Hybrid Coronary Revascularization for the Treatment of Multivessel Coronary Artery Disease: A Multicenter Observational Study

Abstract

Background: Hybrid coronary revascularization (HCR) combines minimally invasive surgical coronary artery bypass grafting of the left anterior descending artery with percutaneous coronary intervention (PCI) of non-left anterior descending vessels. HCR is increasingly used to treat multivessel coronary artery disease that includes stenoses in the proximal left anterior descending artery and at least 1 other vessel, but its effectiveness has not been rigorously evaluated.

Objectives: This National Institutes of Health-funded, multicenter, observational study was conducted to explore the characteristics and outcomes of patients undergoing clinically indicated HCR and multivessel PCI for hybrid-eligible coronary artery disease, to inform the design of a confirmatory comparative effectiveness trial.

Methods: Over 18 months, 200 HCR and 98 multivessel PCI patients were enrolled at 11 sites. The primary outcome was major adverse cardiac and cerebrovascular events (MACCE) (i.e., death, stroke, myocardial infarction, repeat revascularization) within 12 months post-intervention. Cox proportional hazards models were used to model time to first MACCE event. Propensity scores were used to balance the groups.

Results: Mean age was 64.2 ± 11.5 years, 25.5% of patients were female, 38.6% were diabetic, and 4.7% had previous stroke. Thirty-eight percent had 3-vessel coronary artery disease, and the mean SYNTAX (Synergy Between PCI With Taxus and Cardiac Surgery) score was 19.7 ± 9.6. Adjusted for baseline risk, MACCE rates were similar between groups within 12 months post-intervention (hazard ratio [HR]: 1.063; p = 0.80) and during a median 17.6 months of follow-up (HR: 0.868; p = 0.53).

Conclusions: These observational data from this first multicenter study of HCR suggest that there is no significant difference in MACCE rates over 12 months between patients treated with multivessel PCI or HCR, an emerging modality. A randomized trial with long-term outcomes is needed to definitively compare the effectiveness of these 2 revascularization strategies. (Hybrid Revascularization Observational Study; NCT01121263).

Keywords: coronary artery bypass; coronary vessels; drug-eluting stents; follow-up studies; percutaneous coronary intervention.

Copyright © 2016 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

Figures

FIGURE 1. Study Flowchart

Ninety of the patients from the angiogram screening cohort were combined with 208 patients with hybrid coronary revascularization (HCR)-eligible coronary artery disease (CAD) treated with either HCR or multivessel percutaneous coronary intervention (PCI) to compose the 298 patients who consented to be enrolled in this observational clinical study. Of those 298 enrolled patients, 200 were treated with HCR and 98 were treated with multivessel PCI at the discretion of local cardiologists and surgeons. DES = drug-eluting stent(s).

CENTRAL ILLUSTRATION. Multicenter HCR Study: MACCE-Free Survival at End of Study Follow-Up

In this first multicenter observational study of hybrid coronary revascularization (HCR) and multivessel percutaneous coronary intervention (PCI) for patients with hybrid-eligible coronary anatomy, risk-adjusted major adverse cardiovascular and cerebrovascular events (MACCE) rates were similar between groups through 12 months of follow-up. During longer follow-up, at 18 months, MACCE-free survival curves for HCR versus PCI began to diverge, with increasing MACCE in the multivessel PCI group. DES = drug-eluting stent(s).