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Practice Patterns and Clinical Outcomes After Hybrid Coronary Revascularization in the United States: An Analysis From the Society of Thoracic Surgeons Adult Cardiac Database
Study Questions:
What are the in-hospital outcomes between hybrid coronary revascularization (HCR) and conventional coronary artery bypass grafting (CABG)?
Methods:
Patients were included who underwent HCR (staged/concurrent) or isolated CABG in the Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database (July 2011–March 2013). In-hospital outcomes including the composite endpoint of mortality and major morbidity were presented as odds ratios (ORs) and 95% confidence intervals (CIs) and p-values with adjusting for potential confounders using logistic regression with the generalized estimating equations (to account for the correlation in the same site) for the composite endpoint and for operative mortality. Potential confounders were based on the previously developed and validated STS CABG mortality model.
Results:
HCR represented 0.48% (n = 950; staged = 809, concurrent = 141) of the total CABG volume (n = 198,622) during the study period, and was performed in one-third of participating centers (n = 361). Patients who underwent HCR had higher cardiovascular risk profiles compared with patients undergoing CABG. Compared with CABG, median sternotomy (98.5% for CABG, 61.1% for staged-HCR, and 52.5% for concurrent-HCR), direct vision harvesting (98.9%, 66.0%, and 68.1%) and cardiopulmonary bypass (83.4%, 45%, and 36.9%) were less frequently used for staged and concurrent HCR, while robotic assistance (0.7%, 33.0%, and 30.5%) was more common. After adjustment, no differences were observed for the composite of in-hospital mortality and major morbidity (OR, 0.93; 95% CI, 0.75-1.16; p = 0.53 for staged-HCR, and OR, 0.94; 95% CI,0.56-1.56; p = 0.80 for concurrent-HCR compared with CABG). There was no statistically significant association between operative mortality and either treatment group (OR, 0.74; 95% CI, 0.42-1.30; p = 0.29 for staged-HCR, and OR, 2.26; 95% CI, 0.99-5.17; p = 0.053 for concurrent-HCR compared with CABG).
Conclusions:
The authors concluded that although HCR may appear to be an equally safe alternative for CABG surgery, further randomized study is warranted.
Perspective:
This study reports that in contemporary practice, HCR, either performed as staged or concurrent procedures, remains uncommon, as it represents only a mere half percent of the total CABG volume. Moreover, even among the hospitals that performed HCR, the use of HCR was <1% of the total CABG volume. The low adoption of HCR among US hospitals can in part be attributed to the low use of minimally invasive surgical techniques. Adjusted in-hospital clinical outcomes were overall comparable between HCR and conventional CABG, but randomized clinical trials are indicated to assess the safety and efficacy of HCR compared with CABG and/or multivessel percutaneous coronary intervention among patients who are deemed appropriate candidates. Unless the overall patient satisfaction, outcomes, and cost-effectiveness of HCR are significantly better than standard CABG alone in the long-term, HCR will continue to play a limited role in coronary revascularization.
Keywords: Odds Ratio, Sternotomy, Hospital Mortality, Robotics, Patient Satisfaction, Risk Factors, Confidence Intervals, Cardiopulmonary Bypass, Coronary Artery Bypass, Cardiac Surgical Procedures, Logistic Models, Percutaneous Coronary Intervention
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