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. Author manuscript; available in PMC: 2015 Feb 24.
Published in final edited form as: Ann Thorac Surg. 2013 Dec;96(6):2268–2277. doi: 10.1016/j.athoracsur.2013.07.093

Status Quo of Hybrid Coronary Revascularization for Multi-Vessel Coronary Artery Disease

Ralf E Harskamp 1, Zhe Zheng 1, John H Alexander 1, Judson B Williams 1, Ying Xian 1, Michael E Halkos 1, J Matthew Brennan 1, Robbert J de Winter 1, Peter K Smith 1, Renato D Lopes 1
PMCID: PMC4339110  NIHMSID: NIHMS660732  PMID: 24446561

Abstract

Hybrid coronary revascularization (HCR) combines bypass grafting of the left anterior descending (LAD) coronary artery with percutaneous coronary intervention (PCI) of non-LAD vessels. HCR has been performed as an alternative to CABG or multi-vessel PCI in thousands of patients since the late 1990s. In this review article, we provide an overview on patient selection, procedural sequence and timing, use of surgical techniques and anti- platelet agents. Additionally, patient recovery, satisfaction, costs and clinical outcomes of individual studies after HCR are evaluated. Future directions are also discussed, including the need for adequately powered randomized trials.

Coronary revascularization provides symptomatic relief and improves long-term outcomes in patients with multi-vessel coronary artery disease [1]. The optimal revascularization strategy remains controversial, and depends on the anatomic complexity of the lesions requiring revascularization, comorbidities, and the ability to use dual antiplatelet therapy [2, 3]. Although coronary artery bypass graft (CABG) surgery is a long-established revascularization approach and hence considered “gold standard,” rapid developments in percutaneous techniques and devices as well as advances in medical therapy continue to challenge the status quo [4]. The major therapeutic benefits of CABG surgery over percutaneous coronary intervention (PCI) is the use of the left internal mammary artery (LIMA) to bypass the left anterior descending (LAD) artery irrespective of its lesion complexity. The superior patency of LIMA-to-LAD graft provides prophylaxis against future proximal LAD lesions, which translates into better event-free survival and relief of angina [5]. The benefits of bypassing other non-LAD coronary vessels are much less clear [6]. Conduits for a non-LAD vessel may include other arterial grafts (“multi-arterial” or “complete arterial” revascularization) but the saphenous vein is by far the most commonly used. A major limitation of CABG with saphenous vein grafts (SVG) lies in the high graft failure rates with reports ranging from 13% to 29% at 1 year and up to 50% at 10 years after surgery [7–9]. Although direct comparison data between SVG failure and PCI is not available, restenosis rates (<10%) and stent thrombosis rates (<1%) of drug-eluting stent (DES) in non-LAD lesions are markedly lower [10–12] (also see Fig 1). Additionally, subsequent revascularization for SVG failure is challenging and associated with much higher rates of periprocedural complications than native vessel PCI [8, 13, 14]. From a patient perspective, PCI also has the advantage of being minimally invasive with less patient discomfort, faster return to normal activities, and lower risk of complications such as stroke [15]. In order to combine the superior patency of the LIMA-to-LAD graft with the low restenosis rates of PCI to non-LAD regions, a hybrid approach was introduced to coronary revascularization. The present study provides an overview of evidence for the use of hybrid coronary revascularization (HCR) in the current DES era and explores strategies that may help improve the future role and implementation of HCR in patients with multi-vessel coronary artery disease.

Fig 1.

Fig 1

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Rates of vein graft failure with 1-year angiography and restenosis and stent thrombosis rates in drug-eluting stents [7–12, 66].

