Hybrid Coronary Revascularization Vs Traditional Coronary Artery Bypass Graft: A Better Revascularization Modality

Introduction

Hybrid coronary revascularization is a treatment strategy for coronary artery disease (CAD), which offers an alternative to either traditional coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) alone. With the goal being to reduce the risk of the procedure and maximize the bene- fit, hybrid therapy capitalizes on the strengths of each approach. Since first being described by Angelina and colleagues in 1996, Hybrid coronary revascularization (HCR) procedures introduced in 2011 by the American Heart Association/American College of Cardiology Foundation updated guidelines for coronary artery bypass grafting (CABG) surgery [1,2]. The LIMA-LAD graft may be responsible for the majority of the benefit of CABG sur- gery. Whether non-LAD vessels are treated with SVGs or PCI may be less important. This is the premise on which the modern era of hybrid coronary revascularization is based. Advances in both surgical and catheter-based techniques have made hybrid therapy a more attractive option for the treatment of multi-ves- sel CAD. Using one of several minimally invasive techniques, the left anterior descending coronary artery is grafted with the left internal mammary (LIMA), and percutaneous intervention is applied to single or two vessel coronary arteries. In this ap- proach, the well-established survival benefit of the LIMA graft is capitalized upon and, being done with minimally invasive tech- niques, the increased morbidity of a full sternotomy is avoided. Additionally, the use of the LIMA graft confers benefit related to the relief of angina and long-term patency [3]. Newer gener- ation drug eluting stents have continued to improve long-term patency following PCI, to rates similar to or even surpassing that of saphenous vein grafts [4,5]. Smaller series continue to be published some study [6-8]. The advantage elderly patient spe- cially women high-risk patients (recent myocardial infarction, prior stroke, frailty, end-stage renal disease on dialysis) in whom a less invasive approach may reduce the operative time and isch- emic time [9-11].

Methodology

Total 15 patients were enrolled in a study their baseline charac- teristic collected by electronic medical records showed in Table 1 patients who underwent HCR with surgical LIMA grafting to the LAD combined with PCI to non-LAD vessels (hybrid group). The selection of HCR or CABG for revascularization was at the discretion of the clinical site cardiologist and surgeon. Comparative effectiveness trial of HCR and CABG were used in this observational study to compare clinical outcomes with Hybrid vs CABG.

Inclusion Criteria

• Elderly patient specially women

• High-risk patients (recent myocardial infarction, prior stroke, frailty, end-stage renal disease on dialysis

• Nephropathy A GFR of 50 ml/min.

• Patients who have left vein disease wit multiverse will ex- cluded for HRS

• Patient with low heart function EF as measured by echo <35%

Exclusion criteria

• Patient with concomitant left main disease with other coro- nary artery disease

• Patient with three vessel disease with long diffuse disease

• Patient have valvular heart disease with multi vessel CAD

• GFR below 30ml/min.

Statistical Analysis

Data was entered in SPSS version 24 base line characteristics were compared by using independent T test and chis-square test with p value less then<0.5 was considered significant and for outcome variable multiple variate logistic regression analysis by calculating ODD ration with 95% confidence interval with p val- ue less the 0.05 was consider significant

Intervention

HCR was defined as a planned surgical revascularization of the LAD combined with percutaneous revascularization of at least one non-LAD target and stenting of other lesions by PCI with DES was done after 24 hrs. Conventional CABG was performed by all the surgical venous and arterial conduit

Outcome Measures

The primary outcome was the incidence of MACC bleeding, ne- phropathy hospital stay defined as death, stroke, myocardial in- farction (MI), or repeat revascularization at 12 months following the initial procedure described in Table 2.

                                             Table 2: In Hospital Outcomes Measurement in Two Groups

Results

In HCR more elderly more patient which have high risk features like prior stroke MI in CABG group more patient with diffuse CAD more obese and more patient having peripheral vascular disease no gender difference in both groups and interesting 14 patients were Asian Expect Racial difference in CAD needs to be further trials is the contribution of genetics play a role in high CAD in UAE.

Selection of Patient in Both Groups

Heart team interventional cardiologist 2 and 2 cardiac surgeon and Cath lab nurse did selection.

HCR Group

• NSTEMI n 3 patients AWMI 2 patients

• Coronary anatomy coronary total LAD obstruction (CTO) discrete lesion LCX and RCA and EF 35% first underwent lima to LAD mini key hole surgery remain if remained sta- ble after 24 hrs., PCI of LCX and RCA was done with DES

• Mean EF 38%

• No procedure complication

• Contrast used was 70 cc patient

• Total hospital stay was 4 days

• Use of GP 11b/111a inhibitors in 3 patients

• Bleeding complication at side of PCI 3 patients

one case of HCR was described this patient presented with acute AWMI coronary anatomy showed osteal LAD with short left main underwent LIMA to LAD and long lesion with 99% RCA EF 40% procedure was uncomplicated hospital stay was 8 days Pic of HRS (123).

