 year to 5 years) and long-term (5 years and above) follow-up period were similar to those in the CABG group. The mortality rates of patients in perioperative, short-term and medium-term follow-up were similar to those in the CABG group, but lower than that in the CABG group at long-term follow-up (OR = 0.35, 95% CI 0.18-0.69, p = 0.002). The revascularization rate was higher in the HCR group during the perioperative period (OR = 3.50, 95% CI 2.07-5.94, p < 0.001), short-term (OR = 3.28, 95% CI 1.62-6.64, p < 0.001) and mid-term follow-up (OR = 2.84, 95% CI 1.64-4.92, p < 0.001).

CONCLUSION

Our results reveal that HCR is a safe and therapeutically effective alternative in treatments for MVD patients. It has not only less short-term adverse effect, but also better long-term effect, especially in death.

One-Stop Hybrid Coronary Revascularization Versus Off-Pump Coronary Artery Bypass Grafting

One-stop hybrid coronary revascularization (HCR) is a promising revascularization strategy for treating multivessel coronary artery disease (MVCAD). However, its safety and feasibility remain controversial. Therefore, we introduced our experience with midterm follow-up of HCR in patients with MVCAD and compared it with conventional off-pump coronary artery bypass grafting (CABG).Patients with MVCAD undergoing one-stop HCR at Beijing Chaoyang Hospital between March 2018 and December 2020 were retrospectively enrolled. These patients were matched in a 1:2 ratio to patients treated with off-pump CABG at the same period via a propensity score analysis with the nearest neighbor matching algorithm.In the adjusted analysis, no significant difference was found in the rate of perioperative myocardial infarction, stroke, death, prolonged ventilation, reoperation for bleeding, and renal failure between the HCR group and the CABG group. No in-hospital repeated revascularization occurred in either group. HCR was associated with lower blood transfusion rate (HCR 11.0% versus CABG 22.8%; P = 0.006) and shorter postoperative length of stay (> 10 days: 31.5% versus 81.0%; P < 0.001) compared with CABG. After the median 21-month follow-up, no significant difference was found in the major adverse cardiac and cerebrovascular events (MACCE), death, myocardial infarction, repeated revascularization, and stroke rate. Besides, the freedom-from MACCE survival rate was similar between the two groups.One-stop HCR seemed to be a safe and feasible revascularization strategy in patients with MVCAD, with faster recovery and similar outcomes when compared with off-pump CABG.

Hybrid revascularization vs. coronary bypass for coronary artery disease: a systematic review and meta-analysis

INTRODUCTION

Coronary artery bypass graft is the mainstay of treatment for multivessel coronary artery disease and is superior to percutaneous coronary intervention. Combined approaches such as hybrid coronary revascularization integrate coronary artery bypass grafting with percutaneous coronary intervention during the same procedure or weeks apart. These attempt to improve surgical morbidity and long-term outcomes.

EVIDENCE ACQUISITION

Per PRISMA criteria, a systematic review of keywords "Hybrid Revascularization," "Hybrid Coronary Revascularization," "Surgical," "Surgery," "Treatment," "CABG," "HCR" and "PCI" was conducted in PubMed, EMBASE and SCOPUS. Studies comparing this technique's performance on either single or two-stage approach against traditional multiple vessel coronary artery bypass grafting were screened and analyzed for our review.

EVIDENCE SYNTHESIS

Twenty-two studies totaling 6981 participants were ultimately included for analysis. Mean differences in operative time, bleeding, ventilator time and length of stay were significantly lower in the hybrid coronary revascularization group. Odds ratios in transfusions and in-hospital myocardial infarction were also lower in the hybrid coronary revascularization group. Results for in-hospital and all-cause mortality, major adverse cardiac events (MACE), stroke, reintervention, and complete revascularization were not significantly different.

CONCLUSIONS

Our analysis shows hybrid coronary revascularization is a feasible alternative to traditional coronary artery bypass grafting. Short-and long-term outcomes including mortality, MACE, and postoperative morbidity are similar between both groups, while hybrid approaches are associated with decreased perioperative morbidity.