Material and Methods

Two authors (R.E.H., R.D.L.) searched the MEDLINE database using the PubMed interface to identify published studies that examined hybrid coronary revascularization and were published from January 1, 1996 through May 1, 2013. The search was performed using the following terms: “hybrid coronary revascularization,” “integrated coronary revascularization,” and “hybrid myocardial revascularization.” Additionally, we reviewed references from these articles for studies not found through the initial search. Both original and review articles were included, and publications were restricted to studies published in the English literature. From the available literature we distilled information on patient selection, timing and sequence of procedures, surgical and interventional techniques, antiplatelet drugs, clinical outcomes, patient satisfaction, and costs.

Patient Selection for Hybrid Coronary Revascularization

Patients who would qualify for HCR are those with symptoms or signs of ischemia, due to multi-vessel disease with significant proximal LAD disease, along with lesions suitable for PCI in the left main, left circumflex or right coronary artery territories. As such, cases with chronic total occlusions, highly calcified segment, and diffusely diseased and bifurcation coronary lesions were usually deferred to conventional CABG. Patients with a lack of suitable conduits, prior sternotomy, severe ascending aortic disease, or coronary arteries not amenable for bypass, may also be suitable candidates. Those cases in which the decision to perform additional PCI based on intraoperative findings (poor conduits, ungraftable vessels, graft defects) and patients who underwent CABG after PCI, either for ongoing ischemia or complications, are considered unplanned HCR [16]. This also includes cases in the setting of acute coronary syndrome, where PCI of the culprit vessel is followed by CABG during the same hospitalization for grafting of the non-culprit coronary arteries. Table 1 summarizes clinical and angiographic characteristics that one should consider when opting for HCR. Decision making when opting for hybrid CABG, should involve close consultation between interventional cardiologist and cardiac surgeon, preferably in the setting of a “heart team.”

Table 1.

Recommendations for Suitable Candidates for Hybrid Coronary Revascularization Versus Conventional Coronary Revascularization

Characteristic PCI HCR CABG
Angiographic characteristics
    ULMD - + +
    Intramyocardial LAD + - -
    Complex LAD lesion [53, 54, 55] - + +
    Complex non-LAD lesion [53, 54] - - +
Comorbidities
    Advanced age + + -
    Frailty [53, 54] + + -
    LVEF <30% - + +
    Diabetes mellitus - + +
    Renal insufficiency - + +
    Severe chronic lung disease + - -
    Prior left thoracotomy + - +
    Prior sternotomy [55] + + -
    Limited vascular access - - +
    Lack of available conduits [53, 54] + + -
    Severe aortic calcification [53, 54] + + -
    Contraindication for DAPT - - +
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+ = recommended; - = not recommended.

CABG = coronary artery bypass graft; DAPT = dual antiplatelet therapy; HCR = hybrid coronary revascularization; LAD = left anterior descending artery; LVEF = left ventricular ejection fraction; PCI = percutaneous coronary intervention; ULMD = unprotected left main disease.

Timing and Sequence of Hybrid Revascularization

Planned HCR can be performed as either a concomitant procedure in a hybrid operating room in which CABG and PCI are performed in the same anesthesia setting, or performed in 2 stages in which PCI and CABG are performed separately within hours, days, or weeks. When HCR is performed staged, PCI can be performed first followed by CABG or vice versa. These approaches all have their merits and disadvantages, as displayed in Table 2. However, recommendations on the optimal choice of HCR are based on expert opinion and supported by very few data that actually support one HCR strategy over another. Table 3 summarizes available evidence on comparisons of various HCR strategies.

Table 2.

Advantages and Limitations of Use of Various HCR Approaches

Factor One-Setting CABG Followed by PCI PCI Followed by CABG
LIMA-LAD patency Assessment directly after completing anastomosis Assessment during follow-up PCI Not routinely assessed
Suitable in non-elective setting No No Yes
PCI of complex lesions Possible Possible Possible, but more risky with non-revascularized LAD
Arterial access for PCI Obtain before anticoagulation administered for surgery Obtain at the time of PCI Obtain at the time of PCI
Anticoagulation Administered once Administered twice Administered twice
Discontinue DAPT No No Yes/No
Risk for intraoperative bleeding High Low High (if DAPT continued)
Risk of acute stent thrombosis Intermediate Low High
DES use Suitable Suitable Not suitable
LOS Likely to be shorter Likely to be longera Likely to be longera
Degree of coordination between teams High degree of coordination Lesser degree of coordination Lesser degree of coordination
Costs Hybrid room Two procedures Two procedures
Training of personnel Reimbursement Reimbursement
Reimbursement
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a

The difference between LOS in 1-setting and staged settings depends primarily on the time interval between the 2 staged procedures.

