Current trends in hybrid coronary revascularization

Alice K. Jacobs, MD, FACC, FAHA, Chair Jeffrey L. Anderson, MD, FACC, FAHA, Chair-Elect Nancy Albert, PhD, CCNS, CCRN, FAHA Mark A. Creager, MD, FACC, FAHA Steven M. Ettinger, MD, FACC Robert A. Guyton, MD, FACC Jonathan L. Halperin, MD, FACC, FAHA Judith S. Hochman, MD, FACC, FAHA

Background: The current guideline-recommended intervention for left main (LM) disease is coronary artery bypass grafting (CABG). Hybrid coronary revascularization (HCR) combines robotic coronary artery bypass and percutaneous coronary intervention (PCI) and offers a less invasive approach for patients with LM and multivessel coronary artery disease. We aim to compare clinical outcomes at 30 days, 6 months and 1 year between HCR and CABG in patients with LM disease. Methods: We retrospectively screened 761 patients who underwent bypass for LM disease between 2019 and 2023 at a single institution. A total of 118 patients who underwent either HCR (n=59) or CABG (n=59) were included after propensity matching for baseline characteristics. The primary endpoint was major adverse cardiovascular events (MACE), defined as death, myocardial infarction, repeat revascularization and stroke, at 30 days, 6 months and 1 year, which was assessed using chi-squared tests. Secondary outcomes are individual components of MACE at 30 days, 6 months and 1 year. Kaplan-Meier curves were used to visualize the difference in 1-year cumulative MACE-free survival across groups coupled with a log-rank test. Results: The mean age was 68.93±11 years for HCR patients and 68.41±10.11 years for CABG patients (p=0.394). SYNTAX score was high (> 33) for 49.1% of HCR patients and 67.3% of CABG patients (p=0.15). Hospital length of stay was shorter for HCR compared to CABG (4.07 ± 1.21 days vs. 7.58 ± 7.71 days, p<0.001). MACE events were significantly lower in the HCR group at 30 days (0% vs 10.2%; p=0.01), 6 months (0% vs 17%; p=0.002) and 1 year (2.4% vs 20.5%; p=0.01). The cumulative MACE-free survival at 1 year was significantly higher in the HCR group (p=0.007). There were no significant differences in secondary outcomes at any time point with the exception of lower repeat revascularization at 6 months in the HCR group (0% vs 10.9%; p=0.02). Conclusion: This retrospective study demonstrates that HCR is a viable alternative to CABG for LM disease. While randomized clinical trial data is still needed, this less invasive approach is a promising treatment strategy for patients with high surgical risk.

Objective To compare the immediate and mid-term clinical outcomes between two-staged hybrid coronary revascularization and off-pump coronary artery bypass grafting (OPCAB) in patients with multi-vessel coronary artery disease (CAD) and diabetes mellitus (DM). Methods A total of 30 patients with multi-vessel CAD (including anterior descending lesions) and DM, who underwent two-staged hybrid coronary revascularization were enrolled in the 7th People's Hospital of Zhengzhou from January 2011 to June 2015. Propensity score method was used to match 60 patients who had undergone OPCAB (including anterior descending lesions) as control group with 1∶2 ratio. Primary endpoint of the study was the major adverse cardiac and cerebrovascular events (MACCE) including death, myocardial infarction (MI) and stroke or target vessel revascularization during follow-up. Secondary endpoint was the postoperative hospitalization outcome. Results The 24 hours post-operative chest drainage volumes, total chest drainage volumes, post-operative mechanical ventilation time and packed red blood cells transfusion rates were significantly lower in two-staged hybrid group than in OPCAB group (all P 0.05). But stroke rate was significantly reduced in two-staged hybrid group (0 vs. 3.3%, P=0.037). Conclusions Two-staged hybrid coronary revascularization may be a safe and effective treatment for coronary artery revascularization in patients with multi-vessel CAD and DM. Key words: Coronary artery disease; Diabetes mellitus; Two-staged hybrid coronary revascularization; Coronary artery bypass, off-pump

Hybrid coronary revascularization intends to combine the durability and survival advantage of the left internal mammary artery to left anterior descending coronary artery graft by a minimally invasive surgical procedure and the interventional therapy for non-left anterior descending coronary artery vessels to achieve complete revascularization. It provides a feasible and attractive alternative to conventional coronary artery bypass grafting and percutaneous coronary intervention to target multivessel coronary artery disease, and advances the individualized, patient-oriented treatment for heart disease. In initial experiences, this new approach has yielded favorable early or midterm results in selected patients with multivessel coronary artery disease. However, available data related to these outcomes following hybrid revascularization are limited to retrospective studies with relatively small sample sizes. In this review, we aim to provide an overview of hybrid revascularization, and discuss appropriate patient selection, procedure techniques, and the main literature pertaining to the hybrid revascularization.

