Hybrid coronary revascularization rarely performed in the US

Despite being shown to be a promising alternative to CABG, hybrid coronary revascularization represented less than 1% of the total US CABG volume in a recent study.

Ralf E. Harskamp, MD, with the University of Amsterdam, the Netherlands, and Duke Clinical Research Institute, Durham, N.C., and fellow study researchers performed an analysis of patients from the Society of Thoracic Surgeons Adult Cardiac Surgery Database who were treated with staged or concurrent hybrid coronary revascularization (HCR) or isolated CABG between July 2011 and March 2013.

Among 198,622 CABG procedures performed in the study period, 0.48% were HCR procedures. Of those 950 interventions, 809 used the staged approach and 141 used the concurrent approach. These procedures were performed at approximately one-third of the participating sites (n=361).

Higher CV risk profiles were reported in the hybrid group compared with the CABG group.

Median sternotomy was less frequent in the staged hybrid group (61.1%) and the concurrent hybrid group (52.5%) than in the CABG group (98.5%). Similarly, direct-vision harvesting rates were 66% for staged and 68.1% for concurrent HCR compared with 98.9% for CABG. Cardiopulmonary bypass rates were 45% for staged and 36.9% for concurrent HCR, while that rate was 83.4% for CABG.

Robotic assistance was more common in both hybrid groups than in the CABG group (staged, 33%; concurrent, 30.5%; CABG, 0.7%).

Ralf E. Harskamp

No differences were observed in terms of in-hospital mortality rates and major morbidity for CABG compared with staged HCR (OR=0.93; 95% CI, 0.75-1.16) or concurrent procedures (OR=0.94; 95% CI, 0.56-1.56), according to results of an adjusted analysis.

Operative mortality rates also were similar for CABG compared with staged (OR=0.74; 95% CI, 0.42-1.30) and concurrent (OR=2.26; 95% CI, 0.99-5.17) HCR.

“Although HCR may appear to be an equally safe alternative for CABG surgery, further randomized study is warranted,” Harskamp and colleagues concluded.

In an accompanying editorial, Igor Gosev, MD, and Marzia Leacche, MD, of the division of cardiac surgery at Brigham and Women’s Hospital in Boston, wrote that the true value of HCR remains undetermined. “HCR, albeit with higher initial procedural costs but lower in-hospital costs related to lower morbidity, may have the same or better initial value than regular CABG surgery which is probably offset by future coronary re-intervention due to stent restenosis,” they wrote. “Therefore, the wide application of HCR is limited by the uncertainty of the long-term effectiveness of [drug-eluting stents] and the higher cost.”

Improvements in patient experiences overall, cost and outcomes are necessary for this procedure to move beyond a “limited niche in coronary revascularization,” according to Gosev and Leacche.

“HCR remains a valuable alternative to conventional CABG surgery in the hands of expert centers where there is integration between cardiac surgery and cardiologists and cardiac surgeons are trained in minimally invasive procedures,” they wrote. “Patients with complex lesions in the LAD (high SYNTAX score derived from LAD lesions) are most amenable to LIMA to LAD bypass and PCI to non-complex non-LAD lesions. The ideal subset of patients in whom the medical and financial risks of a minimally invasive procedure are acceptable is still to be determined.”

For more information:

Harskamp RE. Circulation. 2014;doi:10.1161/circulationaha.114.009479.

Leacche M. Circulation. 2014;doi:10.1161/circulationaha.114.011857.

Disclosure: The researchers report financial disclosures with Boehringer Ingelheim, Direct Flow Medical, Edwards Lifesciences, Eli Lilly, Genentech, Janssen Pharmaceuticals, Maquet, Medtronic, Merck, Sanofi-Aventis, Sorin Group and St. Jude Medical.