Simultaneous Hybrid Revascularization Versus Conventional Percutaneous Coronary Intervention For Multivessel Coronary Artery Disease

Objective:Percutaneous coronary intervention (PCI) has been used more and more frequently in patients with multivessel coronary artery disease (CAD). While it remains unknown whether PCI combined with grafting left internal thoracic artery (LITA) to the left anterior descending artery (LAD) through a ministernotomy (hybrid coronary revascularization procedure) would provide better outcomes than conventional PCI.Methods:From June 2007 to June 2010, simultaneous hybrid coronary revascularization procedure was performed in 129 consecutive patients at Fuwai hospital. By using propensity score, these patients were 1:1 matched with patients who had received PCI during the same period. We compared in-hospital clinical outcomes, hospital costs and major adverse cardiac or cerebrovascular events (MACCEs) between two groups at a mean follow-up of 26.46 months (26.46±11.22). The primary end point was freedom from major adverse cardiac or cerebrovascular events (MACCEs), a composite of death, myocardial infarction, neurologic event (stroke or transient ischemic attack), target lesion or vessel repeat revascularization and late stent thrombosis. Secondary end points were in-hospital and follow-up outcomes, including post procedure lengths of stay (LOS) in hospital, complications, in-hospital costs, follow-up readmission and recurred consistent chest pain. Follow-up by mail, telephone, or hospital record review was 100% complete. A multivariate logistic regression model was used to develop a propensity score for each patient. Nearest-neighbor propensity score matching was used to match patients in the simultaneous hybrid group with those in the PCI group. Continuous data are expressed as mean±standard deviation and categoric data as frequency and percentage. Mean values of continuous variables were compared by using the Student t test for variables with normal distribution and the Wilcoxon rank sum tests for variables that were not normally distributed. Categoric variables were compared using the chi-square test between groups. The Fisher exact and the Mann-Whitney tests were used when appropriate. Kaplan-Meier methodology was used to calculate actuarial freedom from end points. Cox proportional hazards models stratified on the matched pairs was applied to estimate the association of the treatment with various outcomes. A p value of less than 0.05 was considered statistically significant.Results:Baseline characteristics were similar between two groups. There were 219 (84.9%) male in the whole study cohort. The mean age was 57.31±11.40 years old. All patients in hybrid group underwent graft to LAD. Stent implantation was performed in 128 (99.2%) hybrid patients. The mean total number of stents implanted in a patient was 1.79±0.93. The mean total length of the stents was 39.95±22.41 mm. In the PCI group, the mean total number of stents implanted in a patient was 1.95±1.35. The mean total length of the stents was 52.41±31.44 mm.There was no significant difference in in-hospital postoperative outcomes between two groups. At a mean follow-up of 26.46 months, there were no deaths, MI, stroke in hybrid group, the rate of repeat revascularization was significantly lower in hybrid group versus traditional PCI group (1.6%vs.10.1%, log-rank p= 0.013),1 patient (0.78%) was reported as clinically evident stroke in PCI group, MACCEs was significantly lower in hybrid group than in traditional group (1.6% vs.10.9%, log-rank p= 0.008).Conclusions:Compared with conventional PCI, the hybrid coronary revascularization resulted in equivalent in-hospital outcomes and superior mid-term outcomes. Backgrounds:The SYNTAX (Synergy Between Percutaneous Coronary Intervention With TAXUS and Cardiac Surgery) score has been developed as a combination of several validated angiographic classifications aiming to grade the coronary lesions with respect to their functional impact, location, and complexity. The purpose of our study was to investigate the utility of the SYNTAX score in aiding patient selection for percutaneous coronary intervention (PCI) in patients with severe multi-vessel coronary artery disease involving left anterior descending artery.Methods:Data was collected prospectively from patients undergoing "One-Stop" hybrid procedure from June 2007 when the first hybrid operation room was built in China to December 2009. A total number of 104 patients were involved consecutively. At the same time, a database of 2046 patients with multivessel coronary artery disease (especially including LAD target lesions) received PCI in our own center was built. A total 104 pairs of patients were selected from these two databases using a method of nearest propensity score matching. We compared clinical outcomes in patients with SYNTAX score<27 and patients with SYNTAX score≥27. The follow-up time was 25.2±7.9 months. Kaplan-Meier survival analyses and Cox proportional hazards models were used to compare various outcomes between two groups.Results:Baseline patient characteristics were similar between the two groups in preoperative and intraoperative variables. In PCI arms, the rates of mortality, myocardial infarction, stroke and stent thrombosis were similar between two groups. Higher rates of repeat revascularization (18.2% vs.4.2%, p=0.027) and MACCE (major adverse cerebro-cardiovascular events) (24.2% vs.7.0%, p=0.014) were shown in patients with SYNTAX score≥27. After multivariate adjustment, a significant higher risk of repeat revascularization (hazard ratio:6.25,95% confidence interval:1.48 to 26.37, p=0.013) and MACCE (hazard ratio:4.49,95% confidence interval:1.41 to 14.35, p=0.011) were also found in patients with SYNTAX score≥27. When comparing the PCI arms with Hybrid arms in the patients with SYNTAX score≥27, higher rate of MACCE (24.2%vs.1.64%, p= 0.005) was shown.Conclusions:A SYNTAX score threshold of 27 may be useful in identifying a cohort of patients with multi-vessel coronary artery disease involving left anterior descending coronary artery who will not benefit from PCI in terms of higher rate of repeat revascularization and MACCE. Hybrid procedure may be a suitable method.