Invited Commentary

Abstract

Advanced hybrid coronary revascularization (AHCR) marries the long-term patency and survival benefits of multiple internal mammary arterial grafts to the effectiveness of drug-eluting stents for residual stenoses among patients with complex left main and 3-vessel coronary artery disease. This technique affords patients a sternal-sparing approach, potentially allowing patients an earlier return to full activity while avoiding the risk of sternal wound complications associated with standard coronary artery bypass grafting (CABG). In this issue of The Annals of Thoracic Surgery, Balkhy and colleagues1Balkhy H.H. Kitahara H. Hirai T. Matsukage H. Nathan S. Residual SYNTAX score after advanced hybrid robotic totally endoscopic coronary revascularization.Ann Thorac Surg. 2020; 109: 1826-1833Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar report outcomes from their series of AHCR using multiple internal mammary arterial grafts and second-generation drug-eluting stents. Patients were evaluated by an experienced heart team that calculated baseline and residual Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery (SYNTAX) scores. Compared with open surgical revascularization, operative times were prolonged, but the authors should be congratulated for excellent early outcomes with no 30-day mortality, surgical site infection, perioperative stroke, or reexploration for bleeding. Another strength of the current study was the routine use of follow-up angiography, leading to a more comprehensive assessment of the completeness of revascularization. Incomplete revascularization has been more rigorously defined by the residual SYNTAX score (rSS). A key finding by Balkhy and associates1Balkhy H.H. Kitahara H. Hirai T. Matsukage H. Nathan S. Residual SYNTAX score after advanced hybrid robotic totally endoscopic coronary revascularization.Ann Thorac Surg. 2020; 109: 1826-1833Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar is that patients with increased rSSs (suggesting incomplete revascularization) were associated with higher mortality and major adverse cardiac events, which indicates the importance of complete revascularization to optimize clinical results in complex coronary artery disease. As the authors noted, however, it is difficult to elucidate whether these outcomes arise directly from incomplete revascularization, as this group did have greater comorbidities and the sample size was too small to allow for adjustments. Inferior outcomes have been associated with incomplete revascularization in previous studies of percutaneous coronary intervention, and standard CABG and hybrid coronary revascularization, particularly in patients on renal dialysis. When heart teams consider AHCR options, the concept of a “predictive rSS” for all possible revascularization options may guide the optimal treatment strategy. Each lesion should be assessed regarding the feasibility of both percutaneous coronary intervention and CABG and hypothetical rSSs, presuming the failure of various revascularization strategies could be calculated. In this fashion, heart teams could assess revascularization options based on predictive “worst case” scenarios and their presumed likelihood, providing insight into the potential best strategy. To date, only one randomized controlled trial has been conducted.2Gąsior M. Zembala M.O. Tajstra M. et al.Hybrid revascularization for multivessel coronary artery disease.JACC Cardiovasc Interv. 2014; 7: 1277-1283Crossref PubMed Scopus (89) Google Scholar Although underpowered for long-term outcomes and lacking protocol-driven angiographic follow-up, reduced perioperative complications were demonstrated with an increased risk of long-term revascularization. Inclusion of large observational studies in meta-analyses has also demonstrated similar results.3Nolan S. Filion K.B. Atallah R. Moss E. Reynier P. Eisenberg M.J. Hybrid coronary revascularization vs. complete coronary artery bypass grafting for multivessel coronary artery disease: a systematic review and meta-analysis.J Invasive Cardiol. 2018; 30: E131-E149PubMed Google Scholar The effectiveness of AHCR can only be ascertained through a multicenter prospective randomized controlled trial of complex revascularization comparing standard CABG with AHCR. Ideally, this study would assess the differences in initial surgical complications along with long-term major adverse cardiac events and revascularization rates and include a cohort of protocol-driven angiographic follow-up to ascertain the mode of revascularization failure. The future for AHCR remains bright, but will rely heavily on experienced heart teams. With persistence in continued training, the development of simplified robotic techniques, and appropriate funding for dedicated prospective clinical trials to determine which patient subsets benefit most, AHCR may ultimately be proven to be the best approach for many patients to improve outcomes and minimize complications. Residual SYNTAX Score After Advanced Hybrid Robotic Totally Endoscopic Coronary RevascularizationThe Annals of Thoracic SurgeryVol. 109Issue 6PreviewAdvanced hybrid coronary revascularization (AHCR) combines multivessel robotic beating-heart totally endoscopic coronary artery bypass with percutaneous coronary intervention. The aim of this study was to quantify the remaining coronary artery disease after AHCR using the residual Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery (SYNTAX) study score. Full-Text PDF