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Hybrid Coronary Revascularization Improves Early Recovery With Equivalent Survival To Multi-arterial Bypass Grafting
Yashraj Srivastava1, Korri Hershenhouse2, Brandon E. Ferrell2, Hersh V. Gupta1, Abigail Haber1, Abdulbasit Oyefeso1, Arjun S. Kumar1, John Skendelas2, Joseph J. DeRose2.
1Albert Einstein College of Medicine, Bronx, NY, USA, 2Montefiore Medical Center, Bronx, NY, USA.
BACKGROUND: The survival benefit of coronary artery bypass grafting (CABG) over percutaneous coronary intervention (PCI) is attributed to left internal thoracic artery-left anterior descending (LITA-LAD) patency. Hybrid coronary revascularization (HCR) combines robotic-assisted minimally invasive coronary artery bypass (RACAB) with PCI to non-LAD targets, avoiding sternotomy and cardiopulmonary bypass. While HCR offers improved perioperative recovery, long-term survival versus multi-arterial CABG remains undefined. This study compares an 18-year single-surgeon cohort of HCR to multi-arterial CABG.
METHODS: HCR included RACAB with robotic LITA harvest and beating heart LITA-LAD via a small anterior thoracotomy. CABG was performed via median sternotomy on cardiopulmonary bypass. Patients presenting emergently, with single-vessel disease, off-pump or beating heart surgery, or <2 arterial anastomoses were excluded. Variable nearest-neighbor matching (1:1-3) was performed (caliper 0.2, standardized mean difference ≤0.1). Outcomes were compared using stratified regression and Kaplan-Meier survival.
RESULTS: A total of 239 HCR and 568 CABG patients met inclusion criteria. The cohorts were diverse (HCR: 30.1% White, 31.0% Hispanic, 18.0% Black; CABG: 32.8% White, 33.1% Hispanic, and 15.2% Black). A large proportion of each cohort also resided in ZIP codes within the highest distressed communities index (DCI) quintile (HCR: 37.7%, CABG: 25.0%). After matching, 175 HCR and 294 CABG patients were compared, with median (IQR) follow-up of 70.2 (98.0) and 58.5 (90.2) months. HCR was performed RACAB-first in 57.7% and PCI-first in 42.3% of patients, with median (IQR) intervals to staged revascularization of 8 (4) and 33.5 (20) days, respectively. CABG patients received a mean (SD) of 2.4 (0.6) distal arterial anastomoses (vs 1.1 (0.3) in HCR). RACAB demonstrated shorter operative times (173.6 vs 296.2 minutes, p<0.01) and lower postoperative transfusions (13.1% vs 29.9%, p<0.01), had shorter ICU (2 vs 3 days, p<0.01) and hospital stays (4 vs 5 days, p<0.01), and allowed more discharges to home (93.7% vs 86.7%, p=0.02) (Fig. 1A). Operative mortality (0.6% vs 1.4%, p=1.0) was comparable, as was 1-, 5-, and 10-year survival (Fig. 1B).
CONCLUSIONS: In a rigorously matched single-surgeon cohort, HCR demonstrated improved perioperative recovery with long-term survival comparable to multi-arterial CABG. These findings support HCR as an effective alternative for high-risk patients with multivessel disease.
FIGURE 1 LEGEND: (A) Early post-operative outcomes of matched HCR and CABG cohorts. (B) Kaplan-Meier Survival Curves: Hybrid Coronary Revascularization vs. Multi-Arterial CABG.
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