CABG = coronary artery bypass graft; DAPT = dual antiplatelet therapy; DES = drug-eluting stent; LAD = left anterior descending artery; LIMA = left internal mammary artery; LOS = length-of-stay; PCI = percutaneous coronary intervention.

Table 3.

Available Data on Outcomes After Simultaneous and Staged HCR Strategies

Author, Year (Ref) No. PCI Strategy CABG
Strategy		 In-Hospital
Mortality		 In-Hospital
Stroke		 Reoperation
For Bleeding		 In-Hospital
LIMA
Patency		 Hospital
Stay
(Days)		 F/U
Period		 Survival Freedom
From
MACCEa 		TLR
Simultaneous HCR
Kon, 2008 [17] 15 DES (100) MIDCAB 0 0 0 100 3.7 ± 1.4 12 mo 100 93 6.7
Bonatti, 2008 [45] 5 DES (100) TECAB 0 0 0 100 6 (5-7) 6 mo 100 100 0
Kiaii, 2008 [30] 58 DES (90), BMS (10) Endo-ACAB 0 1.7 5.2 93 4.3 ± 1.4 20 mo 100 100 2.3
Reicher, 2008 [31] 13 DES (100) MIDCAB 0 0 0 100 3.6 ± 1.5 14 100 92 7.6
Zhao, 2009 [16] 112 DES (84), BMS (8) On-pump CABG (90), OPCAB (22) 2.7 1.8 2.7 93 6 (1-97) — — — —
Hu, 2011 [28] 104 DES (98), BMS (2) MIDCAB 0 0 3.8% 96 8.2 ± 2.6 18 100 99 1.9
Staged HCR: PCI followed by CAB
Lewis, 1999 [56] 14 BMS (100) MIDCAB 0 0 0 100 3.4 ± 2.1a 1-14 mo 100 90 9.6
Lee, 2004 [57] 6 BMS (100) MIDCAB 0 0 0 — 6 (4-7) 12 mo 100 — 16
Gilard, 2007 [44] 70 BMS (100) On-pump CABG 1.4 0 0 100 — 33 mo 98.6 96 2.3
Staged HCR: CAB followed by PCI
Isomura, 2000 [58] 37 PTCA (100) MIDCAB 0 0 — 100 — 0-24 mo 97.3 92 8.1
Wittwer, 2000 [59] 35 PTCA (70), BMS (30) MIDCAB 0 0 0 100 7.5 ± 4.1 — — — —
Cisowksi, 2002 [41] 50 PTCA (22), BMS (78) Endo-ACAB 0 0 2.8 100 4.4 ± 1.7 12 mo 100 88 10
Riess, 2002 [39] 57 PTCA (7), BMS (93) MIDCAB 0 0 0 98 5.7 ± 1.8 24 mo 98.2 98 14
Gao, 2009 [35] 10 BMS (67), DES (33) Endo-ACAB (6), TECAB (4) 0 0 0 100 — 5 mo 100 100 0
Delhaye, 2010 [46] 18 DES (100) OPCAB (5), On-pump CABG (13) 0 0 0 100 10 (10-11.2) 12 mo 100 89 12
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a

In the case series of Lewis et al [56], PCI and MIDCAB occurred within 1 day, but took place in 2 stages.

