Skip to main content
SpringerLink
Log in

A review of hybrid coronary revascularization

  • Review Article
  • Published:
Indian Journal of Thoracic and Cardiovascular Surgery Aims and scope Submit manuscript

Abstract

Purpose

Hybrid coronary revascularization is an emerging treatment strategy for coronary artery disease. We will review the reasons for the development of this strategy, describe surgical techniques, and review outcomes. Finally, we will discuss the future of hybrid revascularization and explain why it will grow as a treatment modality.

Methods

For this review, we conducted an unstructured review of the literature for articles related to hybrid coronary revascularization, bypass surgery, and percutaneous coronary interventions.

Results

Hybrid coronary revascularization has been shown in large series to have excellent results. These include fast recovery time, low mortality and rates of complications, and excellent surgical graft patency. There may be increased need for revascularization over conventional bypass surgery.

Conclusions

The combination improved surgical techniques including a robotic surgery platform, as well as the ever-improving efficacy and durability of coronary stents have made hybrid coronary revascularization an attractive option for many patients. It offers a minimally invasive approach to surgery while avoiding the poor patency of saphenous vein grafts. In appropriately selected patients, this may be an ideal treatment strategy that minimizes risks and maximizes short- and long-term benefits.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  1. Loop FD, Lytle BW, Cosgrove DM, et al. Influence of the internal-mammary-artery graft on 10- year survival and other cardiac events. N Engl J Med. 1986;314:1–6.

    Article  CAS  PubMed  Google Scholar 

  2. Barner HB, Barnett MG. Fifteen- to twenty-one-year angiographic assessment of internal thoracic artery as a bypass conduit. Ann Thorac Surg. 1994;57:1526-8.

  3. Windecker S, Stortecky S, Stefanini GG, et al. Revascularisation versus medical treatment in patients with stable coronary artery disease: network meta-analysis. BMJ. 2014;348:g3859.

  4. Al-Lamee R, Thompson D, Dehbi HM, et al. Percutaneous coronary intervention in stable angina (ORBITA): a double-blind, randomised controlled trial. Lancet. 2018;391:31–40.

    Article  PubMed  Google Scholar 

  5. Garcia S, Sandoval Y, Roukoz H, et al. Outcomes after complete versus incomplete revascularization of patients with multivessel coronary artery disease: a meta-analysis of 89,883 patients enrolled in randomized clinical trials and observational studies. J Am Coll Cardiol. 2013;62:1421–31.

    Article  PubMed  Google Scholar 

  6. Puskas JD, Williams WH, Mahoney EM, et al. Off-pump vs conventional coronary artery bypass grafting: early and 1-year graft patency, cost, and quality-of-life outcomes: a randomized trial. JAMA. 2004;291:1841–9.

    Article  CAS  PubMed  Google Scholar 

  7. Yun KL, Wu Y, Aharonian V, et al. Randomized trial of endoscopic versus open vein harvest for coronary artery bypass grafting: six-month patency rates. J Thorac Cardiovasc Surg. 2005;129:496–503.

    Article  PubMed  Google Scholar 

  8. Mehta RH, Ferguson TB, Lopes RD, et al. Saphenous vein grafts with multiple versus single distal targets in patients undergoing coronary artery bypass surgery: one-year graft failure and fiveyear outcomes from the Project of Ex-Vivo Vein Graft Engineering via Transfection (PREVENT) IV trial. Circulation. 2011;124:280–8.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Itagaki S, Cavallaro P, Adams DH, Chikwe J. Bilateral internal mammary artery grafts, mortality and morbidity: an analysis of 1 526 360 coronary bypass operations. Heart. 2013;99:849–53.

    Article  PubMed  Google Scholar 

  10. Aldea GS, Bakaeen FG, Pal J, et al. The Society of Thoracic Surgeons Clinical Practice Guidelines on Arterial Conduits for Coronary Artery Bypass Grafting. Ann Thorac Surg. 2016;101:801–9.

    Article  PubMed  Google Scholar 

  11. Toumpoulis IK, Theakos N, Dunning J. Does bilateral internal thoracic artery harvest increase the risk of mediastinitis? Interact Cardiovasc Thorac Surg. 2007;6:787–91.

    Article  PubMed  Google Scholar 

  12. Patel MR, Calhoon JH, Dehmer GJ, et al. ACC/AATS/AHA/ASE/ASNC/SCAI/SCCT/STS 2017 Appropriate Use Criteria for Coronary Revascularization in Patients With Stable Ischemic Heart Disease: A Report of the American College of Cardiology Appropriate Use Criteria Task Force, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, and Society of Thoracic Surgeons. J Am Coll Cardiol. 2017;69:2212–41.

