Hybrid coronary revascularization: at the crossroads of surgical and percutaneous interventions

Hybrid coronary revascularization involves any planned combination of percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) in patients with multi-vessel and/or left main disease. In clinical practice a more restricted definition is used in which placement of a left internal mammary artery (LIMA) graft to the left anterior descending (LAD) coronary artery is combined with stents for non-LAD lesions. This approach is referred to as "best-of-both-worlds" principle, based on the rationale that the long-term performance of drug-eluting stents for non-LAD disease may surpass those seen when using non-arterial grafts, while the long-term patency of the LIMA graft may be superior to stenting of the LAD. Additionally, when using minimally invasive surgical techniques, a hybrid approach may offer an additional benefit over CABG in reducing peri-procedural complications and faster in-hospital recovery. In this thesis we show that while hybrid coronary revascularization is currently not a widely adapted revascularization strategy, a more prominent role is expected, as technology advances and operator familiarity, interdisciplinary relations and commitment improve. Registry studies and meta-analytic data show that hybrid coronary revascularization is associated with faster recovery, fewer complications, lower cardiac troponin release, and comparable clinical results compared with CABG. These findings are irrespective of the approach used (concurrent or staged), and are consistent among various high-risk patient populations, including those with diabetes and of advanced age. Adequate patient selection, based on local expertise and data from large registries and well-designed randomized clinical studies, are of key importance to determine its future success.