International Journal of Cardiology 179 (2015) 484–488
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Hybrid coronary revascularization versus coronary artery bypass surgery: Systematic review and meta-analysis☆ Kevin Phan a,b, Sophia Wong c, Nelson Wang a, Steven Phan a, Tristan D. Yan a,b,⁎ a b c
The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia Sydney Medical School, University of Sydney, Sydney, Australia Gosford Hospital, Gosford, Australia
a r t i c l e
i n f o
Article history: Received 8 October 2014 Accepted 5 November 2014 Available online 6 November 2014 Keywords: Hybrid coronary revascularization Bypass graft Percutaneous coronary intervention Systematic review
Hybrid coronary revascularization (HCR) is a recentlyintroduced, minimally invasive option for patients requiring revascularization for coronary lesions [1–3]. This technique utilizes a combination of coronary artery bypass grafting (CABG) for left anterior descending (LAD) lesions and percutaneous coronary interventions for non-LAD coronary lesions. In an era focused on minimally invasive interventions, HCR aims to reduce recovery duration, hospital complications and surgical trauma, whilst maintaining durability outcomes similar to that of CABG [1,4,5]. However there is a lack of robust clinical evidence, mostly limited to observational studies with short-term follow-up, on the efficacy and complications of HCR amidst concerns of financial cost [6] and learning curve. Thus, in order to assess the relative benefits of HCR versus CABG based on the available evidence, a systematic review and meta-analysis was performed. Electronic searches were performed using Ovid MEDLINE, Cochrane Central Register of Controlled Trails, Cochrane Database of Systematic Reviews, ACP Journal club, and Database of Abstracts of Review of Effectiveness. To achieve the maximum sensitivity of the search strategy and identify all studies, we combined the terms: “hybrid”, “hybrid revascularization”, “percutaneous coronary
☆ Funding: None. ⁎ Corresponding author at: The Collaborative Research (CORE) Group, Macquarie University, 2 Technology Place, Sydney, Australia. E-mail address: [email protected] (T.D. Yan).
http://dx.doi.org/10.1016/j.ijcard.2014.11.061 0167-5273/© 2014 Elsevier Ireland Ltd. All rights reserved.
intervention”, and “coronary artery bypass” as key words or MeSH headings. Inclusion criteria included studies comparing hybrid versus CABG approaches, with at least 10 patients in each cohort. Studies that did not use HCR, did not compare with CABG, or did not include mortality or complications as endpoints, were excluded. When institutions published duplicate studies with accumulating numbers of patients or increased lengths of follow-up, only the most complete reports were included for quantitative assessment at each time interval. Abstracts, case reports, conference presentations, editorials, and expert opinions were excluded. All data were extracted from article texts, tables, and figures. Meta-analysis was performed by combining all results of reported incidences of mortality or complications. The relative risk (RR) was used as a summary statistic for dichotomous variables, and weighted mean difference (WMD) for continuous variables. The DerSimonian– Laird random effects model was used. χ2 tests were used to study heterogeneity between trials. Cochrane Q and I 2 statistics were used to estimate the percentage of total variation across studies, owing to heterogeneity. All statistical analysis was conducted with Review Manager Version 5.2 (Cochrane Collaboration, Software Update, Oxford, UK). After application of the search strategy, eight studies [1,4,5,7–11] met the inclusion criteria involving 1664 patients. Baseline characteristics are summarized in Table 1. Four studies [1,5,7,10] used a one-stage HCR approach, versus four studies using a staged approach [4,8,9,11]. All studies employed off-pump CABG except for Delhaye et al. [9] who used on-pump CABG. Of the included patients, 505 underwent