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Use of Hybrid Coronary Revascularization in Patients with Multivessel Coronary Artery Disease
Study Overview
Objective. To investigate the 5-year clinical outcome of patients undergoing hybrid revascularization for multivessel coronary artery disease (CAD).
Design. Multicenter, open-label, prospective randomized control trial.
Setting and participants. 200 patients with multivessel CAD referred for conventional surgical revascularization were randomly assigned to undergo hybrid coronary revascularization (HCR) or coronary artery bypass grafting (CABG).
Main outcome measures. The primary endpoint was all-cause mortality at 5 years.
Main results. After excluding 9 patients who were lost to follow-up before 5 years, 191 patients (94 in HCR group and 97 in CABG group) formed the basis of the study. All-cause mortality at 5-year follow-up was similar in the 2 groups (6.4% versus 9.2%, P = 0.69). The rates of myocardial infarction (4.3% versus 7.2%, P = 0.30), repeat revascularization (37.2% versus 45.4%, P = 0.38), stroke (2.1% versus 4.1%, P = 0.35), and major adverse and cardiac and cerebrovascular events (45.2% versus 53.4%, P = 0.39) were similar in the 2 groups. These findings were consistent across all levels of risk for surgical complications (EuroScore) and for complexity of revascularization (SYNTAX score).
Conclusion. HCR has similar 5-year all-cause mortality when compared with conventional CABG.
Commentary
HCR has been proposed as a less invasive, effective alternative revascularization strategy to conventional CABG for patients with multivessel CAD. The hybrid approach typically combines the long-term durability of grafting of the left anterior descending artery (LAD) using the left internal mammary artery and the percutaneous coronary intervention (PCI) for non-LAD stenosis; this approach has been shown to have similar or perhaps even better long-term patency compared with saphenous vein grafts.1,2 Previous studies have demonstrated the feasibility of HCR by comparing HCR to conventional CABG at 1 year.2 However, the long-term outcome of HCR compared to conventional CABG has not been previously reported.
In this context, Tajstra et al reported the 5-year follow-up from their prospective randomized pilot study. They report that among the 200 patients with multivessel coronary disease randomly assigned to either HCR or CABG, all-cause mortality at 5-year follow-up was similar in the 2 groups (6.4% versus 9.2%, P = 0.69). The rates of myocardial infarction, repeat revascularization, stroke, and major adverse and cardiac and cerebrovascular event (MACCE) were also similar in the 2 groups.
This is an important study because it is the first to compare the long-term outcome of HCR with conventional CABG; previous studies have been limited due to their short- to mid-term follow-up.2 However, because this study was not powered to assess the superiority of the HCR compared to conventional CABG, future randomized control trials with a larger number of patients are needed.
Future studies must address some important questions. First, the patients in the present study were younger (mean age, 62.1 ± 8.3 years) with less comorbidity and a relatively low SYNTAX score (23.6 ± 6.1 for the HCR arm). As CABG and PCI are associated with similar long- term outcomes in patients with low (< 22) to intermediate (22–32) SYNTAX score,3 comparisons between HCR and multivessel PCI using the current generation of drug-eluting stents are needed. The results from the ongoing Hybrid Coronary Revascularization Trial (NCT03089398) will shed light on this clinical question. Second, whether these findings can be extended to patients with a high baseline SYNTAX score needs further study. Nonetheless, outcomes were similar between the 2 strategies in the intermediate (n = 98) and high (n = 8) SYNTAX score groups. Interestingly, there is no clear benefit of HCR in the high surgical risk groups as measured by EuroScore. Third, in addition to the hard outcomes (death and MACCE), the quality of life of patients measured by an established metric, such as the Seattle Angina Questionnaire, need to be assessed. Last, the completeness of revascularization in each group needs to be further evaluated because incomplete revascularization is a known predictor of adverse outcomes.4,5
Applications for Clinical Practice
In patients with multivessel coronary disease with low SYNTAX score, the 5-year outcome for HCR was similar to that of conventional CABG. Further larger studies are needed to assess the superiority of this approach.
