Hybrid Coronary Revascularization Versus Off‐Pump Coronary Artery Bypass Grafting: Comparative Effectiveness Analysis With Long‐Term Follow‐up

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Abstract

Background

Hybrid coronary revascularization ( HCR) involves the integration of coronary artery bypass grafting ( CABG) and percutaneous coronary intervention to treat multivessel coronary artery disease. Our objective was to perform a comparative analysis with long‐term follow‐up between HCR and conventional off‐pump CABG.

Methods and Results

We compared all double off‐pump CABG (n=216) and HCR (n=147; robotic‐assisted minimally invasive direct CABG of the left internal thoracic artery to the left anterior descending artery and percutaneous coronary intervention to one of the non–left anterior descending vessels) performed at a single institution between March 2004 and November 2015. To adjust for the selection bias of receiving either off‐pump CABG or HCR, we performed a propensity score analysis using inverse‐probability weighting. Both groups had similar results in terms of re‐exploration for bleeding, perioperative myocardial infarction, stroke, blood transfusion, in‐hospital mortality, and intensive care unit length of stay. HCR was associated with a higher in‐hospital reintervention rate ( CABG 0% versus HCR 3.4%; P=0.03), lower prolonged mechanical ventilation (>24 hours) rate (4% versus 0.7%; P=0.02), and shorter hospital length of stay (8.1±5.8 versus 4.5±2.1 days; P<0.001). After a median follow‐up of 81 (48–113) months for the off‐pump CABG and 96 (53–115) months for HCR, the HCR group of patients had a trend toward improved survival (85% versus 96%; P=0.054). Freedom from any form of revascularization was similar between the 2 groups (92% versus 91%; P=0.80). Freedom from angina was better in the HCR group (73% versus 90%; P<0.001).

Conclusions

HCR seems to provide, in selected patients, a shorter postoperative recovery, with similar excellent short‐ and long‐term outcomes when compared with standard off‐pump CABG.

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Most cited references 14

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Efficacy and safety of edifoligide, an E2F transcription factor decoy, for prevention of vein graft failure following coronary artery bypass graft surgery: PREVENT IV: a randomized controlled trial.

John H Alexander, Gail Hafley, Robert A Harrington … (2005)

Coronary artery bypass graft (CABG) surgery with autologous vein grafting is commonly performed. Progressive neointimal hyperplasia, however, contributes to considerable vein graft failure. Edifoligide is an oligonucleotide decoy that binds to and inhibits E2F transcription factors and thus may prevent neointimal hyperplasia and vein graft failure. To assess the efficacy and safety of pretreating vein grafts with edifoligide for patients undergoing CABG surgery. A phase 3 randomized, double-blind, placebo-controlled trial of 3014 patients undergoing primary CABG surgery with at least 2 planned saphenous vein grafts and without concomitant valve surgery, who were enrolled between August 2002 and October 2003 at 107 US sites. Vein grafts were treated ex vivo with either edifoligide or placebo in a pressure-mediated delivery system. The first 2400 patients enrolled were scheduled for 12- to 18-month follow-up angiography. The primary efficacy end point was angiographic vein graft failure (> or =75% vein graft stenosis) occurring 12 to 18 months after CABG surgery. Other end points included other angiographic variables, adverse events through 30 days, and major adverse cardiac events. A total of 1920 patients (80%) either died (n = 91) or underwent follow-up angiography (n = 1829). Edifoligide had no effect on the primary end point of per patient vein graft failure (436 [45.2%] of 965 patients in the edifoligide group vs 442 [46.3%] of 955 patients in the placebo group; odds ratio, 0.96 [95% confidence interval {CI}, 0.80-1.14]; P = .66), on any secondary angiographic end point, or on the incidence of major adverse cardiac events at 1 year (101 [6.7%] of 1508 patients in the edifoligide group vs 121 [8.1%] of 1506 patients in the placebo group; hazard ratio, 0.83 [95% CI, 0.64-1.08]; P = .16). Failure of at least 1 vein graft is quite common within 12 to 18 months after CABG surgery. Edifoligide is no more effective than placebo in preventing these events. Longer-term follow-up and additional research are needed to determine whether edifoligide has delayed beneficial effects, to understand the mechanisms and clinical consequences of vein graft failure, and to improve the durability of CABG surgery. Clinical Trial Registration ClinicalTrials.gov Identifier: NCT00042081.