Hybrid revascularization for multivesselcoronary artery disease.

Background: Hybrid coronary revascularisation (HCR) integrates minimally invasive coronary artery bypass grafting (CABG) with percutaneous coronary intervention (PCI), presenting a viable alternative for managing severe triple-vessel disease (TVD). Although conventional CABG is the benchmark for multivessel disease, HCR has arisen as a method intended to diminish surgical morbidity while preserving long-term revascularisation advantages. This systematic study assesses the long-term clinical results of HCR in comparison to CABG. Methods: A computerised literature search was conducted across three search engines (Google Scholar, PUBMED, Crossref) for the years 2014-2025, with the keywords: CABG, Hybrid, TVD, and Triple Vessel. Quality of studies assessed using the Mixed Methods Appraisal Tool (MMAT) version 2018. Results: Initially, 1339 papers were retrieved; utilizing the PRISM algorithm, 2 articles were ultimately reviewed. Basman et al. (2020) discovered that the 8-year survival rates were comparable between HCR (5.0%) and CABG (4.0%), with no significant disparity in Major Adverse Cardiovascular Events (MACE) rates. Esteves et al. (2020) observed a greater incidence of adverse events in HCR (19.3%) compared to CABG (5.9%) at two years, primarily due to increased unexpected revascularisation; however, HCR demonstrated feasibility with acceptable safety. Both studies indicated that HCR is most appropriate for specific patients in whom PCI can successfully enhance minimally invasive bypass methods. Conclusions: HCR has benefits like reduced hospital durations and diminished surgical morbidity; however its long-term results do not surpass those of CABG. Increased revascularisation rates in HCR prompt apprehensions over its longevity in comparison to normal CABG. Future extensive randomised trials are necessary to formulate definitive clinical recommendations for patient selection.

Hybrid coronary revascularization (HCR) combines the respective strengths of coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) for selected patients with multivessel coronary artery disease. HCR includes the minimally invasive direct coronary artery bypass of a left internal thoracic artery graft to the left anterior descending artery (LAD) with stenting of non-LAD lesions with PCI, in onestop or staged hybrid procedures.HCR can prove superiority to conventional CABG in clinical complications. Many available data suggests that HCR is feasible and safe in skilled hands. Further large-scale randomized controlled trials are in great need. HCR may become another more commonly used interventional strategy for certain patients with multivessel coronary artery disease.

Surgical Versus Percutaneous Coronary Revascularization in Patients With Diabetes and Acute Coronary Syndromes