    Article  PubMed  Google Scholar 

  13. Serruys PW, Morice MC, Kappetein AP, et al. Percutaneous coronary intervention versus coronary-artery bypass grafting for severe coronary artery disease. N Engl J Med. 2009;360:961–72.

    Article  CAS  PubMed  Google Scholar 

  14. Park SJ, Ahn JM, Kim YH, et al. Trial of everolimus-eluting stents or bypass surgery for coronary disease. N Engl J Med. 2015;372:1204–12.

    Article  CAS  PubMed  Google Scholar 

  15. Farkouh ME, Domanski M, Sleeper LA, et al. Strategies for multivessel revascularization in patients with diabetes. N Engl J Med. 2012;367:2375–84.

    Article  CAS  PubMed  Google Scholar 

  16. Makikallio T, Holm NR, Lindsay M, et al. Percutaneous coronary angioplasty versus coronary artery bypass grafting in treatment of unprotected left main stenosis (NOBLE): a prospective, randomised, open-label, non-inferiority trial. Lancet. 2016;388:2743–52.

    Article  PubMed  Google Scholar 

  17. Stone GW, Sabik JF, Serruys PW, et al. Everolimus-eluting stents or bypass surgery for left main coronary artery disease. N Engl J Med. 2016;375:2223–35.

    Article  CAS  PubMed  Google Scholar 

  18. Patel MR, Dehmer GJ, Hirshfeld JW, et al. ACCF/SCAI/STS/AATS/AHA/ASNC/HFSA/SCCT 2012 appropriate use criteria for coronary revascularization focused update: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, Society for Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons, American Association for Thoracic Surgery, American Heart Association, American Society of Nuclear Cardiology, and the Society of Cardiovascular Computed Tomography. J Thorac Cardiovasc Surg. 2012;143:780–803.

    Article  PubMed  Google Scholar 

  19. Kaluski E, Alfano D, Randhawa P, et al. Length of hospital stay after percutaneous coronary interventions. J Cardiovasc Nurs. 2008;23:345–8.

    Article  PubMed  Google Scholar 

  20. Stamou SC, Hill PC, Dangas G, et al. Stroke after coronary artery bypass: incidence, predictors, and clinical outcome. Stroke. 2001;32:1508–13.

    Article  CAS  PubMed  Google Scholar 

  21. Mathew JP, Parks R, Savino JS, et al. Atrial fibrillation following coronary artery bypass graft surgery: predictors, outcomes, and resource utilization. MultiCenter Study of Perioperative Ischemia Research Group. JAMA. 1996;276:300–6.

    Article  CAS  PubMed  Google Scholar 

  22. Stover EP, Siegel LC, Parks R, et al. Variability in transfusion practice for coronary artery bypass surgery persists despite national consensus guidelines: a 24-institution study. Institutions of the Multicenter Study of Perioperative Ischemia Research Group. Anesthesiology. 1998;88:327–33.

    Article  CAS  PubMed  Google Scholar 

  23. Epstein AJ, Polsky D, Yang F, Yang L, Groeneveld PW. Coronary revascularization trends in the United States, 2001-2008. JAMA. 2011;305:1769–76.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  24. Dangas GD, Serruys PW, Kereiakes DJ, et al. Meta-analysis of everolimus-eluting versus paclitaxel-eluting stents in coronary artery disease: final 3-year results of the SPIRIT clinical trials program (Clinical Evaluation of the Xience V Everolimus Eluting Coronary Stent System in the Treatment of Patients With De Novo Native Coronary Artery Lesions). JACC Cardiovasc Interv. 2013;6:914–22.

    Article  PubMed  Google Scholar 

  25. Rothberg MB, Sivalingam SK, Ashraf J, et al. Patients' and cardiologists' perceptions of the benefits of percutaneous coronary intervention for stable coronary disease. Ann Intern Med. 2010;153:307–13.

    Article  PubMed  Google Scholar 

  26. Kipp R, Lehman J, Israel J, Edwards N, Becker T, Raval AN. Patient preferences for coronary artery bypass graft surgery or percutaneous intervention in multivessel coronary artery disease. Catheter Cardiovasc Interv. 2013;82:212–8.

    Article  PubMed  PubMed Central  Google Scholar 

  27. Hannan EL, Racz MJ, Gold J, et al. Adherence of catheterization laboratory cardiologists to American College of Cardiology/American Heart Association guidelines for percutaneous coronary interventions and coronary artery bypass graft surgery: what happens in actual practice? Circulation. 2010;121:267–75.