BMS = bare-metal stents; CABG = coronary artery bypass grafting; CAD = coronary artery disease; DES = drug-eluting stent; Endo-ACAB = endoscopic atraumatic coronary artery bypass; F/U = follow-up; HCR = hybrid coronary revascularization; LIMA = left internal mammary artery; MACCE = major adverse cardiac and cerebrovascular events; MIDCAB = minimally invasive direct coronary artery bypass; mo = months; OPCAB = off pump coronary artery bypass; PCI = percutaneous coronary intervention; PTCA = percutaneous transluminal coronary angioplasty; TLR = target lesion revascularization.

One-Stage HCR

The advent of hybrid operating suites allowed for complete revascularization at the same sitting, the ability to perform routine imaging of the LIMA-LAD, a safety net when PCI fails which also allows the performance of PCI in more challenging lesions such as bifurcation and left main lesions [17, 18]. Additionally, the simultaneous approach reduces waste and duplication of resources and is likely to result in a shorter length of stay compared with other approaches of HCR. However, some investigators do not favor the use of a 1-staged approach due to concerns about bleeding because of the use of dual anti-platelet therapy and incomplete heparin reversal, as well as the concern for acute stent thrombosis due to the proinflammatory milieu directly after surgery [19]. Other challenges that limit the applicability of 1-staged HCR in general practice are increased costs, need for a hybrid operating suite with trained personnel, inadequate hospital reimbursement, and the logistical difficulties of coordinating 2 different teams in the same operating room at different times.

Two-Stage: PCI Followed by CABG

Although performing PCI of non-LAD lesions prior to CABG has several advantages, it is currently reserved for patients with acute coronary syndrome with a non-LAD culprit. In cases where DES is used, this approach may complicate the surgical procedure because of bleeding risks associated with the need for continued use of dual antiplatelet therapy [20, 21]. Newer antiplatelet agents may lower bleeding rates compared with clopidogrel, but further study is required [22, 23]. Also, compared with other HCR approaches, PCI followed by CABG does not allow routine assessment of the patency of the LIMA-LAD graft.

Two-Stage: CABG Followed by PCI

The LIMA-LAD grafting and PCI-DES for non-LAD lesions is currently the most adopted HCR strategy. Unlike the other strategies, dual antiplatelet therapy can be freely given postoperatively without concern for intra-operative bleeding. Similar to 1-stage HCR, the patency of LIMA-LAD can be confirmed with angiography at the time of PCI. Although performing PCI after the CABG avoids operating on patients who have taken antiplatelet agents, in the rare scenario of a PCI complication or failure, an additional transfer to the operating room and emergent CABG would still be required. For the surgeon, this approach is also more challenging due to a higher risk for inducing ischemia during the hybrid surgical procedure, due to significant coronary disease in the non-LAD vessels.

Surgical Techniques Used for HCR

Single bypass graft of the LIMA to the LAD can be performed with a number of techniques, as summarized in Table 4. The rationale for the use of minimally invasive techniques is to perform isolated LIMA-LAD revascularization while avoiding thoracic access through median sternotomy, or aortic manipulation due to cross-clamping and cardiopulmonary bypass, which may reduce the incidence of adverse neurologic events, infection, bleeding, and pulmonary complications as seen in conventional CABG surgery [17, 24–27]. Choosing the right surgical approach for LIMA-LAD anastomosis depends on the individual patient characteristics as well as surgeon's familiarity with each of these techniques.

Table 4.

Surgical Techniques Used for LAD Revascularization During Hybrid Coronary Revascularization