Techniques and technology for treating coronary artery disease (CAD) have evolved significantly over the past 40 years. Although there are cases in which the best treatment approach (medical, surgical, or catheter-based) is clear, the best choice of intervention is not obvious for the majority of patients. Five, 7, and 10 years after initial treatment, mortality is lower for coronary artery bypass grafting (CABG) than for medical treatment alone. These survival benefits of CABG are particularly substantial for patients with three-vessel or left main artery disease, severe angina, or a positive pretreatment exercise stress test. Most trials comparing CABG with catheter-based interventions (CBIs) in patients with multivessel disease have shown similar short-term survival benefits for both treatments, but CBIs have been associated with less periprocedural morbidity and CABG with longer-lasting revascularization. Substantial evidence suggests that CABG is preferable to CBI in certain types of patients, including the one third of CAD patients who have chronic total occlusion of one or more vessels, and those with diabetes mellitus. Meta-analyses of large numbers of CABG studies report 30-day mortality rates in the 1% to 2% range. Numerous CABG techniques have evolved that seem to produce equally good results. Substantial evidence suggests that internal mammary artery grafts more effectively promote short- and longterm survival than do saphenous vein grafts, especially when used to graft the left anterior descending (LAD) coronary artery. In fact, the bulk of the evidence suggests that CABG with left internal mammary artery (LIMA)-to-LAD grafting provides better long-term results than does either CABG with other types of conduits or CBI. Technical innovations made in the attempt to reduce the negative impact of cardiopulmonary bypass (CPB) include coating the internal surface with heparin or other polymers to reduce contact between blood and the CPB mechanism, minimizing hemodilution by shrinking the bypass circuit to reduce the amount of crystalloid prime needed to start CPB, and using hemofiltration to protect the heart and end organs. Current United States estimates (based on industry reports) suggest that 18% to 25% of the 370,000 annual CABG procedures are performed without the use of CPB. There is not yet complete agreement about the relative safety and efficacy of off-pump coronary artery bypass (OPCAB) and conventional CABG with CPB. The difficulty in comparing the OPCAB and standard CABG stems in part from the low incidences of mortality and significant morbidity associated with both techniques. A meta-analysis of 37 randomized, controlled trials of OPCAB suggests that it is associated with significantly decreased transfusion and inotrope requirements, atrial fibrillation, respiratory infections, ventilation time, intensive care unit stay, hospital stay, and overall in-hospital and (1-year) postdischarge costs compared with standard CABG. Data from many large nonrandomized studies suggest that OPCAB is associated with a lower incidence of death, stroke, intraaortic balloon pump requirement, and postoperative transfusion, and a shorter average time on ventilator and length of hospital stay compared with conventional CABG. However, selection bias cannot be ruled out as a potential confounding variable in these data. Devices and techniques for lateral and inferior wall exposure have enabled surgeons performing OPCAB to attach grafts to all aspects of the heart. Recent series show no difference in the average number of grafts constructed in OPCAB and standard CABG, and several series have shown excellent graft patency. Off-pump bypass is ideal for patients with significant atheroma or calcification of the ascending aorta. A few studies have shown that OPCAB is associated with a reduced incidence of neurocognitive dysfunction compared with conventional CABG with CPB, but other studies have shown no significant differences. Results of small randomized trials suggest that, in patients with stenosis of the proximal LAD, minimally invasive direct coronary artery bypass (MIDCAB) is associated with a longer in-hospital recovery period and higher costs than is direct stenting, but that MIDCAB produces similar or better short- and long-term outcomes. Totally videoscopic LIMA-to-LAD procedures have been performed in which surgical robots were used to mobilize the LIMA and make the sutured anastomosis, but robots are not likely to be in widespread use for CABG in the near future because of their expense and the challenges involved in learning to use them. Although port-access CPB has been used successfully in multivessel CABG performed through small fifth intercostal space thoracotomies, this procedure has fallen out of favor, partly because of the difficulty of constructing grafts of appropriate length and lie.

The decision for coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) in patients with multi-vessel coronary artery disease (mCAD) is currently made by a heart-team approach. Patients' preference is less well investigated. All consecutive patients with prior CABG and at least 2 PCI procedures were interviewed whether they would elect bypass surgery or staged PCI in case of a hypothetical scenario in which they had mCAD and CABG or PCI will equally improve symptoms and survival. A total 213 patients were surveyed. About 21 (10%) patients had multiple CABG, and mean number of PCI per patient was 4.0±2.7. Complications during CABG were reported in 19.7% and in 14% after PCI, respectively. About 15% experienced complications after both CABG and PCI, and 51% had no complications at all. Mean symptom-free period was 5.2 (following CABG) vs 1.8years (following PCI); P<.001. Duration of recovery was significant shorter after PCI (mean 9.2±1.2 vs 136.4±57.9 days; P<.01). Based on their personal experience with both procedures, 15% of the participants elected CABG in the hypothetical scenario and 67% choose staged PCI, 18% were equally happy with either. More participants preferred PCI when age was ≥70, complications following CABG occurred, and when undergoing CABG first. Gender, number of CABG or PCI procedures per patient, and complications following PCI did not affect participants' preference. In our hypothetical scenario, the majority of participants preferred staged PCI over CABG. Preferences were related to age, complications following CABG, and whether CABG was performed first.

