Clinical Investigation
Interventional Cardiology
Clinical outcomes after hybrid coronary revascularization versus coronary artery bypass surgery: a meta-analysis of 1,190 patients

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Background

Hybrid coronary revascularization (HCR) represents a minimally invasive revascularization strategy in which the durability of the internal mammary artery to left anterior descending artery graft is combined with percutaneous coronary intervention to treat remaining lesions. We performed a systematic review and meta-analysis to compare clinical outcomes after HCR with conventional coronary artery bypass graft (CABG) surgery.

Methods

A comprehensive EMBASE and PUBMED search was performed for comparative studies evaluating in-hospital and 1-year death, myocardial infarction (MI), stroke, and repeat revascularization.

Results

Six observational studies (1 case control, 5 propensity adjusted) comprising 1,190 patients were included; 366 (30.8%) patients underwent HCR (185 staged and 181 concurrent), and 824 (69.2%) were treated with CABG (786 off-pump, 38 on-pump). Drug-eluting stents were used in 328 (89.6%) patients undergoing HCR. Hybrid coronary revascularization was associated with lower in-hospital need for blood transfusions, shorter length of stay, and faster return to work. No significant differences were found for the composite of death, MI, stroke, or repeat revascularization during hospitalization (odds ratio 0.63, 95% CI 0.25-1.58, P = .33) and at 1-year follow-up (odds ratio 0.49, 95% CI 0.20-1.24, P = .13). Comparisons of individual components showed no difference in all-cause mortality, MI, or stroke, but higher repeat revascularization among patients treated with HCR.

Conclusions

Hybrid coronary revascularization is associated with lower morbidity and similar in-hospital and 1-year major adverse cerebrovascular or cardiac events rates, but greater requirement for repeat revascularization compared with CABG. Further exploration of this strategy with adequately powered randomized trials is warranted.

Section snippets

Data source and exclusion criteria

A comprehensive literature search was performed from electronic databases including Cochrane Library, EMBASE, and MEDLINE updated to June 26, 2013. The terms “hybrid coronary revascularization,” “hybrid myocardial revascularization,” “integrated myocardial revascularization,” and “coronary artery disease” and their variations were used as keywords in a PubMed search. The search was limited to records in humans. Both English and non-English language articles were included (n = 247). Two

Studies selection

The study selection process is illustrated in Figure 1. The search strategy identified 247 studies. After screening of titles and abstracts, we excluded nonoriginal studies, case reports, or small case series (<10) and unrelated studies on noncoronary hybrid surgical or imaging procedures. This resulted in 37 unique studies that were comprehensively reviewed. After critical appraisal, we excluded 27 studies because of the lack of a comparative study arm, clinical outcome was not provided, or

Discussion

In this meta-analysis of more than 1,100 patients from 6 observational cohort studies, we observed the following: (1) patients undergoing HCR with IMA-to-LAD grafting and PCI of non-LAD lesions have a similar risk of the composite of death, MI, stroke, and repeat revascularization than those treated with CABG during hospitalization and during follow-up; (2) although death, MI, and stroke rates were numerically but not statistically lower with HCR, the need for repeat revascularization occurred

Conclusion

In this contemporary meta-analysis of patients with multivessel CAD undergoing coronary revascularization, HCR was associated with similar rates of death, MI, stroke, and repeat revascularization during hospitalization and at follow-up, but with higher rates of repeat revascularization compared with conventional CABG. These findings seem to be similar irrespective of whether a 1-staged or 2-staged approach is used. Our findings may be used as reference for future clinical trials comparing HCR

Disclosures

Drs Harskamp, Bagai, Bachinsky, and de Winter do not report any relevant disclosures. Dr Rao receives research grants from Cordis Corportation, Ikaria, and Sanofi-Aventis and received consulting fees for Zoll, the Medicines Company, Terumo Medical, and Daiichi Sankyo Lilly. Dr Patel receives research funding from MAQUET Cardiovascular, Johnson & Johnson, The National Heart, Lung, and Blood Institute, and Agency for Healthcare Research and Quality's and consulting fees from Genzyme corporation.

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    Studies that compared hybrid coronary revascularization (HCR) in 2 or more diseased vessels (minimally invasive CABG plus PCI) arrived at similar conclusions. Harskamp and colleagues22 conducted a meta-analysis of 6 studies with a total of 366 HCR patients and 824 CABG patients. The authors found no differences in the composite of death, MI, stroke, or repeat revascularization during hospitalization.

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Marc Cohen, MD, served as guest editor for this article.

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