    Article  PubMed  Google Scholar 

  28. Thiele H, Neumann-Schniedewind P, Jacobs S, et al. Randomized comparison of minimally invasive direct coronary artery bypass surgery versus sirolimus-eluting stenting in isolated proximal left anterior descending coronary artery stenosis. J Am Coll Cardiol. 2009;53:2324–31.

    Article  PubMed  Google Scholar 

  29. Blazek S, Holzhey D, Jungert C, et al. Comparison of bare-metal stenting with minimally invasive bypass surgery for stenosis of the left anterior descending coronary artery: 10-year follow-up of a randomized trial. JACC Cardiovasc Interv. 2013;6:20–6.

    Article  PubMed  Google Scholar 

  30. Angelini GD, Wilde P, Salerno TA, Bosco G, Calafiore AM. Integrated left small thoracotomy and angioplasty for multivessel coronary artery revascularisation. Lancet. 1996;347:757–8.

    Article  CAS  PubMed  Google Scholar 

  31. Panoulas VF, Colombo A, Margonato A, Maisano F. Hybrid coronary revascularization: promising, but yet to take off. J Am Coll Cardiol. 2015;65:85–97.

    Article  PubMed  Google Scholar 

  32. Sellke FW, Chu LM, Cohn WE. Current state of surgical myocardial revascularization. Circ J. 2010;74:1031–7.

    Article  PubMed  PubMed Central  Google Scholar 

  33. Diegeler A, Hirsch R, Schneider F, et al. Neuromonitoring and neurocognitive outcome in offpump versus conventional coronary bypass operation. Ann Thorac Surg. 2000;69:1162–6.

    Article  CAS  PubMed  Google Scholar 

  34. Czerny M, Baumer H, Kilo J, et al. Inflammatory response and myocardial injury following coronary artery bypass grafting with or without cardiopulmonary bypass. Eur J Cardiothorac Surg. 2000;17:737–42.

    Article  CAS  PubMed  Google Scholar 

  35. Shroyer AL, Hattler B, Wagner TH, et al. Five-year outcomes after on-pump and off-pump coronary-artery bypass. N Engl J Med. 2017;377:623–32.

    Article  PubMed  Google Scholar 

  36. Benetti FJ, Ballester C, Sani G, Doonstra P, Grandjean J. Video assisted coronary bypass surgery. J Card Surg. 1995;10:620–5.

    Article  CAS  PubMed  Google Scholar 

  37. McGinn JT Jr, Usman S, Lapierre H, Pothula VR, Mesana TG, Ruel M. Minimally invasive coronary artery bypass grafting: dual-center experience in 450 consecutive patients. Circulation. 2009;120:S78–84.

    Article  PubMed  Google Scholar 

  38. Halkos ME, Liberman HA, Devireddy C, et al. Early clinical and angiographic outcomes after robotic-assisted coronary artery bypass surgery. J Thorac Cardiovasc Surg. 2014;147:179–85.

    Article  PubMed  Google Scholar 

  39. Bonatti J, Schachner T, Bonaros N, Lehr EJ, Zimrin D, Griffith B. Robotically assisted totally endoscopic coronary bypass surgery. Circulation. 2011;124:236–44.

    Article  PubMed  Google Scholar 

  40. Byrne JG, Leacche M, Vaughan DE, Zhao DX. Hybrid cardiovascular procedures. JACC Cardiovasc Interv. 2008;1:459–68.

    Article  PubMed  Google Scholar 

  41. DeRose JJ. Current state of integrated "hybrid" coronary revascularization. Semin Thorac Cardiovasc Surg. 2009;21:229–36.

    Article  PubMed  Google Scholar 

  42. Hu S, Li Q, Gao P, et al. Simultaneous hybrid revascularization versus off-pump coronary artery bypass for multivessel coronary artery disease. Ann Thorac Surg. 2011;91:432–8.

    Article  PubMed  Google Scholar 

  43. Bonatti JO, Zimrin D, Lehr EJ, et al. Hybrid coronary revascularization using robotic totally endoscopic surgery: perioperative outcomes and 5-year results. Ann Thorac Surg. 2012;94:1920–6.

    Article  PubMed  Google Scholar 

  44. Repossini A, Tespili M, Saino A, et al. Hybrid revascularization in multivessel coronary artery disease. Eur J Cardiothorac Surg. 2013;44:288–93.

    Article  PubMed  Google Scholar 

  45. Adams C, Burns DJ, Chu MW, et al. Single-stage hybrid coronary revascularization with longterm follow-up. Eur J Cardiothorac Surg. 2014;45:438–42.

    Article  PubMed  Google Scholar 

  46. Halkos ME, Walker PF, Vassiliades TA, et al. Clinical and angiographic results after hybrid coronary revascularization. Ann Thorac Surg. 2014;97:484–90.

