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J Thorac Cardiovasc Surg 2008;135:367-375
© 2008 The American Association for Thoracic Surgery

Evolving Technology

Simultaneous hybrid coronary revascularization reduces postoperative morbidity compared with results from conventional off-pump coronary artery bypass

^a Division of Cardiac Surgery, Department of Surgery, University of Maryland Medical System, Baltimore, Md
^c Department of Cardiology, University of Maryland Medical System, Baltimore, Md
^d University of Maryland Medical System, Baltimore, Md
^b Department of Information Systems, University of Maryland Baltimore County, Baltimore, Md

Received for publication May 21, 2007; revisions received August 10, 2007; accepted for publication September 24, 2007.

^_* Address for reprints: Robert S. Poston, MD, University of Maryland School of Medicine, Division of Cardiac Surgery, N4W94 22 S Greene St, Baltimore, MD 21201. (Email: rposton{at}smail.umaryland.edu).

Objectives: Less-invasive options are available for surgical treatment of multivessel coronary artery disease. We hypothesized that stenting combined with grafting of the left anterior descending artery with the left internal thoracic artery through a minithoracotomy (hybrid procedure) would provide the best outcome.

Methods: Patients with equivalent numbers of coronary lesions (2.8 ± 0.4) underwent either hybrid (n = 15) or off-pump coronary artery bypass through a sternotomy (n = 30). Early and 1-year outcomes were compared. Blood drawn from the aorta and coronary sinus immediately postoperatively was analyzed for activation of coagulation (prothrombin fragment 1.2 and activated Factor XII), myocardial injury (myoglobin), and inflammation (interleukin 8) by using an enzyme-linked immunosorbent assay. Target-vessel patency was determined by means of computed tomographic angiographic analysis.

Results: The hybrid procedure was associated with significantly shorter lengths of intubation and stays in the intensive care unit and hospital and perioperative morbidity (P < .05). Intraoperative costs were increased but postoperative costs were reduced for the hybrid procedure compared with off-pump coronary artery bypass through a sternotomy. As a result, overall total costs were not significantly different between the groups. After adjusting for potential confounders, assignment to the hybrid group was an independent predictor of shortened time to return to work (t = –2.12, P = .04). Patient satisfaction after the hybrid procedure, as judged on a 6-point scale, was greater versus that after off-pump coronary artery bypass through a sternotomy. Finally, the hybrid procedure showed significantly reduced transcardiac gradients of markers of coagulation, myocardial injury, and inflammation and a trend toward significant improvement in target-vessel patency.

Conclusions: Perhaps because of reduced myocardial injury, inflammation, and activation of coagulation, patients undergoing the hybrid procedure had better perioperative outcomes and satisfaction, with excellent patency at 1 year's follow-up. These promising preliminary findings warrant further investigation of this procedure.

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