Introduction: Off-pump coronary artery bypass or «beating heart» surgery is a form of coronary ar­tery bypass graft (CABG) surgery performed without cardiopulmonary bypass as treatment for cor­onary artery disease. When a cardiac surgeon chooses the CABG procedure off-pump, also known as OPCAB (Off-pump Coronary Artery Bypass), the heart is still beating while the graft attachments are made to bypass a blockage. Using the OPCAB technique for multi-vessel myocardial revascular­ization in high-risk patients significantly reduces the incidence of perioperative myocardial infarc­tion and other major complications. Even though the OPCAB group includes a significantly higher proportion of older patients with poor Left Ventricle (LV) function and renal problems, the benefi­cial effect of OPCAB is evident. Materials and methods: The case report describes a 75-year old man with class III angina pectoris, class II chronic left heart failure, class III hypertension, dyslipidaemia and LV hypertrophy who has been suffering from chest pain, breathlessness and easy tiredness. After cardiac catheterization, the patient was diagnosed with three vessel coronary artery disease. Due to the patient`s comorbidities, his age and the higher perioperative risk of conventional CABG, the patient was considered as suit­able for OPCAB surgery in planned order. Results: Blood flow in the coronary arteries was restored with four grafts - Left Internal Mammary Artery (LIMA) to Left Anterior Descending coronary artery (LAD), Right Coronary Artery (RCA) to Posterior Descending Coronary Artery (Pd) to First Marginal Branch of the circumflex coronary artery (OM1) to Ramus Intermedius Artery (RIM) - free Right Internal Mammary Artery (RIMA) jump. Proximally the free RIMA is anastomosed terminal-laterally to in situ LIMA. Postoperatively no rhythm or conduction disorders have been registered. Conclusion: OPCAB has advantages in reducing postoperative complications such as: systemic in­flammatory response and myocardial, renal and cerebral injuries compared to on-pump coronary ar­tery bypass grafting.

Background Coronary artery disease (CAD) significantly contributes to morbidity and mortality globally, particularly in individuals with diabetes mellitus, who are at a heightened risk for cardiovascular complications. The complexity of coronary lesions and diffuse atherosclerosis in diabetic patients presents challenges in their treatment and prognosis. Coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) are primary revascularization strategies for managing multi-vessel CAD in diabetic patients. Despite advancements in both techniques, their relative efficacy and safety remain debated, especially in the diabetic population. Objective This multicenter study aims to compare the long-term outcomes of CABG and PCI in diabetic patients with multi-vessel CAD. The primary endpoints include overall survival and the incidence of major adverse cardiac events (MACE). Secondary endpoints encompass revascularization success and procedural complication rates. Methods This retrospective cohort study was conducted across multiple centers, and the research spanned from January 2020 to December 2021. A total of 500 diabetic patients with multi-vessel CAD were included: 250 underwent CABG and 250 received PCI. Data were collected from electronic health records, capturing demographic details, clinical characteristics, procedural specifics, and follow-up outcomes over 24 months. Statistical analyses were performed using SPSS version 25 (IBM Corp., Armonk, NY), including Kaplan-Meier survival curves and Cox proportional hazards regression. Results The mean age of participants was 60.3 ± 10.5 years, with males constituting 52% of each group. Both groups achieved a high revascularization success rate of 90%. The CABG group treated more vessels on average (2.3 ± 0.7) compared to the PCI group (1.9 ± 0.8) (p < 0.001). Survival rates were higher in the CABG group (88%) compared to the PCI group (82%) (p = 0.08). MACE incidence was lower in the CABG group (22%) compared to the PCI group (28%) (p = 0.10). Procedural complications were marginally higher in the CABG group (16%) than in the PCI group (14%) (p = 0.60). Conclusion Both CABG and PCI are effective revascularization options for diabetic patients with multi-vessel CAD. CABG may offer a slight advantage in long-term survival and reduction in MACE, although the differences were not statistically significant. These findings suggest that individualized treatment strategies should be considered to optimize patient outcomes.

AimsThere is a scarcity of studies comparing percutaneous coronary intervention (PCI) using new-generation drug-eluting stents (DES) with coronary artery bypass grafting (CABG) in patients with multi-vessel coronary artery disease.Methods and resultsThe CREDO-Kyoto PCI/CABG registry Cohort-3 enrolled 14927 consecutive patients who underwent first coronary revascularization with PCI or isolated CABG between January 2011 and December 2013. The current study population consisted of 2464 patients who underwent multi-vessel coronary revascularization including revascularization of left anterior descending coronary artery (LAD) either with PCI using new-generation DES (N = 1565), or with CABG (N = 899). Patients in the PCI group were older and more often had severe frailty, but had less complex coronary anatomy, and less complete revascularization than those in the CABG group. Cumulative 5-year incidence of a composite of all-cause death, myocardial infarction or stroke was not significantly different between the 2 groups (25.0% versus 21.5%, P = 0.15). However, after adjusting confounders, the excess risk of PCI relative to CABG turned to be significant for the composite endpoint (HR 1.27, 95%CI 1.04–1.55, P = 0.02). PCI as compared with CABG was associated with comparable adjusted risk for all-cause death (HR 1.22, 95%CI 0.96–1.55, P = 0.11), and stroke (HR 1.17, 95%CI 0.79–1.73, P = 0.44), but with excess adjusted risk for myocardial infarction (HR 1.58, 95%CI 1.05–2.39, P = 0.03), and any coronary revascularization (HR 2.66, 95%CI 2.06–3.43, P<0.0001).ConclusionsIn this observational study, PCI with new-generation DES as compared with CABG was associated with excess long-term risk for major cardiovascular events in patients who underwent multi-vessel coronary revascularization including LAD.