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Comparison of an everolimus-eluting stent and a paclitaxel-eluting stent in patients with coronary artery disease: a randomized trial.

Gregg Stone, Mark Midei, William Newman … (2008)

A thin, cobalt-chromium stent eluting the antiproliferative agent everolimus from a nonadhesive, durable fluoropolymer has shown promise in preliminary studies in improving clinical and angiographic outcomes in patients with coronary artery disease. To evaluate the safety and efficacy of an everolimus-eluting stent compared with a widely used paclitaxel-eluting stent. The SPIRIT III trial, a prospective, randomized, single-blind, controlled trial enrolling patients at 65 academic and community-based US institutions between June 22, 2005, and March 15, 2006. Patients were 1002 men and women undergoing percutaneous coronary intervention in lesions 28 mm or less in length and with reference vessel diameter between 2.5 and 3.75 mm. Angiographic follow-up was prespecified at 8 months in 564 patients and completed in 436 patients. Clinical follow-up was performed at 1, 6, 9, and 12 months. Patients were randomized 2:1 to receive the everolimus-eluting stent (n = 669) or the paclitaxel-eluting stent (n = 333). The primary end point was noninferiority or superiority of angiographic in-segment late loss. The major secondary end point was noninferiority assessment of target vessel failure events (cardiac death, myocardial infarction, or target vessel revascularization) at 9 months. An additional secondary end point was evaluation of major adverse cardiac events (cardiac death, myocardial infarction, or target lesion revascularization) at 9 and 12 months. Angiographic in-segment late loss was significantly less in the everolimus-eluting stent group compared with the paclitaxel group (mean, 0.14 [SD, 0.41] mm vs 0.28 [SD, 0.48] mm; difference, -0.14 [95% CI, -0.23 to -0.05]; P < or = .004). The everolimus stent was noninferior to the paclitaxel stent for target vessel failure at 9 months (7.2% vs 9.0%, respectively; difference, -1.9% [95% CI, -5.6% to 1.8%]; relative risk, 0.79 [95% CI, 0.51 to 1.23]; P < .001). The everolimus stent compared with the paclitaxel stent resulted in significant reductions in composite major adverse cardiac events both at 9 months (4.6% vs 8.1%; relative risk, 0.56 [95% CI, 0.34 to 0.94]; P = .03) and at 1 year (6.0% vs 10.3%; relative risk, 0.58 [95% CI, 0.37 to 0.90]; P = .02), due to fewer myocardial infarctions and target lesion revascularization procedures. In this large-scale, prospective randomized trial, an everolimus-eluting stent compared with a paclitaxel-eluting stent resulted in reduced angiographic late loss, noninferior rates of target vessel failure, and fewer major adverse cardiac events during 1 year of follow-up. clinicaltrials.gov Identifier: NCT00180479.

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The final 10-year follow-up results from the BARI randomized trial.

(2007)

We sought to compare 10-year clinical outcomes in the BARI (Bypass Angioplasty Revascularization Investigation) trial patients who were randomly assigned to percutaneous transluminal coronary balloon angioplasty (PTCA) versus coronary artery bypass grafting (CABG). Angioplasty and bypass surgery have been compared in numerous studies, but long-term clinical outcomes are limited. Symptomatic patients with multivessel coronary artery disease (n = 1,829) were randomly assigned to initial treatment with PTCA or CABG and followed up for an average of 10.4 years. Analyses were conducted on an intention-to-treat basis. The 10-year survival was 71.0% for PTCA and 73.5% for CABG (p = 0.18). At 10 years, the PTCA group had substantially higher subsequent revascularization rates than the CABG group (76.8% vs. 20.3%, p < 0.001), but angina rates for the 2 groups were similar. In the subgroup of patients with no treated diabetes, survival rates were nearly identical by randomization (PTCA 77.0% vs. CABG 77.3%, p = 0.59). In the subgroup with treated diabetes, the CABG assigned group had higher survival than the PTCA assigned group (PTCA 45.5% vs. CABG 57.8%, p = 0.025). There was no significant long-term disadvantage regarding mortality or myocardial infarction associated with an initial strategy of PTCA compared with CABG. Among patients with treated diabetes, CABG conferred long-term survival benefit, whereas the 2 initial strategies were equivalent regarding survival for patients without diabetes.

