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Hybrid Coronary Revascularization for the Treatment of Multivessel Coronary Artery Disease: A Multicenter
John D Puskas1, Michael E Halkos2, Joseph J DeRose3
1Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai Cardiovascular Institute, New York, New York; Mount Sinai Heart at Mount Sinai Beth Israel, New York, New York.
Insights
Hybrid coronary revascularization (HCR) and multivessel PCI show similar 12-month outcomes for coronary artery disease. Further randomized trials are needed to confirm effectiveness of these revascularization strategies.
Area of Science:
- Cardiology
- Interventional Cardiology
- Cardiac Surgery
Background:
- Hybrid coronary revascularization (HCR) combines surgical bypass of the left anterior descending artery with percutaneous coronary intervention (PCI) for other vessels.
- HCR is increasingly used for multivessel coronary artery disease but lacks rigorous effectiveness evaluation.
Purpose of the Study:
- To explore characteristics and outcomes of patients undergoing HCR versus multivessel PCI.
- To inform the design of a comparative effectiveness trial for hybrid-eligible coronary artery disease.
Main Methods:
- A multicenter, observational study enrolled 200 HCR and 98 multivessel PCI patients.
- The primary outcome was major adverse cardiac and cerebrovascular events (MACCE) within 12 months.
- Propensity scores balanced groups for analysis of time to MACCE.
Main Results:
- Mean patient age was 64.2 years; 38.6% had diabetes.
- The mean SYNTAX score was 19.7, indicating complex disease.
- Adjusted MACCE rates were similar between HCR and multivessel PCI groups at 12 months (HR: 1.063) and during follow-up (HR: 0.868).
Conclusions:
- Observational data suggest no significant difference in 12-month MACCE rates between HCR and multivessel PCI.
- A randomized trial is necessary to definitively compare the long-term effectiveness of these revascularization strategies.
Background:
Hybrid coronary revascularization (HCR) combines minimally invasive surgical coronary artery bypass grafting of the left anterior descending artery with percutaneous coronary intervention (PCI) of non-left anterior descending vessels. HCR is increasingly used to treat multivessel coronary artery disease that includes stenoses in the proximal left anterior descending artery and at least 1 other vessel, but its effectiveness has not been rigorously evaluated.
Objectives:
This National Institutes of Health-funded, multicenter, observational study was conducted to explore the characteristics and outcomes of patients undergoing clinically indicated HCR and multivessel PCI for hybrid-eligible coronary artery disease, to inform the design of a confirmatory comparative effectiveness trial.
Methods:
Over 18 months, 200 HCR and 98 multivessel PCI patients were enrolled at 11 sites. The primary outcome was major adverse cardiac and cerebrovascular events (MACCE) (i.e., death, stroke, myocardial infarction, repeat revascularization) within 12 months post-intervention. Cox proportional hazards models were used to model time to first MACCE event. Propensity scores were used to balance the groups.
Results:
Mean age was 64.2 ± 11.5 years, 25.5% of patients were female, 38.6% were diabetic, and 4.7% had previous stroke. Thirty-eight percent had 3-vessel coronary artery disease, and the mean SYNTAX (Synergy Between PCI With Taxus and Cardiac Surgery) score was 19.7 ± 9.6. Adjusted for baseline risk, MACCE rates were similar between groups within 12 months post-intervention (hazard ratio [HR]: 1.063; p = 0.80) and during a median 17.6 months of follow-up (HR: 0.868; p = 0.53).
Conclusions:
These observational data from this first multicenter study of HCR suggest that there is no significant difference in MACCE rates over 12 months between patients treated with multivessel PCI or HCR, an emerging modality. A randomized trial with long-term outcomes is needed to definitively compare the effectiveness of these 2 revascularization strategies. (Hybrid Revascularization Observational Study; NCT01121263).
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