Advances in coronary artery bypass grafting (CABG) surgery and percutaneous coronary intervention (PCI) with drug-eluting stents have dramatically improved results of these procedures. The optimal treatment for patients with multivessel coronary artery disease is uncertain given the lack of prospective, randomized data reflecting current practice. This study represents a "real-world" evaluation of current technology in the treatment of multivessel coronary artery disease. A total of 1680 patients undergoing revascularization for multivessel coronary artery disease were identified. Of these, 1080 patients were treated for 2-vessel disease (196 CABG and 884 PCI) and 600 for 3-vessel disease (505 CABG and 95 PCI). One-year mortality, cerebrovascular events, Q-wave myocardial infarction, target vessel failure, and composite major adverse cardiovascular and cerebrovascular events were compared between the CABG and PCI cohorts. Outcomes were adjusted for baseline covariates and reported as hazard ratios. The unadjusted major adverse cardiovascular and cerebrovascular event rate was reduced with CABG for patients with 2-vessel disease (9.7% CABG versus 21.2% PCI; P<0.001) and 3-vessel disease (10.8% CABG versus 28.4% PCI; P<0.001). Adjusted outcomes showed increased major adverse cardiovascular and cerebrovascular event with PCI for patients with 2-vessel (hazard ratio 2.29; 95% CI 1.39 to 3.76; P=0.01) and 3-vessel disease (hazard ratio 2.90; 95% CI 1.76 to 4.78; P<0.001). Adjusted outcomes for the nondiabetic subpopulation demonstrated equivalent major adverse cardiovascular and cerebrovascular event with PCI for 2-vessel (hazard ratio 1.77; 95% CI 0.96 to 3.25; P=0.07) and 3-vessel disease (hazard ratio 1.70; 95% CI 0.77 to 3.61; P=0.19). Compared with PCI with drug-eluting stents, CABG resulted in improved major adverse cardiovascular and cerebrovascular event in patients with 2- and 3-vessel coronary artery disease, primarily in those with underlying diabetes. Coronary artery bypass surgery may be the preferred revascularization strategy in diabetic patients with multivessel coronary artery disease.

Background: Data on one-stop hybrid coronary revascularization (HCR) are limited. This study aimed to compare the early and midterm outcomes of one-stop HCR with off-pump coronary artery bypass grafting (OPCAB) in patients with multivessel coronary artery disease.Methods: From April 2018 to May 2021, 752 patients with multivessel coronary artery disease who underwent isolated one-stop HCR or OPCAB were retrospectively included in this analysis. After exclusion and propensity score matching, 151 patients who underwent HCR were matched with 151 patients who underwent OPCAB. The primary endpoints were midterm major adverse cardiovascular and cerebrovascular events (MACCE) after the procedure. The secondary endpoints were in-hospital complications and outcomes.Results: The preprocedural characteristics were well balanced between the two groups after matching. The HCR group was associated with a lower rate of perioperative transfusion (23.8 vs. 53.0%, p < 0.001) and new-onset atrial fibrillation (AF) (5.3 vs. 15.2%, p = 0.004), shorter time of mechanical ventilation (h) [15 (16, 17) vs. 17 (16, 20), p < 0.001], and shorter length of stay (LOS) in the hospital (days) [19 (16, 24) vs. 22 (18, 27), p = 0.001]. Cumulated MACCE rates were similar between the two groups (15.9 vs. 14.0%, p = 0.59) during a median follow-up of 20 months.Conclusions: One-stop HCR is safe and efficacious with less invasiveness and faster postoperative recovery in selected patients with multivessel coronary artery disease. Randomized controlled trials with larger sample sizes and long-term follow-up are warranted to confirm these findings.