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Author and article information

Contributors

Bob Kiaii: bob.kiaii@lhsc.on.ca

Journal

Journal ID (nlm-ta): J Am Heart Assoc

Journal ID (iso-abbrev): J Am Heart Assoc

Journal ID (doi): 10.1002/(ISSN)2047-9980

Journal ID (publisher-id): JAH3

Journal ID (hwp): ahaoa

Title: Journal of the American Heart Association: Cardiovascular and Cerebrovascular Disease

Publisher: John Wiley and Sons Inc. (Hoboken )

ISSN (Electronic): 2047-9980

Publication date (Electronic): 12 December 2019

Publication date Collection: 17 December 2019

Volume: 8

Issue: 24 ( doiID: 10.1002/jah3.v8.24 )

Electronic Location Identifier: e014204

Affiliations

[ ¹ ] Division of Cardiac Surgery Department of Surgery Western University London Health Sciences Centre London Ontario Canada

[ ² ] Department of Anesthesia and Perioperative Medicine Western University London Health Sciences Centre London Ontario Canada

[ ³ ] Division of Cardiology Department of Medicine Western University London Health Sciences Centre London Ontario Canada

Author notes

[*] [* ] Correspondence to: Bob Kiaii, MD, FRCSC, Division of Cardiac Surgery, London Health Sciences Centre, Room B6‐120, 339 Windermere Rd, London, Ontario, Canada N6A 5A5. E‐mail: bob.kiaii@ 123456lhsc.on.ca

Article

Publisher ID: JAH34689

DOI: 10.1161/JAHA.119.014204

PMC ID: 6951054

PubMed ID: 31826727

SO-VID: 85c6adf7-7fba-4db7-97b7-a5aed0bcbcfd

License:

This is an open access article under the terms of the http://creativecommons.org/licenses/by-nc-nd/4.0/ License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non‐commercial and no modifications or adaptations are made.

History

Date received : 05 September 2019

Date accepted : 15 November 2019

Page count

Figures: 0, Tables: 2, Pages: 7, Words: 5408

Custom metadata

source-schema-version-number 2.0

component-id jah34689

cover-date December 2019

details-of-publishers-convertor Converter:WILEY_ML3GV2_TO_NLMPMC version:5.7.2 mode:remove_FC converted:16.12.2019

ScienceOpen disciplines: Cardiovascular Medicine

Keywords: cardiac surgery,coronary artery bypass graft surgery,hybrid,percutaneous coronary intervention,robotic‐assisted cabg,cardiovascular surgery,catheter-based coronary and valvular interventions,revascularization,stent

Data availability:

ScienceOpen disciplines: Cardiovascular Medicine

Keywords: cardiac surgery, coronary artery bypass graft surgery, hybrid, percutaneous coronary intervention, robotic‐assisted cabg, cardiovascular surgery, catheter-based coronary and valvular interventions, revascularization, stent

Hybrid Coronary Revascularization Versus Off‐Pump Coronary Artery Bypass Grafting: Comparative Effectiveness Analysis With Long‐Term Follow‐up

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Abstract

Background

Methods and Results

Conclusions

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Karger: Cardiovascular System

Most cited references 14

Efficacy and safety of edifoligide, an E2F transcription factor decoy, for prevention of vein graft failure following coronary artery bypass graft surgery: PREVENT IV: a randomized controlled trial.

Comparison of an everolimus-eluting stent and a paclitaxel-eluting stent in patients with coronary artery disease: a randomized trial.

The final 10-year follow-up results from the BARI randomized trial.

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