—Taishi Hirai, MD, University of Missouri Medical Center, Columbia, MO; Hiroto Kitahara, MD, University of Chicago Medical Center, Chicago, IL; and John Blair, MD, Medstar Washington Hospital Center, Washington, DC
1. Lee PH, Kwon O, Ahn JM, et al. Safety and effectiveness of second-generation drug-eluting stents in patients with left main coronary artery disease. J Am Coll Cardiol. 2018;71:832-841.
2. Gasior M, Zembala MO, Tajstra M, et al. Hybrid revascularization for multivessel coronary artery disease. JACC Cardiovasc Interv. 2014;7:1277-1283.
3. Serruys PW, Onuma Y, Garg S, et al. Assessment of the SYNTAX score in the Syntax study. EuroIntervention. 2009;5:50-56.
4. Genereux P, Palmerini T, Caixeta A, et al. Quantification and impact of untreated coronary artery disease after percutaneous coronary intervention: the residual SYNTAX (Synergy Between PCI with Taxus and Cardiac Surgery) score. J Am Coll Cardiol. 2012;59:2165-2174.
5. Choi KH, Lee JM, Koo BK, et al. Prognostic implication of functional incomplete revascularization and residual functional SYNTAX score in patients with coronary artery disease. JACC Cardiovasc Interv. 2018;11:237-245.
Study Overview
Objective. To investigate the 5-year clinical outcome of patients undergoing hybrid revascularization for multivessel coronary artery disease (CAD).
Design. Multicenter, open-label, prospective randomized control trial.
Setting and participants. 200 patients with multivessel CAD referred for conventional surgical revascularization were randomly assigned to undergo hybrid coronary revascularization (HCR) or coronary artery bypass grafting (CABG).
Main outcome measures. The primary endpoint was all-cause mortality at 5 years.
Main results. After excluding 9 patients who were lost to follow-up before 5 years, 191 patients (94 in HCR group and 97 in CABG group) formed the basis of the study. All-cause mortality at 5-year follow-up was similar in the 2 groups (6.4% versus 9.2%, P = 0.69). The rates of myocardial infarction (4.3% versus 7.2%, P = 0.30), repeat revascularization (37.2% versus 45.4%, P = 0.38), stroke (2.1% versus 4.1%, P = 0.35), and major adverse and cardiac and cerebrovascular events (45.2% versus 53.4%, P = 0.39) were similar in the 2 groups. These findings were consistent across all levels of risk for surgical complications (EuroScore) and for complexity of revascularization (SYNTAX score).
Conclusion. HCR has similar 5-year all-cause mortality when compared with conventional CABG.
Commentary
HCR has been proposed as a less invasive, effective alternative revascularization strategy to conventional CABG for patients with multivessel CAD. The hybrid approach typically combines the long-term durability of grafting of the left anterior descending artery (LAD) using the left internal mammary artery and the percutaneous coronary intervention (PCI) for non-LAD stenosis; this approach has been shown to have similar or perhaps even better long-term patency compared with saphenous vein grafts.1,2 Previous studies have demonstrated the feasibility of HCR by comparing HCR to conventional CABG at 1 year.2 However, the long-term outcome of HCR compared to conventional CABG has not been previously reported.
In this context, Tajstra et al reported the 5-year follow-up from their prospective randomized pilot study. They report that among the 200 patients with multivessel coronary disease randomly assigned to either HCR or CABG, all-cause mortality at 5-year follow-up was similar in the 2 groups (6.4% versus 9.2%, P = 0.69). The rates of myocardial infarction, repeat revascularization, stroke, and major adverse and cardiac and cerebrovascular event (MACCE) were also similar in the 2 groups.
This is an important study because it is the first to compare the long-term outcome of HCR with conventional CABG; previous studies have been limited due to their short- to mid-term follow-up.2 However, because this study was not powered to assess the superiority of the HCR compared to conventional CABG, future randomized control trials with a larger number of patients are needed.