hybrid revascularization compared with 1159 patients undergoing CABG. There was no significant difference found between hybrid and CABG cohorts in terms of in-hospital MACCE (RR, 0.61; 95% CI, 0.24–1.58; I 2 = 0%; P = 0.31) or postoperative MACCE (RR, 0.78; 95% CI, 0.34–1.78; I2 = 0%; P = 0.55), with no significant heterogeneity detected (Fig. 1). From data of 1664 patients, 30-day mortality rates of hybrid and CABG approaches were comparable (RR, 0.88; 95% CI, 0.34–2.33; I2 = 0%; P = 0.80). Postoperative myocardial infarction (RR, 0.67; 95% CI, 0.49–0.93; I 2 = 0%; P = 0.01) and blood transfusions (RR, 0.54; 95% CI, 0.40–0.74; I 2 = 36%; P b 0.0001) were both significantly lower in the hybrid cohort (Fig. 2). Stroke rates were similar (RR, 1.03; 95% CI, 0.33–3.24; I 2 = 0%; P = 0.96). However, rates of repeat revascularization were lower in the CABG group (RR, 3.58; 95% CI, 2.03–6.31; I2 =
60.1 ± 9.3 51.48 ± 12 54.7 ± 8.7 56.6 ± 7.6 60 (55–65)c 54 (10–72)c 45 ± 14 55 ± 7 61.83 ± 6.9 55.3 ± 10.4 54.6 ± 8.7 56.6 ± 7.7 60 (54–65)c 50 (15–70)c 47 ± 14 56 ± 5 42.6 44 12.7 6.2 16.7 12 57 20 32.6 20 13.6 7.4 27.8 17 67 25 31.9 48 35.5 28.4 38.9 0.39 40 25 CABG, coronary artery bypass grafting; ACS, acute coronary syndrome; LVEF, left ventricular ejection fraction; R, retrospective; P, prospective; OS, observational. a Multivessel disease only. b Left main disease only. c Range.
26.2 36 39.5 29.6 44.5 39 0.27 20 63.2 ± 8.5 66.78 ± 10.7 64.3 ± 12.5 63.9 ± 12.7 60 (53–68)c 63 (32–89)c 65 ± 10 63 ± 13 62 ± 10.1 63.2 ± 10.5 64.3 ± 12.8 63.9 ± 13.7 62 (55–70)c 63 (32–85)c 61 ± 10 62 ± 9 One-stage One-stage Staged: CABG first Staged: CABG first staged: CABG first One-stage One-stage Staged: PCI first R, OS P, OS R, OS R, OS P, OS R, OS P, OS R, OS 141 25 147 27 18 112 15 20 2007–2011 2009–2011 2003–2010 2003–2010 2006–2008 2005–2007 2005–2006 1997 China USA USA USA France USA USA Belgium, USA 2014 2012 2011 2011 2010 2009 2008 2001 Zhou Bachinsky Halkosa Halkos2b Delhaye Zhao Kon de Canniere
141 27 588 81 18 254 30 20
LVEF (%) ACS (%) Diabetes (%)
Hybrid
Number of hybrid patients Study period Country Year of study First author
Table 1 Baseline characteristics of included studies.
Number of CABG patients
Study design
Staging strategy
CABG Age (years)
Hybrid
CABG
Hybrid
CABG
Hybrid
CABG
K. Phan et al. / International Journal of Cardiology 179 (2015) 484–488
485
0%; P b 0.0001). Intensive care unit (ICU) stay (WMD, − 0.62; P = 0.004) and hospital stay (WMD, − 1.40 days; P = 0.01) durations were both shorter in the hybrid cohort (Fig. 3). This meta-analysis demonstrates that in carefully selected patients, HCR is a feasible and safe option with acceptable MACCE composite outcomes, 30-day mortality rate and stroke rates. Myocardial infarctions and blood transfusions were found to be significantly lower in the HCR group, whilst repeat revascularizations was significantly higher. There are several potential advantages of using the HCR approach compared to conventional bypass approaches. First, HCR still maintains the long-term durability for the left-internal mammary grafts (LIMA) to LAD grafts, consistently viewed as the gold standard anastomosis of coronary revascularization [12]. HCR also uses PCI for non-LAD lesions, given that PCI has demonstrated comparative long-term survival compared to CABG for the right coronary and left circumflex coronary arteries [13,14]. The combination of surgical and percutaneous approaches also allows the opportunity to assess bypass grafts using intraoperative angiography in hybrid operative theatres [10]. Despite this, higher rates of repeat revascularizations were seen in the HCR group in this present review, which may be attributed to more extensive underlying coronary artery disease, however this is still incompletely understood and requires further investigation in long-term follow-up. As such, the long-term quality and patency of coronary grafts remains a concern with the use of HCR. Second, this is the first meta-analysis to demonstrate significantly