Abbreviation Description of Surgical Procedure
MIDCAB Minimally invasive direct coronary artery bypass grafting
Thoracic access: left-sided thoracotomy or lower partial mini-sternotomy
LIMA harvest: direct vision
Anastomosis: direct vision
Single lung ventilation: improves exposure, not required
CPB: not required, but can be performed by cannulation of femoral vein and artery (avoids aorta cross clamping and arresting the heart)
Endo-ACAB Endoscopic atraumatic coronary artery bypass graft surgery
Thoracic access: non/limited rib-spreading left-sided thoracotomy
LIMA harvest: robotic or thoracoscopically
Anastomosis: hand-sutured
Single lung ventilation: required when robot is used
CPB: not required
TECAB Totally endoscopic coronary artery bypass graft surgery
Thoracic access: thoracoscopic access
LIMA harvest: robotic
Anastomosis: thoracoscopically (or robotic → robotic-assisted CAB)
Single lung ventilation: required
CPB: not required
OPCAB Off-pump CABG
Thoracic access: midline sternotomy
LIMA harvest: direct vision
Anastomosis: direct vision with stabilizers
Single lung ventilation: improves exposure
CPB: no
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CAB = coronary artery bypass; CABG = coronary artery bypass grafting; CPB = cardiopulmonary bypass; Endo-ACAB = endoscopic atraumatic coronary artery bypass; LIMA = left internal mammary artery; MIDCAB = minimally invasive direct coronary artery bypass; OPCAB = off pump coronary artery bypass; TECAB = totally endoscopic coronary artery bypass.

Use of (Novel) Antiplatelet Agents in Hybrid Procedures

Two major concerns with HCR in the DES era are bleeding complications and acute stent thrombosis related to perioperative anticoagulation and antiplatelet agents. Guidelines or consensus on the use of antiplatelet therapy specifically for HCR do not exist. A number of studies have reported their experiences with varying degrees of success in preventing acute stent thrombosis as well as perioperative bleeding. Part of the challenge lies in the order of staging (PCI followed by CABG or vice versa) as well as timing of initiation of therapy. In case series of simultaneous HCR (CABG directly followed by PCI), a loading dose of clopidogrel (300 or 600 mg) is given either directly before surgery in the holding area [17], after LIMA insertion [28, 29], or after PCI is completed [17, 30, 31]. Interestingly, although maximal inhibition of platelet aggregation occurs only after a couple of hours [32], meaning there is incomplete platelet inhibition at the time of procedure, the reported rates of acute stent thrombosis are low (0% to 7%). Some authors suggest that in procedures performed with cardiopulmonary bypass, the use of cardiopulmonary bypass may be protective against the risk of stent thrombosis [33]. Although most studies used heparin, 1 study used bivalirudin, claiming that the extended anticoagulation effect of bivalirudin will make up for the lack of adequate antiplatelet inhibition [30]. However, stent thrombosis in this series was higher (7%). As shown in Table 5, the available data do not suggest an increased risk of bleeding that requires reoperation. Some studies even suggest lower bleeding risk after HCR, as demonstrated by less requirements for transfusion, fewer units of red blood cells required, and a trend toward less chest tube output [17, 28, 31]. Newly developed P2Y12 inhibitors such as prasugrel, ticagrelor, and cangrelor, are more potent and have a faster onset of action and reversal than clopidogrel, as shown in various registries and clinical trials among patients undergoing elective and acute PCI [32]. Because of these properties, such new agents may also play an important role in balancing the risk of acute stent thrombosis and perioperative bleeding. Currently, however, there is no experience or data to support the use of these agents in patients undergoing HCR.

Table 5.

Studies Comparing Outcomes After HCR Versus CABG or PCI in the Drug-Eluting Stent Era