Future studies must address some important questions. First, the patients in the present study were younger (mean age, 62.1 ± 8.3 years) with less comorbidity and a relatively low SYNTAX score (23.6 ± 6.1 for the HCR arm). As CABG and PCI are associated with similar long- term outcomes in patients with low (< 22) to intermediate (22–32) SYNTAX score,3 comparisons between HCR and multivessel PCI using the current generation of drug-eluting stents are needed. The results from the ongoing Hybrid Coronary Revascularization Trial (NCT03089398) will shed light on this clinical question. Second, whether these findings can be extended to patients with a high baseline SYNTAX score needs further study. Nonetheless, outcomes were similar between the 2 strategies in the intermediate (n = 98) and high (n = 8) SYNTAX score groups. Interestingly, there is no clear benefit of HCR in the high surgical risk groups as measured by EuroScore. Third, in addition to the hard outcomes (death and MACCE), the quality of life of patients measured by an established metric, such as the Seattle Angina Questionnaire, need to be assessed. Last, the completeness of revascularization in each group needs to be further evaluated because incomplete revascularization is a known predictor of adverse outcomes.4,5
Applications for Clinical Practice
In patients with multivessel coronary disease with low SYNTAX score, the 5-year outcome for HCR was similar to that of conventional CABG. Further larger studies are needed to assess the superiority of this approach.
—Taishi Hirai, MD, University of Missouri Medical Center, Columbia, MO; Hiroto Kitahara, MD, University of Chicago Medical Center, Chicago, IL; and John Blair, MD, Medstar Washington Hospital Center, Washington, DC
Study Overview
Objective. To investigate the 5-year clinical outcome of patients undergoing hybrid revascularization for multivessel coronary artery disease (CAD).
Design. Multicenter, open-label, prospective randomized control trial.
Setting and participants. 200 patients with multivessel CAD referred for conventional surgical revascularization were randomly assigned to undergo hybrid coronary revascularization (HCR) or coronary artery bypass grafting (CABG).
Main outcome measures. The primary endpoint was all-cause mortality at 5 years.
Main results. After excluding 9 patients who were lost to follow-up before 5 years, 191 patients (94 in HCR group and 97 in CABG group) formed the basis of the study. All-cause mortality at 5-year follow-up was similar in the 2 groups (6.4% versus 9.2%, P = 0.69). The rates of myocardial infarction (4.3% versus 7.2%, P = 0.30), repeat revascularization (37.2% versus 45.4%, P = 0.38), stroke (2.1% versus 4.1%, P = 0.35), and major adverse and cardiac and cerebrovascular events (45.2% versus 53.4%, P = 0.39) were similar in the 2 groups. These findings were consistent across all levels of risk for surgical complications (EuroScore) and for complexity of revascularization (SYNTAX score).
Conclusion. HCR has similar 5-year all-cause mortality when compared with conventional CABG.
Commentary
HCR has been proposed as a less invasive, effective alternative revascularization strategy to conventional CABG for patients with multivessel CAD. The hybrid approach typically combines the long-term durability of grafting of the left anterior descending artery (LAD) using the left internal mammary artery and the percutaneous coronary intervention (PCI) for non-LAD stenosis; this approach has been shown to have similar or perhaps even better long-term patency compared with saphenous vein grafts.1,2 Previous studies have demonstrated the feasibility of HCR by comparing HCR to conventional CABG at 1 year.2 However, the long-term outcome of HCR compared to conventional CABG has not been previously reported.
In this context, Tajstra et al reported the 5-year follow-up from their prospective randomized pilot study. They report that among the 200 patients with multivessel coronary disease randomly assigned to either HCR or CABG, all-cause mortality at 5-year follow-up was similar in the 2 groups (6.4% versus 9.2%, P = 0.69). The rates of myocardial infarction, repeat revascularization, stroke, and major adverse and cardiac and cerebrovascular event (MACCE) were also similar in the 2 groups.