lower hospital stay for the HCR cohort compared to CABG for coronary revascularization. This trend is likely driven by the minimally invasive nature of HCR, with no cardiopulmonary bypass, aortic clamping or open sternotomy incisions required [15]. As such, HCR may be a minimally invasive yet efficacious alternative, particularly appealing in elderly and high-risk candidates. The present meta-analysis is constrained by several limitations. First, all included studies were observational studies, susceptible for selection bias. Only two of the included studies were prospective by design. Second, only a short postoperative outcomes were available for analysis. As such, the trends observed in the current study may not be applicable after a long-term follow-up. Third, sample sizes of included studies were small, with most populations under 100 patients each arm, reducing statistical power of the data. Furthermore, there was also heterogeneity in terms of roboticassistance available, one-stage versus two-stage approaches, and baseline characteristics of studied patients. Present trends require further validation in multi-institutional, randomized trials with long-term follow-up. In conclusion, HCR appears to have acceptable short term mortality and complication rates similar to that of CABG. HCR was associated with fewer myocardial infarctions and blood transfusions, more repeat revascularizations but shorter hospitalization. This warrants further validation in multi-centric, adequately powered randomized studies to definitively assess the benefits and risks of HCR. Conflicts of interest The authors report no relationships that could be construed as a conflict of interest. Acknowledgements K.P. is supported by an Australian Postgraduate Award (APA). References [1] Z.N. Kon, E.N. Brown, R. Tran, et al., Simultaneous hybrid coronary revascularization reduces postoperative morbidity compared with results from conventional offpump coronary artery bypass, J. Thorac. Cardiovasc. Surg. 135 (2008) 367–375.
486
K. Phan et al. / International Journal of Cardiology 179 (2015) 484–488
Fig. 1. Forest plot of (a) in-hospital MACCE, (b) postoperative MACCE, from eligible studies comparing hybrid coronary revascularization with coronary artery bypass grafting in a randomeffects model.
[2] G. Davidavicius, F. Van Praet, S. Mansour, et al., Hybrid revascularization strategy: a pilot study on the association of robotically enhanced minimally invasive direct coronary artery bypass surgery and fractional-flow-reserveguided percutaneous coronary intervention, Circulation 112 (2005) I317–I322. [3] T. Wittwer, J. Cremer, P. Boonstra, et al., Myocardial “hybrid” revascularisation with minimally invasive direct coronary artery bypass grafting combined with coronary angioplasty: preliminary results of a multicentre study, Heart 83 (2000) 58–63. [4] M.E. Halkos, T.A. Vassiliades, J.S. Douglas, et al., Hybrid coronary revascularization versus off-pump coronary artery bypass grafting for the treatment of multivessel coronary artery disease, Ann. Thorac. Surg. 92 (2011) 1695–1701 (discussion 701–2). [5] W.B. Bachinsky, M. Abdelsalam, G. Boga, et al., Comparative study of same sitting hybrid coronary artery revascularization versus off-pump coronary artery bypass in multivessel coronary artery disease, J. Interv. Cardiol. 25 (2012) 460–468. [6] M.E. Halkos, L. Ford, D. Peterson, et al., The impact of hybrid coronary revascularization on hospital costs and reimbursements, Ann. Thorac. Surg. 97 (2014) 1610–1615 (discussion 5–6). [7] S. Zhou, Z. Fang, H. Xiong, et al., Effect of one-stop hybrid coronary revascularization on postoperative renal function and bleeding: a comparison study with off-pump coronary artery bypass grafting surgery, J. Thorac. Cardiovasc. Surg. 147 (2014) 1511–1516 (e1). [8] M.E. Halkos, S.T. Rab, T.A. Vassiliades, et al., Hybrid coronary revascularization versus off-pump coronary artery bypass for the treatment of left main coronary stenosis, Ann. Thorac. Surg. 92 (2011) 2155–2160.