Figure 1: Pre and post procedure with LIMA CTO LAD

                        Figure 2: Pre and Post PCI OF RCA

Figure 3: Pre and Post Staged PCI OF LCX

CABG Group

• 3 patients with NSTEMI 5 with unstable angina

• Coronary anatomy 3 patients had LM disease 3 had diffuse three vessel disease

• Mean EF >40

• Bleeding complications in three patients because of reopen- ing

• Use of GP11B/111a and dual ant plates in 4

• No procedure complication

• Mean Hospital stay was 12 days

In Hospital HCR group has more bleeding lesser mean hospital stay but more Repeat revascularization because of high-risk pro- file of patient acute AWMI low EF use of GPII/IIIa inhibitors. Better patient satisfaction and low cost In CABG one patient required reopening because of bleeding that lengthen mean stay one stroke no inpatient mortality one patient need repeat revas- cularization. One-year follow up 3 patients in CABG died of MACE in HCR patient 2 developed nephropathy but not requir- ing dialysis MACE in two patient required repeat revasculariza- tion one patient died of MI.

Discussion

Types of Hybrid Revascularization -stage hybrid: CABG/PCI performed in a hybrid room and in one setting, staged by min- utes or days the appeal of the latter is multifold: improved lo-gistics, lower cost, and better patient satisfaction [12,13]. As in our study, PCI before CABG allows aggressive stunting be- cause if a complication arises or PCI is unsuccessful, CABG can be performed later. Main disadvantage: Performing PCI in an unprotected environment without the benefit of a LIMA-LAD graft and later performing CABG under aggressive antiplate- let agents. PCI after CABG Avoids ant platelet-related bleed- ing complications CABG has advantage-protected environment with a LIMA-LAD graft LIMA graft patency can be verified at the time of PCI. Disadvantage: In the event of PCI complication/ failure, however, a second, higher-risk operation needs to be per- formed. The latter should be rare, however, as emergent CABG after PCI has a low incidence (<1%) Halkos, et al recently pub- lished Study what may be the largest series to date, in which 147 patients who underwent hybrid revascularization between 2003 and 2010 were compared in a 4:1 ratio to patients undergoing multi-vessel off-pump CABG [14]. According to ClinicalTrials. gov, the Hybrid Revascularization Observational Study, funded by the National Heart Lung and Blood Institute, has recently been completed [15]. The largest observational study to date,14 with planned enrollment of over 6000 patients, this study was intended to inform the design of a pivotal comparative effective- ness trial and more optimally identify the population for whom hybrid therapy may be the better option. Primary outcomes are a composite of death, stroke, MI, or repeat revascularization with follow up over 18 to 21 months. To date, no data was published from this study. As noted previously, the numerous studies that have been published to date vary in the surgical and interven- tional followed by PCI techniques, as well as patient selection, anti-platelet strategies and one-stop vs staged approaches as in our study use of gp11/111b inhibitors and antiplatelet were not started as we do LIMA to LAD with PCI, the location of the lesion in the proximal LAD has been identified as an indepen- dent risk factor for in-stent rest enosis with rates between 19% and 44% [16-18]. As occurred in our study with osteal LCX re- quiring Repeat PCI the LIMA–LAD graft has excellent patency rates, which correlates with increased event-free survival. 5-year patency rate ranges between 92% and 99% and at 10 years be- tween 95% and 98%.

With PCI, the location of the lesion in the proximal LAD has been identified as an independent risk factor for in-stent rest eno- sis with rates between 19% and 44%. The LIMA–LAD graft has excellent patency rates, which correlates with increased event- free survival. 5-year patency rate ranges between 92% and 99% and at 10 years between 95% and 98%. In control trial 104 pa- tients with average 18 months follow-up Hybrid significantly reduced in-hospital time and transfusion rate Lower MACCE rate 99% vs. 90.4â?»than Off-pump after 18 months follow-up as described by PR Moreno 2020 JACC Review showed less MACE as our finding. HRS technique has advantages in elderly similar fining described in journal of Geriatric [19-23].

Limitation of our Study

This was observational study with only six patients because its novel technique and lot of cost we need large randomized trial for efficacy hybrid revascularization.

Strength of the Study

It introduced the patient’s alternative option for patients, which are high risk for surgery, are benefited from HRS and more pa- tient satisfaction less MACE and shorter stay.

List Of Abbreviations

CAD: Coronary Artery Disease

PCI: Percutaneous Coronary Intervention

HRS: Hybrid Revascularization

LIMA: Left Internal Memory Artery

LCX: Left Circumflex Artery

RCA: Right Coronary Artery

LAD: Left Anterior Descending Artery

CTO: Chronic Total Occlusion

DES: Drug Eluting Stents

GFR: Glomerular Filtration rate ml/min

Conclusion

In this study, we found hybrid revascularization has more bene- fits less MACE, patient satisfaction and decrease stay in hospital and one-year follow up compared to CABG patients. We need larger scale studies, training of heart team for hybrid revascu- larization and more centers should be open for hybrid revascu- larization, population should be benefited with because CABG refusal is high so death from coronary disease is also is no one cause of death in patients with multivessel disease with low heart function will be reduced the one factor which need atten-tion as this study was done in UAE where insurance covered the procedure but in Pakistan this issue needs to be discussed health policy maker.

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