Hybrid Revascularization Observational Study

The increasing prevalence of coronary artery disease (CAD), advances in coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI), and concomitant medical therapy, and the costs of revascularization have resulted in rising interest regarding the appropriate indications for coronary revascularization. For patients with 3-vessel disease, revascularization by CABG has recently been rated as appropriate while revascularization by PCI has been rated uncertain. Ideally, physicians would like to offer their multi-vessel CAD patients what they truly seek: a solution which provides a safe, minimally invasive treatment that does not compromise long term durability and survival. Integrating the positive features of both PCI and CABG has been the fundamental rationale of "hybrid" coronary revascularization.

Hybrid Coronary Revascularization (HCR) (the intended combination of CABG and PCI) as a scientifically validated approach would have a major healthcare impact. The ability to deliver a new therapy for CAD that provides durability, but without the obligatory trauma and prolonged recovery time characteristic of conventional CABG would be a major advance in the field of cardiovascular medicine. Candidates in whom HCR would be particularly advantageous would be several subgroups of CAD patients that are increasing in numbers: the elderly, patients with a high predicted risk of mortality and/or morbidity for CABG, deconditioned patients or patients with significant disabilities and patients in whom treatment durability is important, but a significantly invasive approach is not an option. Moreover, HCR is likely to bridge the divide in treatment philosophies and approaches that exist between cardiologists and cardiac surgeons. Collaboration rather than competition between these specialties will ultimately benefit patients, hospitals, payers and healthcare providers. The Hybrid Revascularization Observational Study is a multi-center observational study planning grant which will explore target populations for Hybrid Coronary Revascularization (HCR), their outcomes, and variations in specific ways these patients are managed, in order to inform the design of a pivotal comparative effectiveness trial of this emerging therapeutic strategy.

Given the observational nature of the study, the HCR and PCI groups' baseline characteristics and event rates are not directly comparable; rather, the results were intended to inform the design of a larger, randomized pivotal trial. The study was designed in two phases: Cohort 1, which captured demographic, angiographic, and practice patterns data for 6,669 consecutively screened patients; and Cohort 2 which captured demographic, angiographic, practice patterns, and outcome data for 298 patients who underwent either HCR or PCI with DES (90 of whom were also part of Cohort 1).

The following criteria apply to Cohort 2 PCI patients only:

Inclusion criteria

• Signed informed consent, release of medical information, and Health Insurance Portability and Accountability Act (HIPAA) documents
• Age 18 years or older
• Clinical indication for revascularization
• LAD and at least one additional vessel coronary disease (> 70% stenosis) confirmed by angiogram
• Clinical characteristics and multi-vessel disease amenable to both PCI with DES and Hybrid as adjudicated by one interventional cardiologist and one cardiac surgeon
• Ability to tolerate and no plans to interrupt double platelet therapy for ≥ 12 months
• Ability to tolerate to single lung ventilation in the judgment of the investigator
• Willing to comply with all protocol required follow-up

Exclusion criteria

• Previous coronary stent within:

• 1 month prior to enrollment for bare metal stent (BMS) or
• 6 months prior to enrollment for DES
• Evidence of in stent restenosis of a DES or BMS
• Previous cardiac surgery of any kind
• Chronic total occlusion (CTO) in LAD or ≥ 2 CTOs in major coronary territories that are considered targets for revascularization
• Left main disease ≥ 50% stenosis
• Presence of fresh coronary thrombus
• Need for concomitant vascular or other cardiac surgery during the index hospitalization (including, but not limited to, valve surgery, aortic resection, left ventricular aneurysm, carotid endarterectomy or stenting, etc)
• Previous STEMI within 30 days prior to randomization
• Previous stroke within 6 months prior to randomization
• Previous thoracic surgery involving the left pleural space
• Acute decompensated heart failure within 30 days prior to randomization
• Ejection fraction < 30%
• Creatinine clearance ≤ 50 ml/min within 24 hours prior to randomization
• Hemodynamic instability at time of screening
• Body mass index > 40
• Extra-cardiac illness that is expected to limit survival to less than 3 years
• Participation or planned participation in another investigational intervention study within 60 days prior to randomization
• Unable to give informed consent or potential for noncompliance with the study protocol due to psychiatric illness, organic brain disease, dementia, current alcohol abuse, mental retardation, language barrier, or geographical inaccessibility;
• Pregnancy at time of screening or intention to become pregnant