Multi-Spectrum Robotic Cardiac Surgery: Early Outcomes

Objective

The robotic cardiac surgery program at our current institution began in 2013 with an experienced and dedicated team. This review analyzes early outcomes in the first 1103 patients.

Methods

We reviewed all robotic procedures between July 2013 and February 2021. Primary outcomes were mortality and perioperative morbidity. Our robotic approach is totally endoscopic for all cases: off-pump for coronary and epicardial procedures, and on-pump with the endoballoon for mitral valve and other intracardiac procedures.

Results

There were 1103 robotic-assisted cardiac surgeries over 7 years. A total of 585 (53%) were off-pump totally endoscopic coronary artery bypasses, 399 (36%) intracardiac cases (including isolated and concomitant mitral valve procedures, isolated tricuspid valve repair, CryoMaze, atrial or ventricular septal defect repair, benign cardiac tumor, septal myectomy, partial anomalous pulmonary venous drainage, and aortic valve replacement); 80 (7%) epicardial electrophysiology-related procedures (epicardial atrial fibrillation ablation, left atrial appendage ligation, lead placement, and ventricular tachycardia ablation); and 39 (4%) other epicardial procedures (pericardiectomy, unroofing myocardial bridge). Mortality was 1.2% (observed/expected ratio, 0.7). In the totally endoscopic coronary artery bypass and intracardiac groups, mortality was 1.0% (observed/expected, 0.6) and 1.5% (observed/expected, 0.87), respectively. There were 8 conversions to sternotomy (0.7%) and 24 (2.2%) take-backs for bleeding. Mean hospital and intensive care unit lengths of stay were 2.74 ± 1.26 days and 1.28 ± 0.57 days, respectively.

Conclusions

This experience demonstrates that a robotic endoscopic approach can safely be used in a multitude of cardiac surgical procedures both on- and off-pump with excellent early outcomes. An experienced surgeon and team are necessary. Longer-term follow-up is warranted.

Hybrid coronary revascularization versus percutaneous coronary intervention: A systematic review and meta-analysis

BACKGROUND

Hybrid coronary revascularization (HCR) is an emerging approach for multivessel coronary artery disease (MVD) which combines the excellent long-term outcomes of surgery with the early recovery and reduced short-term complications of percutaneous coronary intervention (PCI). Here, we evaluated the effectiveness of HCR compared to PCI in patients with MVD.

METHODS

A systematic database search in PubMed/MEDLINE, Embase, Scopus, and CENTRAL/CCTR was conducted by June 2021. Random-effects meta-analysis was performed, comparing major adverse cardiac and cerebrovascular events (MACCE) at 30 days and at latest follow-up between patients undergoing HCR versus PCI.

RESULTS

A total of 27,041 patients (HCR: 939 patients, PCI: 26,102 patients) were included from seven studies published between 2013 and 2021. At latest follow-up, HCR was associated with lower rates of myocardial infarction (OR 0.40, 95% CI 0.20-0.80, p = 0.010) and target vessel revascularization (OR 0.49, 95% CI 0.37-0.64, p < 0.001), while the difference for MACCE did not reach statistical significance (OR 0.46, 95% CI 0.20-1.05, p = 0.061). No differences were observed in terms of 30-day outcomes, nor rates of mortality or stroke at latest follow-up.

CONCLUSIONS

HCR might be a valid alternative to multivessel PCI, demonstrating a lower incidence of MI and TVR. Center experience, well-coordinated heart team discussions, and good patient selection likely remain essential to ensure optimal outcomes. Future comparative studies are required to define the optimal target population.

