A hybrid revascularization approach combining percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) produced similar five-year outcomes compared to CABG alone, according to a randomized trial of patients with multivessel coronary artery disease (CAD) published in JACC: Cardiovascular Interventions.
Hybrid coronary revascularization (HCR) involves grafting the left internal mammary artery (LIMA) to the left anterior descending (LAD) artery while treating non-LAD lesions with drug-eluting stents via a transcatheter approach. But HCR hasn’t been well-studied and a lack of evidence may contribute to it not being strongly endorsed in American and European guidelines, wrote lead author Mateusz Tajstra, MD, and colleagues.
Among 191 patients randomized 1:1 to either HCR or CABG, there were no significant differences in mortality or components of major adverse cardiovascular or cerebrovascular events. However, five-year event rates were lower for HCR than CABG across the board:
- Mortality, 6.4 percent versus 9.2 percent
- Myocardial infarction, 4.3 percent versus 7.2 percent
- Repeat revascularization, 37.2 percent versus 45.4 percent
- Stroke, 2.1 percent versus 4.1 percent
“We have proved that HCR is safe and feasible in a selected population of patients with (multivessel) CAD and we have recorded that minimally invasive direct coronary artery bypass with LIMA to LAD preceding endovascular as a first-stage procedure in HCR patients was not associated with a significant increase in adverse events,” Tajstra and coauthors wrote. “Regrettably, to our best knowledge, the HYBRID trial is the only randomized trial worldwide and there is still paucity of clinical data including significant number of patients with long-term follow-up.”
The authors said the potential benefits of HCR include avoiding aortic clamping and utilizing a less-invasive approach than CABG, which may reduce perioperative outcomes. But they reiterated their trial lacked the statistical power to demonstrate superiority, maintaining their results should only be hypothesis-generating.
“All the discussion about the statistically insignificant difference that favors a hybrid approach may be speculative, misleading, and should be interpreted with caution,” Tajstra et al. wrote.
In a related editorial, Adrian W. Messerli, MD, and Naoki Misumida, MD—both with the University of Kentucky—agreed it’s too soon to measure HCR’s effectiveness against CABG or multivessel PCI.
“All available data suggest that HCR is feasible and safe in skilled hands,” they wrote, but clinical unknowns, lack of cost-effectiveness analyses and practical limitations have hindered its widespread adoption.
“Until HCR can prove superiority to conventional CABG in clinical outcomes such as significant morbidity or stroke reduction, adoption of this strategy will likely continue to be modest,” Messerli and Misumida wrote.
A 2,400-patient, randomized trial is underway to compare HCR with multivessel PCI, the editorialists noted, which may better inform whether the hybrid approach is worthy of broader use.
Daniel joined TriMed’s Chicago editorial team in 2017 as a Cardiovascular Business writer. He previously worked as a writer for daily newspapers in North Dakota and Indiana.