Hybrid revascularization procedures for multivessel disease: 2021

Abstract

What we can learn from the preceding excellent, albeit pilot, prospective, randomized, trial of hybrid coronary revascularization (Hybrid) versus standard multivessel coronary artery bypass surgery (CABG) from Brazil? It was small, with only 60 patients, and with a 2:1 randomization sequence, only 40 patients underwent hybrid revascularization. The primary endpoint, the composite of cause death, myocardial infarction, stroke or unplanned repeat revascularization at 2 years was 3 times more frequent in the Hybrid group and the need for additional revascularization more than twice as frequent in the same period. While not reaching statistical significance, the likelihood of a Type II error is obvious. As they conservatively stated, hybrid revascularization “should be applied with careful attention in practice.” The report did give us a window into to how often the opportunity for a Hybrid procedure comes up, though. In a span of 4 years, over 1,500 patients with multivessel disease were referred for CABG at this one institution. In that time, only 60 patients were identified and agreed to be part of the trial. Even assuming typical exclusion criteria and patient preferences, this is indeed a small number of eligible patients. Disclaimer: As an interventional cardiologist for several decades both in practice and in an academic institution, I have never referred a patient or been a party to a hybrid coronary revascularization procedure. Nonetheless, the idea and logic of a simpler, less traumatic surgical option facilitated by modern percutaneous revascularization (PCI) seems to be a viable goal. Or is it? My experience with cardiovascular surgeons has been that a Hybrid procedure is generally not seen as necessary from their perspective. It reminds me of their head shaking during the early days of PCI which probably was justified in many instances, as well. But times have changed and these days our surgical colleagues often welcome a percutaneous approach that can avoid high risk surgical intervention and the possible complications that too often ensue in an elderly patient or one with multiple medical issues. However, when offered the Hybrid option on occasional, surgeons have never seemed to feel a need for this hybrid of procedures over standard CABG. Good surgical outcomes and their reluctance to make a “one” procedure into a “two-fer” seems justified in my experience. The question remains, though, where are we now with this Hybrid option? The preceding report nicely addresses this question and gives us an update on the state of Hybrid procedures. Sardar et al, in their meta-analysis referred to only one randomized single center study of 200 patients from Poland and seven observational studies. They concluded that a hybrid approach could be a suitable alternative to conventional CABG. The Polish HYBRID trial initially had a 1 year follow-up period and at 5 years of this randomized trial there were no significant differences in outcomes, however there were differences. Some of those differences could easily have been significant if not for a possible Type II error due to the small number of patients entered. A hybrid procedure, while seemingly straightforward from a technical perspective, is anything but that, from Th planning and coordination compared to the routine of CABG or PCI. More people than usual have to be in place and on time during one hospitalization and unexpected minor events can readily throw a wrench into the plans, be it a scheduling delay, preop laboratory finding, etc. This reality might be less of an issue if a hybrid room is used, but that in itself has the added potential of one or more players being delayed, scheduling, and so on. All of these limitations may go to the wayside in the future if Hybrid procedures are shown to produce better outcomes, whereupon they would become more frequent and routine. In an editorial on the subject, the prescient authors concluded that adoption of this strategy would likely continue to be modest. Received: 10 January 2021 Accepted: 11 January 2021