Review
Hybrid coronary revascularization versus coronary artery bypass grafting for multivessel coronary artery disease: A systematic review and meta-analysis

https://doi.org/10.1016/j.ijcard.2022.04.030Get rights and content

Highlights

  • The aim of this meta-analysis is to compare the short- and mid-term outcomes of Hybrid coronary revascularisation (HCR) with those of coronary artery bypass grafting (CABG) for multi-vessel coronary artery disease (MCAD).

  • HCR can be performed in patients with MCAD with similar rates of mid-term survival and post-operative complications compared to standard CABG, but with a trend in higher short term mortality.

  • HCR has an enhanced recovery with shorter ICU stays, reduced requirement for blood transfusion and shorter hospital stays.

Abstract

Background

Hybrid coronary revascularization (HCR) combines the benefits of a left internal mammary artery to left anterior descending artery anastomosis, via a mini thoracotomy, with percutaneous coronary intervention (PCI) for other diseased coronaries.

Aims

The aim of this meta-analysis is to compare the short- and long-term outcomes of HCR with those of coronary artery bypass grafting (CABG) for multi-vessel coronary artery disease (MCAD).

Methods

We performed a meta-analysis with a primary outcome of short-term mortality and secondary outcomes of mid-term survival, length of hospital stay, stroke, renal failure and mid-term MACE rate.

Results

3399 patients (HCR = 1164, CABG = 2235) were included, with no significant difference in short-term mortality between groups (OR = 1.50, 95% CI = [0.90,2.49], p = 0.11), although a higher mortality rate was seen in the HCR group (0.73% vs 0.64%). The average length of stay in intensive care unit was significantly shorter following HCR than CABG (mean difference = −15.52 h, CI = [−22.47,-8.59], p˂0.001) and overall hospital stay was also shorter in this group, although not statistically significant (mean difference = −3.15 days, 95% CI = [−6.55, 0.25], p = 0.07). HCR was associated with a reduced odds of blood transfusion (OR = 0.34, 95% CI = [0.22,0.54], p < 0.001). There was not a significant difference in mid-term survival (OR = 0.86, 95% CI = [0.62,1.21], p = 0.39) or MACE rate (OR = 0.82, 95% CI = [0.55,1.23], p = 0.34). No differences were found between HCR and CABG for post-operative stroke (OR = 1.36, 95% CI = [0.87, 2.13], p = 0.16) or renal failure (OR = 0.71, 95% CI = [0.43,1.16], p = 0.14).

Conclusions

HCR has a higher incidence of short-term mortality compared to CABG in patients with MCAD, although this difference is not statistically significant. Similar rates of mid-term survival and other short term post-operative complications were found between the two groups. HCR has a shorter ICU stays and reduced requirement for blood transfusion.

Introduction

Coronary artery disease is the major cause of death and disabilities in developed countries [1] and the methods of revascularisation for patients with multi-vessel coronary artery disease (MCAD) include percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG). The former represents a non-surgical revascularisation strategy with some advantages over CABG, such as shorter procedural time and less complicated post-revascularisation recovery, including reduced infection risk and transfusion need [2,3]. In comparison, the latter is a surgical procedure commonly performed via a median sternotomy [4], or in rare cases via a thoracotomy [5], that requires admission to the cardiac intensive care unit (ICU) and an extended hospital stay. Despite the drawback of its invasiveness, in patients with MCAD, CABG results in improved survival and lower rates of major adverse cardiovascular events (MACE) [6] and undoubtedly, the left internal mammary (LIMA) graft to the LAD has a significant beneficial effect on long-term survival after revascularisation secondary to excellent patency rates [7,8]. However, there remains a reliance on saphenous vein conduit to revascularize non-LAD territory disease, with significantly less effective patency rates compared with arterial conduit [9,10]. Hybrid coronary revascularization (HCR) is an innovative approach that combines the benefits of the LIMA to LAD anastomosis, usually via a mini thoracotomy, with PCI for other (non-LAD) diseased coronary arteries [11] with a beneficial effect on patient satisfaction and post-surgery recovery time [12]. Multiple comparative studies have evaluated the safety and efficacy of HCR [2], but contrasting data are available with regards the best surgical approach (HCR vs CABG) in patients with multi-vessel disease. The aim of this meta-analysis is to compare the short-term outcomes, mid-term survival rates and MACE rates of HCR with those of CABG for MCAD.

Section snippets

Methods

We performed a systematic review and meta-analysis following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) [13] statement and registered with PROSPERO (reg.no. CRD42021256014). The data, analytic methods, and study materials will be made available to other researchers on reasonable request to the corresponding author.

Quantity and quality of evidence

Searches returned 651 results from Pubmed, 600 results from Web of sciences and 323 results from the Cochrane library. After removing duplicate results, 1032 results remained and 29 studies were considered in the full-text review stage and 10 of those were included in the final analysis. An additional 6 studies were found by hand-searches and cross-search of the references. Finally, 16 studies were included in our analysis (Table 1, supplementary fig. 1) [12,[18], [19], [20], [21], [22], [23],

Discussion

The main finding of this meta-analysis is that HCR has comparable clinical outcomes to CABG in terms of complications and mid term survival and MACE rates, but with much shorter length of stay on ICU and in hospital and a reduced requirement for blood transfusion. Despite these findings, it must be noted that for the outcome of short-term mortality, the estimated effect had a wide confidence interval which reflects a lack a statistical power. The overall incidence rate of short term mortality

Conclusions

In conclusion, in patients with MCAD, HCR provides similar rates of mid-term survival and post-operative complications compared to standard CABG. Short term mortality rates, although not significantly different, are higher in HCR. HCR has an enhanced recovery with shorter ICU and reduced requirement for blood transfusion.

Declaration of Competing Interest

The authors have no conflict of interest to declare.

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