Hybrid Coronary Revascularization In Multivessel Coronary Artery Disease - Who Can Benefit Most? A Pilot Study
Janusz Konstanty-Kalandyk, Anna Kedziora, Jacek Legutko, Wojciech Zajdel, Lukasz Wiewiorka, Radoslaw Litwinowicz, Piotr Mazur, Boguslaw Kapelak, Jacek Piatek
John Paul II Hospital, Kraków, Poland
BACKGROUND: Despite the development in interventional cardiology, grafting left internal mammary artery (LIMA) to left anterior descending artery (LAD) is considered a gold standard in revascularization, improving both short and long term survival. However, conventional coronary artery bypass grafting (CABG) through sternotomy is an invasive procedure with limited saphenous vein graft patency rates. Minimally invasive coronary artery bypass (MIDCAB) allows to avoid the burden of open-chest procedure and maintain the benefit of LIMA to LAD graft. On the other hand, it is estimated that in 35% of all patients undergoing percutaneous coronary intervention (PCI), significant coronary artery calcifications are present, which may cause reduced stent deliverability, higher rates of periprocedural complications, stent malposition or underexpansion, and unfavourable long-term outcomes when compared with outcomes for noncomplex lesions. For these individuals, PCI-only strategy may not be sufficient to achieve optimal results. Therefore, hybrid coronary revascularisation (HCR), with MIDCAB combined with PCI, can be an effective strategy to obtain complete revascularization (CR), while reducing the periprocedural risk. Nevertheless, HCR safety and efficacy still remains under debate. Most prominent trials report similar mortality and incidence of MACCE at 1, 2 and 5-years follow-up for HCR, multivessel CABG and multivessel PCI. However, in all RCTs the eligibility for all revascularization strategies was an inclusion criteria. Moreover, no data is available on HCR outcomes in non-ST-segment elevation acute coronary syndrome (NSTE-ACS).METHODS: The prospective registry established in 2018 includes two novel groups of patients - with NSTE-ACS or stable coronary artery disease (SCAD) with contraindications to both conventional multivessel CABG (in regards to median sternotomy or predicted completeness of surgical revascularization) and multivessel PCI (high LAD lesion complexity). Fifty consecutive patients who underwent HCR between 2017 to April 2020 were enrolled in this study. All patients were qualified for HCR (MIDCAB LIMA-LAD combined with PCI to non-LAD lesions) by the local Heart Team (HT) due to lacking eligibility to PCI-only or CABG-only strategy.RESULTS: Contraindications to multivessel CABG were more common in SCAD patients (66.7% vs 8.7%; P < 0.001). Advanced age combined with frailty syndrome and obesity were the most common contraindications to full median sternotomy, however 1 case of previous cardiac surgery was noted. Surgical inability to achieve complete revascularization mostly arose from low coronary vessel diameter with calcifications at potential grafting site, however lack of vein graft material was also observed in 1 patient. In all cases, CR was achieved. In general, post-MIDCAB cardiac troponin levels were low and similar in both groups (0.06 vs 0.07 [normal range < 0.014] µg/L; P = 0.55) (Figure 1). No periprocedural deaths were reported, and observed complications were: 1 case of post-surgery low cardiac output syndrome (SCAD group), 1 case of postoperative myocardial infarction with sudden cardiac arrest and successful emergent LM/Cx PCI (SCAD group), and 1 case of pleural hematoma requiring surgical intervention (NSTE-ACS group). All patients remained alive at 30-day follow-up (Figure 1).
CONCLUSIONS: Data from our registry proves that HCR is a safe strategy that allows achieving CR among patients with high LAD-lesion complexity and contraindications to multivessel CABG both in SCAD and NSTE-ACS. Further data acquirement and analysis is warranted in order to develop proper qualification protocol for HCR. 