Author,
Year (Ref)		 No. CAD Group(s) One-Stop Hospital
Stay (Days)		 In-Hospital
Stroke		 Reoperation
for Bleeding		 In-Hospital
Mortality		 LIMA
Patency		 F/U
Period		 Survival
Studies comparing HCR with CABG
Bachinsky, 2012 [51] 52 MVD Robotic HCR (n=25) vs. OPCAB (n=27) Yes 5.1±2.8 vs 8.2±5.4 0% vs 0% 0% vs 0% 0% vs 4% 96% 30 days 100% vs 96%
Hu, 2012 [29] 40 LMD MIDCAB HCR (n=20) vs. OPCAB (n=20) Yes 7.5 (6-14) vs 9 (7-24) 0% vs 0% 0% vs 5% 0% vs 0% 100% 18.5 +/− 9.8 months 100% vs 100%
Leacche, 2013 [50] 381 MVD SYNTAX≥33 + EuroSCORE>5 HCR (n=9), CABG (n=27) Yes 6(1-25) vs 6(4-63) 11% vs 0% 0% vs 0% 22% vs 0% — — —
MVD SYNTAX≥33 + EuroSCORE≤5 HCR (n=5), CABG (n=48) Yes 6.5 (5-32) vs 5 (3-33) 0% vs 2% 0% vs 0% 25% vs 0% — — —
MVD SYNTAX<33 + EuroSCORE>5 HCR (n=25), CABG (n=81) Yes 6(3-19) vs 6(1-32) 4% vs 4% 0% vs 4% 0% vs 5% — — —
MVD SYNTAX<33 + EuroSCORE<5 HCR (n=42), CABG (n=145) Yes 5(3-97) vs 5 (3-28) 0% vs 0% 7% vs 3% 2% vs 1% — — —
Halkos, 2011 [60] 108 LMD Endo-ACAB HCR ± robot (n=27) vs OPCAB (n=81) No 6.6±5.6 vs 5.6±2.0 0.0% vs 0.0% 0% vs 0% 0.0% vs 3.7% 100% 3.2 years 5-year: 88.6% vs 83.4%
Hu, 2011 [28] 208 MVD MIDCAB HCR (n=104) vs. OPCAB (n=104) Yes 8.2±2.6 vs 9.5±4.5 0% vs 0% 3.8% vs 1.9% 0% vs 0% 100% 18 (±7.9) months 100% vs 99%
Halkos, 2011 [61] 735 MVD Endo-ACAB HCR ± robot (n=147) vs. OPCAB (n=588) No (yes <10) 6.6±6.7 vs 6.1±4.7 0.7% vs 0.7% — 0.7% vs 0.9% 99.3% 3.2 years 5-year survival 86.8% vs 84.3%
Delhaye, 2010 [46] 36 MVD HCR (18) vs CABG (18) No 10 (10-11.2) vs 10.5 (10.0-12.5) 0% vs 0% 0% vs 0% 0% vs 0% 100% 12 mo 100% vs 94.4%
Vassiliades, 2009 [62] 4,266 MVD HCR (n=91) vs OPCAB (n=4,175) No 4.2±2.5 (no data OPCAB) 0.0% vs 1.1% 0% 0% vs 1.8% 96% 3 years 3-year 94.0% vs 89.2%
Zhao, 2009 [16] 366 MVD HCR (n=112, unplanned: 45) or CABG (n=254) Yes 6 (1-97) vs 5 (1-33) 1.7% vs 1.1% 3% vs 3% 2.6% vs 1.5% 92% — —
Kon, 2008 [17] 45 MVD MIDCAB HCR (n=15) vs OPCAB (n=30) Yes 3.7 ± 1.4 vs 6.4 ± 2.2 0% vs 3.3% — 0% vs 0% 100% vs 94% (CTA) 12 mo 100% vs 100%
Reicher, 2008 [31] 39 MVD HCR (n=13) vs OPCAB (n=26) Yes 3.6±1.5 vs 6.3±2.3 0% vs 0% 0% vs 0% 0% vs 0% 100% vs 100% (CTA) 6 mo 100% vs 100%
Studies Comparing HCR With PCI (Or CABG)
Puskas, 2013 [63] 298 MVD MIDCABG HCR (n=200) vs MV-PCI (n=98) No (Yes= 24) — — — — — 17.6 (± 6.5) mo 1.5% vs 1.0%
Shen, 2013 [64] 423 MVD MIDCAB HCR (n=141) vs CABG (n=141) vs MV-PCI (n=141) Yes — — — — 100% 3 yrs 0.7% vs 2.8% vs 3.5%
Gao, 2010 [65] 43 MVD MICAB HCR (n=23) vs PCI (n=20) Yes — 0% vs 0% 0% vs 0% 0% vs 0% 100% 30 days 0% vs 0%
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CABG = coronary artery bypass grafting; CAD = coronary artery disease; CTA = computed tomography angiography; DES = drug-eluting stent; Endo-ACAB = endoscopic atraumatic coronary artery bypass; EuroSCORE = European System for Cardiac Operative Risk Evaluation; F/U = follow-up; HCR = hybrid coronary revascularization; LIMA = left internal mammary artery; LMD = left main disease; MACCE = major adverse cardiac and cerebrovascular events; MICAB = minimally invasive coronary artery bypass; MIDCAB = minimally invasive direct coronary artery bypass; mo = months; MVD = multivessel disease; OPCAB = off pump coronary artery bypass; PCI = percutaneous coronary intervention.

