Ann Thorac Surg 2008;86:1860. doi:10.1016/j.athoracsur.2008.09.002
© 2008 The Society of Thoracic Surgeons
Original Articles: Adult Cardiac
Invited Commentary
Turki Albacker, MD, MS
Division of Cardiac Surgery, McGill University Health Center, Royal Victoria Hospital, 687 Pine Ave W, Suite S8.30, Montreal, Quebec, H3A 1A1 Canada
(Email: dr_turki{at}yahoo.com).
Holzhey and colleagues [1] report their experience with minimally invasive hybrid coronary revascularization with short-term and long-term follow-up, and they concluded that minimally invasive hybrid coronary revascularization is a safe approach that is associated with acceptable long-term results and it should be offered to patients with high perioperative risk with sternotomy. This is a large series coming from an experienced center that addresses an important topic. One major drawback of this study, as the authors acknowledged, is the lack of follow-up angiograms, except in those who were symptomatic, which may mask silent occlusions and re-stenoses. This minimally invasive hybrid coronary revascularization strategy is promising because it combines the advantages of percutaneous coronary intervention (PCI) and minimally invasive coronary artery bypass grafting, providing the benefits of proven long-term patency of a left internal mammary artery to a left anterior descending coronary artery graft. However, the Achilles heel of this strategy will predictably remain the high rate of major adverse cardiac and cerebrovascular events (MACCE) and the repeat revascularization rate related to PCI, as previously shown in the Arterial Revascularization Therapies Studies [2] and the New York State Department of Health database [3].
The patients enrolled in this study are low-risk patients, as indicated by the preoperatively calculated mean EUROScore (2.7) with a mortality risk by logistic EUROScore of 4.3%. Although this is a good cohort to study, it may be difficult to demonstrate an advantage in perioperative morbidity and mortality, especially if we have to compare it with multiple bypass grafting in the current era, which is associated with low perioperative mortality and morbidity and good long-term results, especially with the use of arterial grafts and the availability of complete off-pump revascularization. Beneficial effects may be more pronounced in a certain group of high-risk patients. In addition, given the effect of the learning curve, patients should be referred to experienced centers to guarantee the achievement of excellent outcomes that will allow this strategy to be competitive with the current treating modalities. Minimizing the intervals between the two parts of the hybrid strategy is another potential for improvement in the outcomes of this strategy with the ultimate goal of achieving a simultaneous one-stage hybrid procedure in a hybrid revascularization suite. This may decrease the hospital stay and may eliminate the morbidity and mortality related to the time interval, between the two interventions, itself, as well as decrease the number of procedures done with its burden on the hospital, the patient, and the family.
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References
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- Holzhey DM, Jacobs S, Mochalski M, et al. Minimally invasive hybrid coronary artery revascularization Ann Thorac Surg 2008;86:1856-1860.[Abstract/Free Full Text]
- Serruys PW, Ong AT, van Herwerden LA, et al. Five year outcomes after coronary stenting versus bypass surgery for the treatment of multivessel disease: the final analysis of the Arterial Revascularization Therapies Studies (ARTS) randomized trial J Am Coll Cardiol 2005;46:575-581.[Abstract/Free Full Text]
- Hannan EL, Wu C, Walford G, et al. Drug-eluting stents vs. coronary-artery bypass grafting in multivessel coronary disease N Engl J Med 2008;358:331-341.[Medline]
Related Article
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Minimally Invasive Hybrid Coronary Artery Revascularization
- David M. Holzhey, Stephan Jacobs, Michael Mochalski, Denis Merk, Thomas Walther, Friedrich W. Mohr, and Volkmar Falk
Ann. Thorac. Surg. 2008 86: 1856-1860.
[Abstract]
[Full Text]
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