[9] C. Delhaye, A. Sudre, G. Lemesle, et al., Hybrid revascularization, comprising coronary artery bypass graft with exclusive arterial conduits followed by early drugeluting stent implantation, in multivessel coronary artery disease, Arch. Cardiovasc. Dis. 103 (2010) 502–511. [10] D.X. Zhao, M. Leacche, J.M. Balaguer, et al., Routine intraoperative completion angiography after coronary artery bypass grafting and 1-stop hybrid revascularization results from a fully integrated hybrid catheterization laboratory/operating room, J. Am. Coll. Cardiol. 53 (2009) 232–241. [11] D. de Canniere, J.L. Jansens, P. Goldschmidt-Clermont, et al., Combination of minimally invasive coronary bypass and percutaneous transluminal coronary angioplasty in the treatment of double-vessel coronary disease: two-year follow-up of a new hybrid procedure compared with “on-pump” double bypass grafting, Am. Heart J. 142 (2001) 563–570. [12] S. Yusuf, D. Zucker, P. Peduzzi, et al., Effect of coronary artery bypass graft surgery on survival: overview of 10-year results from randomised trials by the Coronary Artery Bypass Graft Surgery Trialists Collaboration, Lancet 344 (1994) 563–570. [13] M.S. Lee, N. Kapoor, F. Jamal, et al., Comparison of coronary artery bypass surgery with percutaneous coronary intervention with drug-eluting stents for unprotected left main coronary artery disease, J. Am. Coll. Cardiol. 47 (2006) 864–870. [14] H. Naik, A.J. White, T. Chakravarty, et al., A meta-analysis of 3,773 patients treated with percutaneous coronary intervention or surgery for unprotected left main coronary artery stenosis, J. Am. Coll. Cardiol. Intv. 2 (2009) 739–747. [15] A. Diegeler, H. Thiele, V. Falk, et al., Comparison of stenting with minimally invasive bypass surgery for stenosis of the left anterior descending coronary artery, N. Engl. J. Med. 347 (2002) 561–566.
Fig. 2. Forest plot of (a) 30-day mortality, (b) myocardial infarctions, (c) strokes, (d) repeat revascularization, (e) blood transfusions, from eligible studies comparing hybrid coronary revascularization with coronary artery bypass grafting in a random-effects model.
K. Phan et al. / International Journal of Cardiology 179 (2015) 484–488
487
488
K. Phan et al. / International Journal of Cardiology 179 (2015) 484–488
Fig. 3. Forest plot of (a) intensive care unit (ICU) stay, (b) hospital stay, from eligible studies comparing hybrid coronary revascularization with coronary artery bypass grafting in a random-effects model.
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Hybrid coronary revascularization versus coronary artery bypass surgery: Systematic review and meta-analysis☆ Kevin Phan a,b, Sophia Wong c, Nelson Wang a, Steven Phan a, Tristan D. Yan a,b,⁎ a b c
The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia Sydney Medical School, University of Sydney, Sydney, Australia Gosford Hospital, Gosford, Australia
a r t i c l e
i n f o
Article history: Received 8 October 2014 Accepted 5 November 2014 Available online 6 November 2014 Keywords: Hybrid coronary revascularization Bypass graft Percutaneous coronary intervention Systematic review
Hybrid coronary revascularization (HCR) is a recentlyintroduced, minimally invasive option for patients requiring revascularization for coronary lesions [1–3]. This technique utilizes a combination of coronary artery bypass grafting (CABG) for left anterior descending (LAD) lesions and percutaneous coronary interventions for non-LAD coronary lesions. In an era focused on minimally invasive interventions, HCR aims to reduce recovery duration, hospital complications and surgical trauma, whilst maintaining durability outcomes similar to that of CABG [1,4,5]. However there is a lack of robust clinical evidence, mostly limited to observational studies with short-term follow-up, on the efficacy and complications of HCR amidst concerns of financial cost [6] and learning curve. Thus, in order to assess the relative benefits of HCR versus CABG based on the available evidence, a systematic review and meta-analysis was performed. Electronic searches were performed using Ovid MEDLINE, Cochrane Central Register of Controlled Trails, Cochrane Database of Systematic Reviews, ACP Journal club, and Database of Abstracts of Review of Effectiveness. To achieve the maximum sensitivity of the search strategy and identify all studies, we combined the terms: “hybrid”, “hybrid revascularization”, “percutaneous coronary
☆ Funding: None. ⁎ Corresponding author at: The Collaborative Research (CORE) Group, Macquarie University, 2 Technology Place, Sydney, Australia. E-mail address: [email protected] (T.D. Yan).
http://dx.doi.org/10.1016/j.ijcard.2014.11.061 0167-5273/© 2014 Elsevier Ireland Ltd. All rights reserved.
