Use of Hybrid Coronary Revascularization in Patients with Multivessel Coronary Artery Disease

In this context, Tajstra et al reported the 5-year follow-up from their prospective randomized pilot study. They report that among the 200 patients with multivessel coronary disease randomly assigned to either HCR or CABG, all-cause mortality at 5-year follow-up was similar in the 2 groups (6.4% versus 9.2%, P = 0.69). The rates of myocardial infarction, repeat revascularization, stroke, and major adverse and cardiac and cerebrovascular event (MACCE) were also similar in the 2 groups.

This is an important study because it is the first to compare the long-term outcome of HCR with conventional CABG; previous studies have been limited due to their short- to mid-term follow-up.² However, because this study was not powered to assess the superiority of the HCR compared to conventional CABG, future randomized control trials with a larger number of patients are needed.

Future studies must address some important questions. First, the patients in the present study were younger (mean age, 62.1 ± 8.3 years) with less comorbidity and a relatively low SYNTAX score (23.6 ± 6.1 for the HCR arm). As CABG and PCI are associated with similar long- term outcomes in patients with low (< 22) to intermediate (22–32) SYNTAX score,³ comparisons between HCR and multivessel PCI using the current generation of drug-eluting stents are needed. The results from the ongoing Hybrid Coronary Revascularization Trial (NCT03089398) will shed light on this clinical question. Second, whether these findings can be extended to patients with a high baseline SYNTAX score needs further study. Nonetheless, outcomes were similar between the 2 strategies in the intermediate (n = 98) and high (n = 8) SYNTAX score groups. Interestingly, there is no clear benefit of HCR in the high surgical risk groups as measured by EuroScore. Third, in addition to the hard outcomes (death and MACCE), the quality of life of patients measured by an established metric, such as the Seattle Angina Questionnaire, need to be assessed. Last, the completeness of revascularization in each group needs to be further evaluated because incomplete revascularization is a known predictor of adverse outcomes.^4,5

Applications for Clinical Practice

In patients with multivessel coronary disease with low SYNTAX score, the 5-year outcome for HCR was similar to that of conventional CABG. Further larger studies are needed to assess the superiority of this approach.

—Taishi Hirai, MD, University of Missouri Medical Center, Columbia, MO; Hiroto Kitahara, MD, University of Chicago Medical Center, Chicago, IL; and John Blair, MD, Medstar Washington Hospital Center, Washington, DC