Case Series Reporting on Clinical Outcomes After HCR

Many case series have been published on the procedural and mid-term outcomes after HCR. In a review study by DeRose [25], 492 cases were reviewed that were published in 13 case series from 1999 to 2009. These series show high LIMA patency rates (93% to 100%) as well as low 30-day mortality (0% to 1.4%). Among case series with mid-term clinical follow-up (6 to 33 months), event-free survival (70% to 100%), as well as target lesion revascularization (0% to 29.6%) varied considerably at follow-up (6 to 33 months) [18, 18, 30, 34–44]. Recent case series in which HCR was performed with exclusively drug-eluting stents, event-free survivals were overall higher (89% to 100%) and target lesion revascularization rates were lower (0% to 7.6%) at follow-up (6 to 18 months) [17, 28, 30, 31, 43, 45–48]. A recently published 2-center experience (n = 226) on long-term outcomes simultaneous HCR with total endoscopic coronary artery bypass grafting (TECAB) and PCI (DES in 70%) on an intention-to-treat basis, showed 5-year survival of 92.9% and freedom from major adverse cardiac and cerebral events of 75.2% [49]. The data from these series suggest that HCR has a good safety profile among experienced operators but they do not provide insights on how HCR compares with conventional CABG.

Studies Comparing Outcomes After HCR Versus CABG and Multi-Vessel PCI

Table 5 summarizes available studies that have compared the outcomes of HCR with CABG or multi-vessel PCI in the era of drug-eluting stents. All studies used a non-randomized design, and involved unmatched, matched, or consecutive cohorts. Overall, in-hospital mortality, stroke, and reoperation for bleeding rates were comparable among reported studies, with the exception of 1 small subset of high-risk patients where favorable outcomes were seen in patients after conventional CABG [50]. In studies reporting long-term follow-up, survival ranges from 86.8% to 100% after HCR and 83.4% to 100% after conventional CABG. These studies suggest that in patients with non-LAD lesions amendable for PCI, the outcomes for HCR and conventional CABG surgery may be similar. However, as none of the studies used random treatment allocation and were individually too small to detect meaningful clinical differences, definite conclusions cannot be drawn.

Patient Satisfaction, Recovery, and Costs After HCR

Studies on patient satisfaction found that although 30-day satisfaction was similar, 1-year patients’ satisfaction was remarkably better in patients after HCR compared with off pump coronary artery bypass (OPCAB) [17, 51]. Quality of life assessment was also found to be better in the HCR group (physical score: 32.8 ± 10.4 vs 41.6 ± 10.3, p = 0.009, using SF-12) [51]. A number of reasons may contribute to this difference in quality of life and patient satisfaction. Postoperative pain management is of importance for patient satisfaction. Although pain experienced after minimally invasive direct coronary artery bypass is higher compared with other minimally invasive surgical techniques and with sternotomy, the duration for pain to subside is shorter after HCR (10.3 ± 10.9 vs 45.5 ± 33.6 days, p = 0.004) [17, 51]. Additionally, the length of intensive care and hospital stay is significantly shorter after HCR compared with CABG or OPCAB, particularly in those who underwent simultaneous or same-day staged HCR (Table 5). After discharge home, patients who underwent HCR returned to work and normal activities much quicker. A study led by Kon and colleagues [17] reported that the odds of returning to work at less than 1 month were significantly better for HCR versus OPCAB after adjusting for potential confounders (odds ratio, 7.60; 95% confidence interval, 1.61 to 35.91; p = 0.01). The average time to return to work in patients after HCR was 1.75 ± 1.0 months versus 4.4 ± 3.1 months after patients who underwent OPCAB. A recent study by Bachinsky and colleagues [51] confirmed these findings in a case series of patients undergoing 1-stage HCR with Endo-ACAB, with average time to return to work of 5.3 ± 3.0 weeks versus 8.2 ± 4.6 weeks (p = 0.01).