intervention”, and “coronary artery bypass” as key words or MeSH headings. Inclusion criteria included studies comparing hybrid versus CABG approaches, with at least 10 patients in each cohort. Studies that did not use HCR, did not compare with CABG, or did not include mortality or complications as endpoints, were excluded. When institutions published duplicate studies with accumulating numbers of patients or increased lengths of follow-up, only the most complete reports were included for quantitative assessment at each time interval. Abstracts, case reports, conference presentations, editorials, and expert opinions were excluded. All data were extracted from article texts, tables, and figures. Meta-analysis was performed by combining all results of reported incidences of mortality or complications. The relative risk (RR) was used as a summary statistic for dichotomous variables, and weighted mean difference (WMD) for continuous variables. The DerSimonian– Laird random effects model was used. χ2 tests were used to study heterogeneity between trials. Cochrane Q and I 2 statistics were used to estimate the percentage of total variation across studies, owing to heterogeneity. All statistical analysis was conducted with Review Manager Version 5.2 (Cochrane Collaboration, Software Update, Oxford, UK). After application of the search strategy, eight studies [1,4,5,7–11] met the inclusion criteria involving 1664 patients. Baseline characteristics are summarized in Table 1. Four studies [1,5,7,10] used a one-stage HCR approach, versus four studies using a staged approach [4,8,9,11]. All studies employed off-pump CABG except for Delhaye et al. [9] who used on-pump CABG. Of the included patients, 505 underwent hybrid revascularization compared with 1159 patients undergoing CABG. There was no significant difference found between hybrid and CABG cohorts in terms of in-hospital MACCE (RR, 0.61; 95% CI, 0.24–1.58; I 2 = 0%; P = 0.31) or postoperative MACCE (RR, 0.78; 95% CI, 0.34–1.78; I2 = 0%; P = 0.55), with no significant heterogeneity detected (Fig. 1). From data of 1664 patients, 30-day mortality rates of hybrid and CABG approaches were comparable (RR, 0.88; 95% CI, 0.34–2.33; I2 = 0%; P = 0.80). Postoperative myocardial infarction (RR, 0.67; 95% CI, 0.49–0.93; I 2 = 0%; P = 0.01) and blood transfusions (RR, 0.54; 95% CI, 0.40–0.74; I 2 = 36%; P b 0.0001) were both significantly lower in the hybrid cohort (Fig. 2). Stroke rates were similar (RR, 1.03; 95% CI, 0.33–3.24; I 2 = 0%; P = 0.96). However, rates of repeat revascularization were lower in the CABG group (RR, 3.58; 95% CI, 2.03–6.31; I2 =
60.1 ± 9.3 51.48 ± 12 54.7 ± 8.7 56.6 ± 7.6 60 (55–65)c 54 (10–72)c 45 ± 14 55 ± 7 61.83 ± 6.9 55.3 ± 10.4 54.6 ± 8.7 56.6 ± 7.7 60 (54–65)c 50 (15–70)c 47 ± 14 56 ± 5 42.6 44 12.7 6.2 16.7 12 57 20 32.6 20 13.6 7.4 27.8 17 67 25 31.9 48 35.5 28.4 38.9 0.39 40 25 CABG, coronary artery bypass grafting; ACS, acute coronary syndrome; LVEF, left ventricular ejection fraction; R, retrospective; P, prospective; OS, observational. a Multivessel disease only. b Left main disease only. c Range.
26.2 36 39.5 29.6 44.5 39 0.27 20 63.2 ± 8.5 66.78 ± 10.7 64.3 ± 12.5 63.9 ± 12.7 60 (53–68)c 63 (32–89)c 65 ± 10 63 ± 13 62 ± 10.1 63.2 ± 10.5 64.3 ± 12.8 63.9 ± 13.7 62 (55–70)c 63 (32–85)c 61 ± 10 62 ± 9 One-stage One-stage Staged: CABG first Staged: CABG first staged: CABG first One-stage One-stage Staged: PCI first R, OS P, OS R, OS R, OS P, OS R, OS P, OS R, OS 141 25 147 27 18 112 15 20 2007–2011 2009–2011 2003–2010 2003–2010 2006–2008 2005–2007 2005–2006 1997 China USA USA USA France USA USA Belgium, USA 2014 2012 2011 2011 2010 2009 2008 2001 Zhou Bachinsky Halkosa Halkos2b Delhaye Zhao Kon de Canniere
141 27 588 81 18 254 30 20
LVEF (%) ACS (%) Diabetes (%)
Hybrid
Number of hybrid patients Study period Country Year of study First author
Table 1 Baseline characteristics of included studies.