Robotic hybrid coronary revascularization-A need for strategy specific data

Robotic totally endoscopic techniques to perform the left internal thoracic artery to left anterior descending graft, coupled with percutaneous coronary intervention (PCI), provide the least invasive option to achieve hybrid coronary revascularization (HCR). Shorter hospital stays and reduced need for blood transfusions have been consistently being reported by several studies along with similar long-term outcomes. Considerable variations exist in the definition of HCR which can be single or two-staged with surgical revascularization being carried out after PCI or vice versa. Variations also exist with respect to usage of cardiopulmonary bypass, surgical incisions, and the use of minimally invasive robotic techniques. The different strategies of HCR do not lead to similar outcomes and the findings of one strategy cannot be extrapolated to the entire group. Studies reporting different strategies of HCR should ideally provide more granular data when reporting outcomes.

Predictive value of ACEF II score in patients with multi-vessel coronary artery disease undergoing one-stop hybrid coronary revascularization

Background

We aimed to investigate the predictive value of recently updated ACEF II score on major adverse cardiac and cerebrovascular events (MACCE) in patients with multi-vessel coronary artery disease (MVCAD) undergoing one-stop hybrid coronary revascularization (HCR).

Methods

Patients with MVCAD undergoing one-stop HCR were retrospectively recruited from March 2018 to September 2020. Several prediction risk models, including ACEF II score, were calculated for each patient. Kaplan-Meier curve was used to evaluate freedom from cardiac death and MACCE survival rates. Differences of prediction performance among risk scores for predicting MACCE were compared by receiver operating characteristic (ROC) curve.

Results

According to the ACEF II score, a total of 120 patients undergoing one-stop HCR were assigned to low-score group (80 cases) and high-score group (40 cases). During the median follow-up time of 18 months, the incidence of MACCE in the low-score group and high-score group were 8.8 % and 37.5 %, respectively (p < 0.001); and the cardiac death rate of the two were 2.5% and 12.5%, respectively (p < 0.05). Moreover, the cumulative freedom from cardiac death (97.5% vs. 86.8, p < 0.05) and MACCE (75.2% vs. 52.8%, p < 0.001) survival rates in the high-score group were significantly lower than in the low-score group. According to the Cox proportional hazards regression, the ACEF II score was an independent prognostic indicator for MACCE with hazards ratio (HR) 2.24, p = 0.003. The ROC curve analysis indicated that the areas under the curve (AUC) of MACCE from the ACEF II score was 0.740 (p < 0.001), while the AUC of MACCE from the SYNTAX score II CABG was 0.621 (p = 0.070) and the AUC from the EuroSCORE II was 0.703 (p < 0.001). Thus, the accurate predictive value of ACEF II score was similar to the EuroSCORE II but much higher than the SYNTAX score II CABG.

Conclusions

The updated ACEF II score is a more convenient and validated prediction tool for MACCE in patients with MVCAD undergoing one-stop HCR comparing to other risk models.

In patients with multi-vessel coronary artery diseases, does hybrid revascularization provide similar outcomes to conventional coronary artery bypass grafting?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: In [patients with multivessel coronary artery diseases (CAD)] is [hybrid revascularization (HCR)] equal to [coronary artery bypass grafting (CABG)] in regard to [mortality, myocardial infarction, stroke and target vessel revascularization (TVR)]? Three-hundred and fifty-five papers were found using the reported search, of which 8 represented the best evidence to answer the question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. The studies included 4 observational studies, 3 randomized controlled trials (RCTs) and 1 meta-analysis. The meta-analysis consisted of predominantly observational data with 1 randomized controlled trial and suggested non-significant differences in all major clinical outcomes. The observational studies generally cited benefit towards hybrid revascularization on the basis of equivalent major clinical outcomes rates compared to coronary artery bypass grafting, yet favourable in-hospital outcomes. One randomized controlled trial provided robust evidence of equivalent 5-year outcomes; however, the others were insufficiently powered for an effective comparison. There is a paucity of robustly designed studies to answer our clinical question effectively, given hybrid procedures are not routine in clinical practice. On the basis of mostly observational and small randomized cohorts with relatively short follow-up intervals, we conclude that current evidence suggests similar mid-term rates of major clinical outcomes after hybrid revascularization and coronary artery bypass grafting. However, without longer-term follow-up, the comparison of the two techniques, particularly relating to repeat revascularization, is still very much uncertain.