title: Hybrid coronary revascularization versus coronary artery bypass surgery with bilateral or single internal mammary artery grafts.
abstract: OBJECTIVE
  Hybrid coronary revascularization (HCR) combines minimally invasive left internal mammary artery (LIMA)-left anterior descending artery (LAD) bypass with percutaneous intervention of non-LAD vessels. The purpose of this study was to compare outcomes of HCR to conventional coronary artery bypass graft (CABG) surgery with single internal mammary artery (SIMA) or bilateral internal mammary artery (BIMA) grafting.
  
  
  METHODS
  Between October 2003 and September 2013, 306 consecutive patients who underwent HCR were compared with 8254 patients who underwent CABG with SIMA (7381; 89.4%) or BIMA (873; 10.6%) at a US academic center. The primary outcome was a composite of 30-day death, myocardial infarction, and stroke (major cerebrovascular and cardiac event [MACCE]). In addition to multiple logistic and linear regression analysis, a propensity score-matched analysis was used to compare HCR with SIMA and with BIMA.
  
  
  RESULTS
  The Society of Thoracic Surgeons-predicted risk of mortality was 1.6% for HCR, 2.1% for SIMA, and 1.1% for BIMA (P < .001). Factors associated with HCR use were older age, lower body mass index, history of percutaneous coronary intervention, and 2-vessel disease. In propensity-matched groups, 30-day MACCE rates were comparable (3.3% for HCR vs 1.3% for BIMA [odds ratio (OR), 2.50; P = .12] and vs 3.6% for SIMA [OR, 1.00; P = 1.00]). In-hospital complications were lower after HCR versus SIMA or BIMA (OR, 0.59; P = .033 and OR, 0.55; P = .015, respectively), as was the need for blood transfusion (OR, 0.44; P < .001 and OR, 0.57; P < .001). HCR was associated with shorter hospital stay compared with SIMA (OR, 1.28; P = .038) or BIMA (OR, 1.40; P = .006). No survival difference between matched groups was found at midterm follow-up (HCR vs SIMA: hazard ratio [HR], 0.66; 95% confidence interval [CI], 0.32-1.38; P = .66; HCR vs BIMA: HR, 1.05; 95% CI, 0.48-2.29; P = .91).
  
  
  CONCLUSIONS
  HCR may represent a safe, less invasive alternative to conventional CABG in carefully selected patients, with similar short-term and midterm outcomes as CABG performed with either SIMA or BIMA grafting.
authors.affiliation: Divisions of Cardiothoracic Surgery and Cardiology, Clinical Research Unit, Emory University School of Medicine, Atlanta Ga.
authors.forename: Joshua M
authors.initials: JM
authors.lastname: Rosenblum
authors.affiliation: Department of Cardiology, VU University Medical Center, Amsterdam, The Netherlands.
authors.forename: Ralf E
authors.initials: RE
authors.lastname: Harskamp
authors.affiliation: Academic Medical Center, University of Amsterdam, The Netherlands.
authors.forename: Niels
authors.initials: N
authors.lastname: Hoedemaker
authors.affiliation: Divisions of Cardiothoracic Surgery and Cardiology, Clinical Research Unit, Emory University School of Medicine, Atlanta Ga.
authors.forename: Patrick
authors.initials: P
authors.lastname: Walker
authors.affiliation: Divisions of Cardiothoracic Surgery and Cardiology, Clinical Research Unit, Emory University School of Medicine, Atlanta Ga.
authors.forename: Henry A
authors.initials: HA
authors.lastname: Liberman
authors.affiliation: Academic Medical Center, University of Amsterdam, The Netherlands.
authors.forename: Robert J
authors.initials: RJ
authors.lastname: de Winter
authors.affiliation: Medtronic Inc, Mounds View, Minn.
authors.forename: Thomas A
authors.initials: TA
authors.lastname: Vassiliades
authors.affiliation: Department of Cardiothoracic Surgery, Mount Sinai Beth Israel, New York, NY.
authors.forename: John D
authors.initials: JD
authors.lastname: Puskas
authors.affiliation: Divisions of Cardiothoracic Surgery and Cardiology, Clinical Research Unit, Emory University School of Medicine, Atlanta Ga. Electronic address: mhalkos@emory.edu.
authors.forename: Michael E
authors.initials: ME
authors.lastname: Halkos
mesh_terms: D000046:Academic Medical Centers; D000368:Aged; D016009:Chi-Square Distribution; D003131:Combined Modality Therapy; D003324:Coronary Artery Disease / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D003331:Coronary Vessels / Q000601:surgery*; D016208:Databases, Factual; D054855:Drug-Eluting Stents; D005260:Female; D005845:Georgia; D006801:Humans; D007387:Internal Mammary-Coronary Artery Anastomosis / Q000009:adverse effects / Q000379:methods* / Q000401:mortality; D053208:Kaplan-Meier Estimate; D016014:Linear Models; D016015:Logistic Models; D008297:Male; D008323:Mammary Arteries / Q000601:surgery*; D008875:Middle Aged; D015999:Multivariate Analysis; D009203:Myocardial Infarction / Q000209:etiology / Q000401:mortality; D016017:Odds Ratio; D062645:Percutaneous Coronary Intervention / Q000009:adverse effects / Q000295:instrumentation / Q000401:mortality; D057216:Propensity Score; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D012307:Risk Factors; D020521:Stroke / Q000209:etiology / Q000401:mortality; D013997:Time Factors; D016896:Treatment Outcome
keywords: CAB; PCI; bilateral internal thoracic arteries; hybrid coronary revascularization