Hybrid coronary revascularization fails to catch on in U.S.

Physicians in the U.S. who treat patients with multivessel coronary disease rarely turn to a hybrid approach for therapy. Over a two-year period, only 0.48 percent of CABG procedures included hybrid coronary revascularization (HCR), reported a study published online July 23 in Circulation.

Researchers led by Ralf E. Harskamp, MD, of the Duke University Medical Center in Durham, N.C., evaluated 198,662 CABG procedures performed between July 2011 and March 2013 that were submitted to the Society of Thoracic Surgeons Adult Cardiac Surgery Database. They found that about one-third of hospitals performing CABG procedures were also handling concurrent or staged HCR. Of those hospitals, HCR accounted for only about 1 percent of total CABG volume.

HCR uses a combination of percutaneous and surgical techniques, often involving a graft first (66.8 percent staged/70.2 percent concurrent) followed by PCI; it is performed either at the same time (concurrent), or staged over a number of individual procedures shortly following the first.

While Harskamp and colleagues found that very few hospitals were performing HCR over the period, those that were had higher CABG volumes. The maximum HCR use was approximately 13 percent of the total hospital CABG volume, however the median use was 0.76 percent.

Resources may be a factor in HCR’s slow uptake in the U.S. “The low adoption of HCR among U.S. hospitals can in part be attributed to the low use of minimally invasive surgical techniques, as hospitals that performed HCR without minimally invasive techniques were also less likely to perform HCR,” they wrote. “Additionally, the low use of concurrent HCR is likely due to the limited availability of hybrid operating rooms.”

Patients undergoing HCR were more likely to present with NSTEMI (34.8 percent concurrent HCR, 32.8 percent staged HCR) as opposed to CABG (23.7 percent). HCR patients had greater frequency of dialysis (8.5 percent concurrent HCR, 6.8 percent staged HCR, 4.8 percent CABG), prior PCI (50.4 percent concurrent, 59 percent staged, 23.5 percent CABG) or history of MI (58.2 percent concurrent, 63 percent staged, 47 percent CABG). Concurrent HCR patients were also more likely to have a history of stroke or peripheral vascular disease than staged HCR or CABG patients.

Initial costs to perform HCR were greater and the procedure more difficult to perform, requiring specialized training, although less on-pump time was required and less blood products were used. Mortality and composite endpoints were statistically similar between CABG and either staged or concurrent HCR. While length of stay was reduced for HCR patients (mean five days HCR vs. six days CABG), the risk of restenosis and repeat revascularization procedures made HCR a less attractive option to hospitals.

The research team found that HCR seemed to be a better option for patients who were more ill, especially as it was marginally less invasive. They recommended further study.

Igor Gosev, MD, and Marzia Leacche, MD, of the Division of Cardiac Surgery at Brigham and Women’s Hospital in Boston wrote in an editorial that while a valuable procedure, HCR likely will remain a niche procedure if it cannot be significantly and favorably compared to CABG in cost and complexity for surgical teams.

“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. However, “[t]he ideal subset of patients in whom the medical and financial risks of a minimally invasive procedure are acceptable is still to be determined.”