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Hybrid Coronary Revascularization in Selected Patients With Multivessel Disease: 5-Year Clinical Outcomes of the Prospective Randomized Pilot Study

Friday, April 20, 2018

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Source Name: JACC: Cardiovascular Interventions


Mateusz Tajstra, Tomasz Hrapkowicz, Michał Hawranek, Krzysztof Filipiak, Marek Gierlotka, Marian Zembala, Mariusz Gąsior, Michael Oscar Zembala, and POLMIDES Study Investigators

The authors present the 5-year follow-up results of the HYBRID trial, wherein 200 patients with multivessel disease requiring revascularization were randomized to either conventional coronary artery bypass grafting (CABG) or hybrid coronary revascularization (HCR).  Notably, the patients undergoing HCR  had a LIMA to LAD via a minimally invasive approach combined with percutaneous coronary intervention (PCI) of the remaining vessels.

The following table summarizes the results from this trial:

Outcome                                               CABG                    HCR                p-value

All-cause mortality                          9.2%                    6.4%                   0.69

Myocardial infarction                       7.2%                   3.4%                   0.30

Repeat revascularization             45.4%                 37.2%                0.38

Stroke                                                     4.1%                   2.1%                   0.35

MACCE                                                   53.4%                 45.2%                0.39

The authors conclude that there were no differences in outcomes between the two types of revascularization.

Comment:  Although none of the differences achieved statistical significance, there does appear to be a trend for better outcomes with HCR.  The lack of significance may be related to inadequate power of the study to detect a difference.

Question:  Is it not time to rethink our approach to HCR?  Most centers are approaching the procedure with a minimally invasive approach using a single mammary artery.  If our main concern is outcomesas it should beis it not time to reassess HCR as a conventional or minimally invasive procedure utilizing both LIMA and RIMA for appropriate targets, and PCI for the rest?  This would seem to be the optimal approach, so that the patient gets the true benefit of both worlds: the superiority of bilateral mammary revascularization over any alternative conduits, and the superiority of PCI over SVG.  What do you think?

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