Hybrid Coronary Revascularization Associated with Fast Recovery

SAN FRANCISCO, CALIF.—Advantages to using hybrid coronary revascularization (minimally invasive CABG plus PCI) include shorter recovery time and return to work, but antiplatelet regimens vary widely depending on the exact hybrid strategy used, according to several sessions devoted to exploring the novel technique.

Johannes Bonatti, MD, of the University of Maryland Medical Center, began the session detailing the advantages associated with hybrid coronary revascularization (HCR) compared with open surgery alone, especially faster recovery (see Figure).

“At our institution, patients are walking outside within 7 days; they start household activities within 2 weeks,” he said. “They usually drive a car within three weeks and are back to normal, meaning sport and work, within 60 days. That is dramatically shorter than the usual 10 to 12 weeks of precautions that we prescribe for sternotomy patients.”

He added that physicians at his institution have observed a 93% long-term survival rate, which was comparable to outcomes recorded for CABG and PCI in clinical trials. Five-year freedom from MACCE results for HCR were similar to those observed in the SYNTAX CABG and ARTS CABG studies.

Available options

Joseph J. DeRose Jr., MD, with the Montefiore-Einstein Heart Center, NY followed Bonatti and discussed potential options for employing a hybrid strategy. A surgeon has several options for employing hybrid revascularization, he said, including staged PCI first,  simultaneous minimally invasive CABG and PCI, and minimally invasive CABG followed by PCI. Additionally, the patient must meet certain surgical and angiographic criteria before undergoing a hybrid procedure.

“There are ways to adapt this procedure to multiple different patients, but it’s critical that you use the right approach,” he said. “Hybrid coronary revascularization is a strategy which promises to augment the advantages of minimally invasive surgery and PCI in selected patients. There are very specific patient and angiographic characteristics that need to be analyzed critically in each patient to figure out the ideal situation for hybrid revascularization. Both simultaneous and staged approaches can be chosen, but there are definitely unique patient and clinical scenarios that have to be taken into consideration.”

Adjunctive therapies

David Zimrin, MD, of the University of Maryland Heart Center, addressed the various antiplatelet and anticoagulant strategies available for use with hybrid revascularization. Like DeRose, he emphasized the wide range of choices available to the treating physician. The easiest hybrid approach, and the one used with 80% of patients treated at the University of Maryland Heart Center, is performing CABG first with a staged approach to PCI.

“There are many options for surgical techniques. The platelet inhibition and anticoagulant therapy needs to be tailored to which option you choose and the patient you are treating,” he said. “The one thing we’re missing now is any kind of systematic study with standarized approaches in the hybrid field. Every institution does this differently.”

Upcoming research

John Puskas, MD, MSc, with Emory University Hospital Midtown, in Atlanta, introduced an NIH observational study that might address some of Zimrin’s concerns. The two-armed multicenter study will explore characteristics of the patient population undergoing hybrid revascularization and look at the feasibility of recruiting those patients into a randomized controlled trial; examine MACCE rates in a population undergoing a hybrid strategy or multivessel PCI; and assess various practices for hybrid revascularization and PCI within and among participating institutions. The primary endpoint will be MACCE at 12 months.

Puskas said recruitment finished earlier this month. Follow-up is ongoing, and researchers expect to make a grant proposal early next year.