    Article  PubMed  Google Scholar 

  47. Modrau IS, Holm NR, Maeng M, et al. One-year clinical and angiographic results of hybrid coronary revascularization. J Thorac Cardiovasc Surg. 2015;150:1181–6.

    Article  PubMed  Google Scholar 

  48. Modrau IS, Nielsen PH, Botker HE, et al. Feasibility and early safety of hybrid coronary revascularisation combining off-pump coronary surgery through J-hemisternotomy with percutaneous coronary intervention. EuroIntervention. 2015;10:e1–6.

    Article  PubMed  Google Scholar 

  49. Detter C, Reichenspurner H, Boehm DH, et al. Minimally invasive direct coronary artery bypass grafting (MIDCAB) and off-pump coronary artery bypass grafting (OPCAB): two techniques for beating heart surgery. Heart Surg Forum. 2002;5:157–62.

    PubMed  Google Scholar 

  50. Harskamp RE, Bagai A, Halkos ME, et al. Clinical outcomes after hybrid coronary revascularization versus coronary artery bypass surgery: a meta-analysis of 1,190 patients. Am Heart J. 2014;167:585–92.

    Article  PubMed  Google Scholar 

  51. Moses JW, Leon MB, Popma JJ, et al. Sirolimus-eluting stents versus standard stents in patients with stenosis in a native coronary artery. N Engl J Med. 2003;349:1315–23.

    Article  CAS  PubMed  Google Scholar 

  52. Bonaros N, Schachner T, Wiedemann D, et al. Quality of life improvement after robotically assisted coronary artery bypass grafting. Cardiology. 2009;114:59–66.

    Article  PubMed  Google Scholar 

  53. Gasior M, Zembala MO, Tajstra M, et al. Hybrid revascularization for multivessel coronary artery disease. JACC Cardiovasc Interv. 2014;7:1277–83.

    Article  PubMed  Google Scholar 

  54. HREVS: A Randomized Trial of PCI vs CABG vs Hybrid Revascularization in Patients With Coronary Artery Disease. Available at https://www.tctmd.com/slide/hrevs-randomized-trial-pci-vscabg-vs-hybrid-revascularization-patients-coronary-artery. Accessed 11/22/2017.

  55. Holzhey DM, Cornely JP, Rastan AJ, Davierwala P, Mohr FW. Review of a 13-year single-center experience with minimally invasive direct coronary artery bypass as the primary surgical treatment of coronary artery disease. Heart Surg Forum. 2012;15:E61–8.

    Article  PubMed  Google Scholar 

  56. Kappert U, Tugtekin SM, Cichon R, Braun M, Matschke K. Robotic totally endoscopic coronary artery bypass: a word of caution implicated by a five-year follow-up. J Thorac Cardiovasc Surg. 2008;135:857–62.

    Article  PubMed  Google Scholar 

  57. Bonatti J, Schachner T, Bernecker O, et al. Robotic totally endoscopic coronary artery bypass: program development and learning curve issues. J Thorac Cardiovasc Surg. 2004;127:504–10.

    Article  CAS  PubMed  Google Scholar 

  58. Puskas JD, Halkos ME, DeRose JJ, et al. Hybrid Coronary Revascularization for the Treatment of Multivessel Coronary Artery Disease: A Multicenter Observational Study. J Am Coll Cardiol. 2016;68:356–65.

    Article  PubMed  PubMed Central  Google Scholar 

  59. Hybrid Coronary Revascularization Trial. Available at https://clinicaltrials.gov/show/NCT03089398. Accessed 11/21/2017.

  60. Harskamp RE, Halkos ME, Xian Y, et al. A nationwide survey on perception, experience, and expectations of hybrid coronary revascularization among top-ranked US hospitals. Am Heart J. 2015;169:557–63.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, USA

    Michael Owen Kayatta & Michael Emanuel Halkos

Authors
  1. Michael Owen Kayatta
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Michael Emanuel Halkos
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Michael Emanuel Halkos.

Ethics declarations

Conflict of interest

Dr. Michael Halkos is a consultant for Medtronic. No funds were received by any of the authors for this review and as such, there are no conflicts of interest. Dr. Kayatta has no potential conflicts of interest.

Ethical approval/ethics statement

The review details a technique, and no patient-specific details are mentioned and as a result, formal ethical approval was not required.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Kayatta, M.O., Halkos, M.E. A review of hybrid coronary revascularization. Indian J Thorac Cardiovasc Surg 34 (Suppl 3), 321–329 (2018). https://doi.org/10.1007/s12055-018-0763-7

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s12055-018-0763-7

Keywords

Search

Navigation