Hybrid Revascularization Still Not Widely Available in US Hospitals Even With Proven Efficacy, Safety

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Despite comparable in-hospital mortality and morbidity between hybrid coronary revascularization and conventional surgery, only one-third of US hospitals that perform coronary artery bypass graft (CABG) surgery offer the hybrid option. Furthermore, hybrid revascularization accounts for less than 1% of all bypass procedures nationwide, according to a study published online July 23, 2014, ahead of print in Circulation. 

Investigators led by Ralf E. Harskamp, MD, of Duke University Medical Center (Durham, NC), looked at 198,662 CABG procedures for multivessel CAD that were performed at 1,050 US hospitals from July 2011 to March 2013. All data were from the Society of Thoracic Surgeons Adult Cardiac Surgery Database.


Of the 950 hybrid procedures (0.48%), the majority were staged (n = 809) as opposed to concurrent (n = 141). Overall, 34.4% of all hospitals in the database performed at least 1 hybrid revascularization during the study period. Median annual CABG volume was higher at hospitals with at least 1 staged procedure (n = 143) compared with those that performed at least 1 concurrent procedure (n = 120) or no hybrid procedures (n = 128; P = .0005). The largest number of hybrid cases performed at a single center was 54. Hospitals with hybrid revascularization were more likely than those without to have surgeons available who performed less-invasive, sternal-sparing bypass procedures. 

Hybrid patients had higher cardiovascular risk profiles compared with those undergoing CABG but less extensive CAD. Hybrid patients more frequently presented with NSTEMI, history of MI, prior PCI, use of dialysis, and higher rates of continuation of dual antiplatelet therapy than those undergoing CABG.

Similar In-Hospital Outcomes Compared With CABG

There were no differences in the composite of in-hospital mortality and major morbidity (primary endpoint) or in operative mortality for either type of hybrid strategy compared with CABG, although there was a trend toward higher mortality in patients who underwent concurrent procedures. Also, postprocedural stroke risk tended to be lower after staged procedures than with CABG (table 1).

Table 1. In-Hospital Outcomes


Adjusted OR (95% CI)

P Value

Staged Hybrid vs CABG

    Major Morbidity or Mortality

    Operative Mortality



0.93 (0.75-1.16)

0.74 (0.42-1.30)

0.39 (0.15-1.07)





Concurrent Hybrid vs CABG

    Major Morbidity or Mortality

    Operative Mortality



0.94 (0.56-1.56)

2.26 (0.99-5.17)

1.16 (0.30-4.49)





a Unadjusted.

For both concurrent and staged hybrid procedures, postoperative length of stay tended to be shorter than for CABG (P = .101 and P = .098, respectively).

Dr. Harskamp and colleagues say the low adoption of hybrid revascularization in the United States is likely due to low use of minimally invasive surgical techniques as well as limited availability of hybrid operating rooms. Although they did not collect data on why physicians opted for a hybrid strategy instead of conventional CABG or multivessel PCI, the authors say other studies suggest that the primary reasons are the minimization of surgical risk and the presence of ungraftable vessels.

“Given the differences in clinical and procedural characteristics in our study, we speculate that similar reasons may have been involved in the decision making for performing [hybrid procedures] in our study population,” they write. “Additionally, our study showed that centers that have experience with less invasive CABG techniques also are more likely to adopt [hybrid] as a revascularization strategy for patients with multivessel coronary disease.”

Patient Selection, Financial Questions Remain

“Unless the overall patient experience, outcomes, and financial implications of [the hybrid strategy] are significantly better than standard CABG alone in the long term, [it] will continue to play a limited niche in coronary revascularization,” write Igor Gosev, MD, and Marzia Leacche, MD, both of Brigham and Women’s Hospital (Boston, MA), in an editorial accompanying the study.

They observe that hybrid coronary revascularization is “a valuable alternative to conventional CABG surgery in the hands of expert centers where there is integration between cardiac [surgeons] and cardiologists and cardiac surgeons are trained in minimally invasive procedures.”

However, it remains unclear which subsets of patients are most ideally suited—medically and financially—for the hybrid strategy. This is important, Drs. Gosev and Leacche note, since although some data do show improved quality of life measures and a faster return to work among hybrid patients compared with those undergoing off-pump CABG, procedural costs are higher. Randomized trials are needed to determine the long-term benefit of the hybrid strategy as well as whether the higher costs are ultimately offset by lower morbidity and shorter hospital stays, they conclude.

1. Harskamp RE, Brennan JM, Xian Y, et al. Practice patterns and clinical outcomes after hybrid coronary revascularization in the United States: an analysis from the Society of Thoracic Surgeons Adult Cardiac Database. Circulation.2014;Epub ahead of print. 

2. Gosev I, Leacche M. Hybrid coronary revascularization: the future of coronary artery bypass surgery or an unfulfilled promise [editorial]? Circulation.2014;Epub ahead of print.


  • Funding for the statistical analysis was provided by the Society of Thoracic Surgeons.
  • Drs. Harskamp, Gosev, and Leacche report no relevant conflicts of interest.

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