This is an important study because it is the first to compare the long-term outcome of HCR with conventional CABG; previous studies have been limited due to their short- to mid-term follow-up.2 However, because this study was not powered to assess the superiority of the HCR compared to conventional CABG, future randomized control trials with a larger number of patients are needed.
Future studies must address some important questions. First, the patients in the present study were younger (mean age, 62.1 ± 8.3 years) with less comorbidity and a relatively low SYNTAX score (23.6 ± 6.1 for the HCR arm). As CABG and PCI are associated with similar long- term outcomes in patients with low (< 22) to intermediate (22–32) SYNTAX score,3 comparisons between HCR and multivessel PCI using the current generation of drug-eluting stents are needed. The results from the ongoing Hybrid Coronary Revascularization Trial (NCT03089398) will shed light on this clinical question. Second, whether these findings can be extended to patients with a high baseline SYNTAX score needs further study. Nonetheless, outcomes were similar between the 2 strategies in the intermediate (n = 98) and high (n = 8) SYNTAX score groups. Interestingly, there is no clear benefit of HCR in the high surgical risk groups as measured by EuroScore. Third, in addition to the hard outcomes (death and MACCE), the quality of life of patients measured by an established metric, such as the Seattle Angina Questionnaire, need to be assessed. Last, the completeness of revascularization in each group needs to be further evaluated because incomplete revascularization is a known predictor of adverse outcomes.4,5
Applications for Clinical Practice
In patients with multivessel coronary disease with low SYNTAX score, the 5-year outcome for HCR was similar to that of conventional CABG. Further larger studies are needed to assess the superiority of this approach.
—Taishi Hirai, MD, University of Missouri Medical Center, Columbia, MO; Hiroto Kitahara, MD, University of Chicago Medical Center, Chicago, IL; and John Blair, MD, Medstar Washington Hospital Center, Washington, DC
1. Lee PH, Kwon O, Ahn JM, et al. Safety and effectiveness of second-generation drug-eluting stents in patients with left main coronary artery disease. J Am Coll Cardiol. 2018;71:832-841.
2. Gasior M, Zembala MO, Tajstra M, et al. Hybrid revascularization for multivessel coronary artery disease. JACC Cardiovasc Interv. 2014;7:1277-1283.
3. Serruys PW, Onuma Y, Garg S, et al. Assessment of the SYNTAX score in the Syntax study. EuroIntervention. 2009;5:50-56.
4. Genereux P, Palmerini T, Caixeta A, et al. Quantification and impact of untreated coronary artery disease after percutaneous coronary intervention: the residual SYNTAX (Synergy Between PCI with Taxus and Cardiac Surgery) score. J Am Coll Cardiol. 2012;59:2165-2174.
5. Choi KH, Lee JM, Koo BK, et al. Prognostic implication of functional incomplete revascularization and residual functional SYNTAX score in patients with coronary artery disease. JACC Cardiovasc Interv. 2018;11:237-245.
1. Lee PH, Kwon O, Ahn JM, et al. Safety and effectiveness of second-generation drug-eluting stents in patients with left main coronary artery disease. J Am Coll Cardiol. 2018;71:832-841.
2. Gasior M, Zembala MO, Tajstra M, et al. Hybrid revascularization for multivessel coronary artery disease. JACC Cardiovasc Interv. 2014;7:1277-1283.
3. Serruys PW, Onuma Y, Garg S, et al. Assessment of the SYNTAX score in the Syntax study. EuroIntervention. 2009;5:50-56.
4. Genereux P, Palmerini T, Caixeta A, et al. Quantification and impact of untreated coronary artery disease after percutaneous coronary intervention: the residual SYNTAX (Synergy Between PCI with Taxus and Cardiac Surgery) score. J Am Coll Cardiol. 2012;59:2165-2174.
5. Choi KH, Lee JM, Koo BK, et al. Prognostic implication of functional incomplete revascularization and residual functional SYNTAX score in patients with coronary artery disease. JACC Cardiovasc Interv. 2018;11:237-245.