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Ann Thorac Surg 2009;88:1047. doi:10.1016/j.athoracsur.2009.02.071
© 2009 The Society of Thoracic Surgeons
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Correspondence

Hybrid Coronary Artery Revascularization: An Evidence-Based Analysis

Walter J. Gomes, MD, PhD

Cardiovascular Surgery Discipline, Escola Paulista de Medicina, Federal University of Sao Paulo, Rua Borges Lagoa 1080 cj 608, São Paulo, 04038-002–SP Brazil

(Email: wjgomes.dcir{at}epm.br).

To the Editor:

Holzhey and colleagues are to be commended for the great amount of effort expended to provide this large case series on this relevant and very timely subject [1]. However, the question posed is: to whom and for what? The benefits afforded to patients and the cost-effectiveness of the procedure should be carefully analyzed in the light of recent trials and scientific evidence.

Coronary revascularization is performed on the premise to improve survival or to afford better quality of life, mainly relieving angina and improving functional status, or both. A recent meta-analysis of randomized trials comparing minimally invasive left internal thoracic artery (LITA) bypass for isolated lesions of the left anterior descending (LAD) artery with percutaneous coronary intervention (PCI) demonstrated no significant difference in rates of myocardial infarction, stroke, or mortality. PCI was associated with a higher rate of recurrence of angina and the need for repeat revascularization [2].

The patients included in this case series were a low-risk cohort, in which 68.4% of the patients had two-vessel disease, with normal left ventricular function (mean ejection fraction, 0.592 ± 0.131), mean European System for Cardiac Operative Risk Evaluation of 2.7, and stable angina (95.7%), making that population roughly comparable to those of the Medicine, Angioplasty, or Surgery Study (MASS-II) and Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trials [3, 4].

In this study, after performance of the LITA-LAD anastomosis, this became a non-LAD single-vessel or double-vessel disease cohort. In 54.7% of these patients, PCI was performed to complement the surgical treatment. Does additional PCI have an effect on late prognosis compared with optimal medical therapy?

In the MASS-II and COURAGE trials, which included mainly low-risk patients with 3-vessel coronary artery disease and normal ejection fraction, PCI complete revascularization was not able to demonstrate superiority in terms of survival benefit or risk of myocardial infarction over medical treatment alone. However, PCI could be indicated in patients with persisting symptoms despite optimal medical therapy or when a moderate to severe degree of ischemia on noninvasive testing is found in the area of the remaining diseased coronary artery. The article failed to mention if these patients remained symptomatic after the operation, even with maximal medical treatment or had noninvasive stress testing showing extensive ischemia, hence justifying further stenting.

Moreover, data from the COURAGE trial found that angioplasty adds $10,000 to treatment costs, with a reasonable probability that optimal medical therapy alone offers better outcome at lower cost. Likewise, the published data on drug-eluting stents indicate no benefit with respect to death in patients with stable coronary artery disease compared with bare-metal stents. No evidence is available from randomized controlled trials if drug-eluting stents effectively relieve angina. Therefore, from the contemporary evidences, the proposed additional procedure is unlikely to improve prognosis, and optimized medical treatment might be as effective as PCI, at comparatively lower cost. A randomized controlled trial should be mandatory before this procedure becomes widespread.


   References
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 References
 

  1. 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]
  2. Aziz O, Rao C, Panesar SS, et al. Meta-analysis of minimally invasive internal thoracic artery bypass versus percutaneous revascularisation for isolated lesions of the left anterior descending artery BMJ 2007;334:617.[Abstract/Free Full Text]
  3. Boden WE, O'Rourke RA, Teo KK, et al. Optimal medical therapy with or without PCI for stable coronary disease N Engl J Med 2007;356:1503-1516.[Medline]
  4. Hueb W, Lopes NH, Gersh BJ, et al. Five-year follow-up of the Medicine, Angioplasty, or Surgery Study (MASS II): a randomized controlled clinical trial of 3 therapeutic strategies for multivessel coronary artery disease Circulation 2007;115:1082-1089.[Abstract/Free Full Text]

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David Holzhey
Ann. Thorac. Surg. 2009 88: 1047-1048. [Extract] [Full Text] [PDF]



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