We live in a constantly evolving environment, where the tailored alignment of therapeutic alternatives with patient characteristics enhances the care we offer. The treatment of structural heart disease exemplifies this phenomenon. However, coronary revascularization remains polarized between surgery (CABG) and percutaneous intervention (PCI). Hybrid revascularization has gained limited popularity, as the drawbacks of each revascularization strategy (CABG: invasiveness, bleeding, postoperative recovery, surgical wound; PCI: restenosis, progression of proximal native disease, dual antiplatelet therapy, vascular access complications) often outweigh its advantages (CABG: patency of arterial graft(s), avoidance of cardiopulmonary bypass (CPB), reduced stent use; PCI: minimally invasive percutaneous treatment, reduced morbidity from graft harvest, angiographic verification of surgical results, complete revascularization supported by the internal mammary artery graft to the left anterior descending artery).

Experience with hybrid revascularization has been limited both in quantity and in the follow-up duration of studies. It remains a minority approach; authors report it represents only 0.48% of CABG procedures in the United States. Thus, we analyze a study that gathered multivessel disease patients treated between 2007 and 2018, including 585 who underwent hybrid revascularization, 15,118 OPCAB, and 54,502 PCI. After propensity score matching, three homogeneous groups of 540 patients each were obtained. Two key factors influencing the results were the method used for hybrid therapy and coronary anatomy characteristics. Firstly, hybrid revascularization was performed using minimally invasive off-pump techniques (MIDCAB) with the left internal mammary artery anastomosed to the left anterior descending artery through a left anterior small thoracotomy (LAST) by experienced surgeons. Sequentially, but in the same procedure, complete revascularization of remaining coronary disease was performed, minimizing any period of protection loss between procedures. The percutaneous procedure reevaluated the surgical outcome angiographically, enabling embolization of dominant collateral branches causing steal, especially in left main coronary artery disease. Secondly, patients had real-world characteristics, with higher SYNTAX scores (mean 27) compared to previous studies (15–23) and higher left main disease (37% vs. 7–17%) and three-vessel disease (62% vs. 34–40%) prevalence. After a median follow-up of more than 8 years, the rate of major adverse cardiac and cerebrovascular events (MACCE) was comparable between hybrid revascularization and OPCAB (28.7% and 23.9%, respectively) and significantly higher in PCI (45.3%; p < 0.001). Mortality did not differ significantly across the three options (OPCAB 9.7%, hybrid 12.7%, and PCI 15.6%; p > 0.05). For MACCE stratified by EuroSCORE II (low <0.9%, medium 0.9–1.5%, high >1.5%), similar outcomes were seen for low- and medium-risk groups, but in the high-risk category, MACCE was lower for hybrid revascularization than OPCAB or PCI (31.9% vs. 47% vs. 53.7%; p = 0.014). For individual MACCE events, the need for repeat revascularization affected stent-based approaches, with rates of 9.8%, 17.3%, and 34.8% for OPCAB, hybrid revascularization, and PCI, respectively; p < 0.001. These differences were non-significant for low-complexity coronary anatomy (SYNTAX score <22). Cost-utility (quality of life) and cost-value analysis revealed similar scores for physical capacity, treatment satisfaction, and quality of life across OPCAB, hybrid revascularization, and PCI, with minimal differences.

The authors conclude that, compared to traditional revascularization strategies, hybrid revascularization offers satisfactory MACCE and functional capacity outcomes for multivessel coronary disease patients.

COMMENTARY:

This study represents the largest and longest follow-up analysis focused on hybrid revascularization outcomes compared to traditional multivessel disease approaches. It optimizes minimally invasive principles, avoids operator bias with highly experienced surgeons, and provides real-world data, positioning hybrid revascularization as an attractive alternative for select patient subgroups.

CABG, with or without CPB, remains the treatment standard for multivessel disease. Regardless of technical variations (grafts, on- or off-pump, aortic manipulation, or proximal anastomoses), CABG principles involve covering the myocardial territories affected by multivessel disease, where tributary coronary artery correspondence may be less defined, especially with artery occlusion. In multivessel disease, “the blood’s pathways may be as intricate as God’s, with collaterals.” Revascularization should apply at least one arterial graft, which, despite other associated graft failures or disease, especially if venous or inadequately used arterial grafts, maintains patency and can supply large myocardial areas. Therefore, the use of multiple arterial grafts can still extend this benefit. Hybrid revascularization assimilates this concept, using stents’ minimal invasiveness while preserving the long-term benefit of the left internal mammary artery graft to the left anterior descending artery.

These results suggest that hybrid revascularization may find its niche in multivessel disease subgroups, specifically non-diabetic, frail patients (limited mobility, comorbidities, high surgical bleeding risk, etc.) and/or those with intermediate surgical risk (EuroSCORE II >1.5, differing significantly from the thresholds used for TAVI), with coronary anatomy complexity suitable for PCI (SYNTAX score <22, currently class I indication for PCI and CABG in non-diabetic patients). The reduction in MACCE, alongside similar survival and revascularization rates relative to OPCAB, positions hybrid revascularization as a tailored alternative for certain patients. Once again, the hybrid nature, not only of the treatments but of the specialists involved, stands out. This combination enhances benefits and overcomes the limitations of two techniques traditionally seen as incompatible.

REFERENCE:

Ding T, Yuan X, Chen K, Shen L, Guan C, Lv F, et al. Simultaneous hybrid coronary revascularization vs. conventional strategies for multivessel coronary artery disease: a 10-year follow-up. JACC Cardiovasc Interv. 2023 Jan 9;16(1):50–60. doi: 10.1016/j.jcin.2022.09.049.