Number of CABG patients
Study design
Staging strategy
CABG Age (years)
Hybrid
CABG
Hybrid
CABG
Hybrid
CABG
K. Phan et al. / International Journal of Cardiology 179 (2015) 484–488
485
0%; P b 0.0001). Intensive care unit (ICU) stay (WMD, − 0.62; P = 0.004) and hospital stay (WMD, − 1.40 days; P = 0.01) durations were both shorter in the hybrid cohort (Fig. 3). This meta-analysis demonstrates that in carefully selected patients, HCR is a feasible and safe option with acceptable MACCE composite outcomes, 30-day mortality rate and stroke rates. Myocardial infarctions and blood transfusions were found to be significantly lower in the HCR group, whilst repeat revascularizations was significantly higher. There are several potential advantages of using the HCR approach compared to conventional bypass approaches. First, HCR still maintains the long-term durability for the left-internal mammary grafts (LIMA) to LAD grafts, consistently viewed as the gold standard anastomosis of coronary revascularization [12]. HCR also uses PCI for non-LAD lesions, given that PCI has demonstrated comparative long-term survival compared to CABG for the right coronary and left circumflex coronary arteries [13,14]. The combination of surgical and percutaneous approaches also allows the opportunity to assess bypass grafts using intraoperative angiography in hybrid operative theatres [10]. Despite this, higher rates of repeat revascularizations were seen in the HCR group in this present review, which may be attributed to more extensive underlying coronary artery disease, however this is still incompletely understood and requires further investigation in long-term follow-up. As such, the long-term quality and patency of coronary grafts remains a concern with the use of HCR. Second, this is the first meta-analysis to demonstrate significantly lower hospital stay for the HCR cohort compared to CABG for coronary revascularization. This trend is likely driven by the minimally invasive nature of HCR, with no cardiopulmonary bypass, aortic clamping or open sternotomy incisions required [15]. As such, HCR may be a minimally invasive yet efficacious alternative, particularly appealing in elderly and high-risk candidates. The present meta-analysis is constrained by several limitations. First, all included studies were observational studies, susceptible for selection bias. Only two of the included studies were prospective by design. Second, only a short postoperative outcomes were available for analysis. As such, the trends observed in the current study may not be applicable after a long-term follow-up. Third, sample sizes of included studies were small, with most populations under 100 patients each arm, reducing statistical power of the data. Furthermore, there was also heterogeneity in terms of roboticassistance available, one-stage versus two-stage approaches, and baseline characteristics of studied patients. Present trends require further validation in multi-institutional, randomized trials with long-term follow-up. In conclusion, HCR appears to have acceptable short term mortality and complication rates similar to that of CABG. HCR was associated with fewer myocardial infarctions and blood transfusions, more repeat revascularizations but shorter hospitalization. This warrants further validation in multi-centric, adequately powered randomized studies to definitively assess the benefits and risks of HCR. Conflicts of interest The authors report no relationships that could be construed as a conflict of interest. Acknowledgements K.P. is supported by an Australian Postgraduate Award (APA). References [1] Z.N. Kon, E.N. Brown, R. Tran, et al., Simultaneous hybrid coronary revascularization reduces postoperative morbidity compared with results from conventional offpump coronary artery bypass, J. Thorac. Cardiovasc. Surg. 135 (2008) 367–375.
486
K. Phan et al. / International Journal of Cardiology 179 (2015) 484–488
Fig. 1. Forest plot of (a) in-hospital MACCE, (b) postoperative MACCE, from eligible studies comparing hybrid coronary revascularization with coronary artery bypass grafting in a randomeffects model.
