INTRODUCTION:
Landmark trials have suggested that coronary artery bypass grafting (CABG) should be considered the revascularization method of choice in patients with multi-vessel disease (1, 2). The benefits of CABG in these patients are largely accrued by the unique advantages of the left internal mammary artery (LIMA) to left anterior descending (LAD) bypass graft, which, in itself, affords a significant long-term survival advantage, and which has consistently demonstrated 10-year patency rates well above 90% (3). On the other hand, saphenous venous grafts to non-LAD targets are more prone to atherosclerotic degeneration and failure, and have been observed to occlude as early as 1 year postoperatively in 6 - 32% of cases (4, 5). By contrast, angiographic surveillance has demonstrated that rates of clinically relevant in-stent restenosis (ISR) after percutaneous coronary intervention (PCI) are less than 5% at 1 year follow-up, especially with the increasing utilization of newer generation drug-eluting stents (DES) (6). One further potential pitfall of traditional CABG is an increased incidence of stroke, as compared to PCI (1, 2).
Hybrid coronary revascularization (HCR) affords the patient the advantages of the LIMA to LAD graft, usually completed via a minimally-invasive approach, coupled with PCI for all non-LAD lesions. Utilizing a minimal access, ‘off-pump’ technique to complete the LIMA to LAD bypass virtually negates the risk of stroke that is associated with traditional CABG, whilst also reducing the infection rate and the perioperative transfusion rate, and hastening recovery time by avoiding a median sternotomy (7, 8).
In the American College of Cardiology Foundation/American Heart Association (ACCF/AHA) Guidelines for Coronary Artery Bypass Graft Surgery, HCR, for the treatment of triple vessel disease (TVD), was denoted a Class IIb recommendation as an alternative method of revascularization to PCI or CABG, in an attempt to improve the overall risk-benefit ratio of the procedures (9). Despite the fact that the first HCR was performed more than two decades ago, this treatment option has constituted less than 0.5% of all CABG volume in the United States (10). A paucity of long-term data has undoubtedly contributed, at least in part, to the relative under-utilization of HCR. Consequently, we sought to evaluate the 8-year survival data after HCR for TVD, and we compared it with that of concurrent matched patients who had either traditional CABG via sternotomy or multi-vessel PCI.