Apart from greater patient satisfaction and shorter length of hospital stay, some studies have also specified costs related to HCR in comparison with complete revascularization with CABG. Some reports suggest that HCR is more costly than OPCAB, the most cost-effective surgical form of complete revascularization [9], while others suggest equal in-hospital costs. We summarized in-hospital cost-specific data for studies using simultaneous HCR with the use of DES versus OPCAB in Figure 2. Hidden cost data include the financial resources spent on the construction of a cardiac hybrid operating room as well as training of personnel. An operational cardiac hybrid room requires a radiolucent operating table suitable for CABG and PCI, X-ray source and imaging camera equipment, surgical and interventional equipment, echocardiography machine, equipment for continuous arterial monitoring and digital imaging, cardiac anesthesia monitoring equipment, and a cardiopulmonary bypass pump. Construction of these rooms usually requires the conversion of at least 2 standard operating rooms [52].

Fig 2.

Fig 2

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In-hospital cost-specific data of the average patient after 1-stage hybrid coronary revascularization (HCR) versus complete revascularization with off-pump coronary artery bypass graft surgery (OPCAB).

Future Directions

Despite the promising early and mid-term results, recovery parameters and patient satisfaction, HCR still remains relatively limited in its use. A number of factors are accountable. First, there have been no randomized clinical trials that have compared HCR with CABG or multi-vessel PCI to establish an accepted standard of use. In order to demonstrate that HCR is non-inferior or even superior to conventional revascularization strategies in terms of long-term death, myocardial infarction, stroke, and additional revascularization, adequately sized randomized controlled clinical trials are warranted. Apart from studies on clinical outcomes, additional studies are needed to study the optimal timing and sequence of procedures as well as the use, timing and dosage of (novel) antiplatelet agents to lower the risks of bleeding and acute stent thrombosis. Particular interest should be given to women, older adults, individuals with diabetes mellitus, or chronic kidney disease because research on those vulnerable patient populations is currently lacking. Apart from clinical trial data, the construction of national registries with detailed in-hospital data and longitudinal follow-up are warranted as single-center registries are currently too small to address these questions. Second, there remain numerous logistical challenges, particularly for centers that want to perform 1-stage HCR, as many institutions do not have the resources for successful implementation of a hybrid revascularization program, which includes the costs associated with planning, hybrid operating room, and training of personnel. Lastly, seamless collaboration of interventional cardiologists and cardiac surgeons, and their respective nursing, technical, and planning teams is required to implement a successful HCR program.

Hybrid coronary revascularization is a promising technique that combines the advantages of the LIMA-to-LAD graft with the superior patency of DES compared with SVGs on non-LAD vessels. As such, HCR provides a minimally invasive alternative to conventional CABG and may provide a more durable alternative to multi-vessel PCI. Despite the rapid advances in stent technology and surgical techniques, experience with HCR is currently limited to a little over a thousand cases in a dozen centers around the globe. In order to find a larger and more permanent role for HCR as a mainstream revascularization strategy in the management of patients with multi-vessel disease, further study into the comparative effectiveness of HCR to both conventional and off-pump CABG and multi-vessel PCI is warranted.

References

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