[2] G. Davidavicius, F. Van Praet, S. Mansour, et al., Hybrid revascularization strategy: a pilot study on the association of robotically enhanced minimally invasive direct coronary artery bypass surgery and fractional-flow-reserveguided percutaneous coronary intervention, Circulation 112 (2005) I317–I322. [3] T. Wittwer, J. Cremer, P. Boonstra, et al., Myocardial “hybrid” revascularisation with minimally invasive direct coronary artery bypass grafting combined with coronary angioplasty: preliminary results of a multicentre study, Heart 83 (2000) 58–63. [4] M.E. Halkos, T.A. Vassiliades, J.S. Douglas, et al., Hybrid coronary revascularization versus off-pump coronary artery bypass grafting for the treatment of multivessel coronary artery disease, Ann. Thorac. Surg. 92 (2011) 1695–1701 (discussion 701–2). [5] W.B. Bachinsky, M. Abdelsalam, G. Boga, et al., Comparative study of same sitting hybrid coronary artery revascularization versus off-pump coronary artery bypass in multivessel coronary artery disease, J. Interv. Cardiol. 25 (2012) 460–468. [6] M.E. Halkos, L. Ford, D. Peterson, et al., The impact of hybrid coronary revascularization on hospital costs and reimbursements, Ann. Thorac. Surg. 97 (2014) 1610–1615 (discussion 5–6). [7] S. Zhou, Z. Fang, H. Xiong, et al., Effect of one-stop hybrid coronary revascularization on postoperative renal function and bleeding: a comparison study with off-pump coronary artery bypass grafting surgery, J. Thorac. Cardiovasc. Surg. 147 (2014) 1511–1516 (e1). [8] M.E. Halkos, S.T. Rab, T.A. Vassiliades, et al., Hybrid coronary revascularization versus off-pump coronary artery bypass for the treatment of left main coronary stenosis, Ann. Thorac. Surg. 92 (2011) 2155–2160.
[9] C. Delhaye, A. Sudre, G. Lemesle, et al., Hybrid revascularization, comprising coronary artery bypass graft with exclusive arterial conduits followed by early drugeluting stent implantation, in multivessel coronary artery disease, Arch. Cardiovasc. Dis. 103 (2010) 502–511. [10] D.X. Zhao, M. Leacche, J.M. Balaguer, et al., Routine intraoperative completion angiography after coronary artery bypass grafting and 1-stop hybrid revascularization results from a fully integrated hybrid catheterization laboratory/operating room, J. Am. Coll. Cardiol. 53 (2009) 232–241. [11] D. de Canniere, J.L. Jansens, P. Goldschmidt-Clermont, et al., Combination of minimally invasive coronary bypass and percutaneous transluminal coronary angioplasty in the treatment of double-vessel coronary disease: two-year follow-up of a new hybrid procedure compared with “on-pump” double bypass grafting, Am. Heart J. 142 (2001) 563–570. [12] S. Yusuf, D. Zucker, P. Peduzzi, et al., Effect of coronary artery bypass graft surgery on survival: overview of 10-year results from randomised trials by the Coronary Artery Bypass Graft Surgery Trialists Collaboration, Lancet 344 (1994) 563–570. [13] M.S. Lee, N. Kapoor, F. Jamal, et al., Comparison of coronary artery bypass surgery with percutaneous coronary intervention with drug-eluting stents for unprotected left main coronary artery disease, J. Am. Coll. Cardiol. 47 (2006) 864–870. [14] H. Naik, A.J. White, T. Chakravarty, et al., A meta-analysis of 3,773 patients treated with percutaneous coronary intervention or surgery for unprotected left main coronary artery stenosis, J. Am. Coll. Cardiol. Intv. 2 (2009) 739–747. [15] A. Diegeler, H. Thiele, V. Falk, et al., Comparison of stenting with minimally invasive bypass surgery for stenosis of the left anterior descending coronary artery, N. Engl. J. Med. 347 (2002) 561–566.
Fig. 2. Forest plot of (a) 30-day mortality, (b) myocardial infarctions, (c) strokes, (d) repeat revascularization, (e) blood transfusions, from eligible studies comparing hybrid coronary revascularization with coronary artery bypass grafting in a random-effects model.
K. Phan et al. / International Journal of Cardiology 179 (2015) 484–488
487
488
K. Phan et al. / International Journal of Cardiology 179 (2015) 484–488
Fig. 3. Forest plot of (a) intensive care unit (ICU) stay, (b) hospital stay, from eligible studies comparing hybrid coronary revascularization with coronary artery bypass grafting in a random-effects model.
