Coronary artery bypass grafting (CABG) remains the gold standard for the treatment of multivessel coronary artery disease (1–3). The left internal mammary artery (LIMA) to left anterior descending (LAD) graft provides most of the survival benefit of CABG due to its long-term patency rate, which can reach 90% at 10 years. However, the 10-year patency for saphenous vein graft (SVG) was only 60%, and conventional CABG is a relatively invasive and high-risk procedure via sternotomy (4–6). In-stent restenosis was <6% in patients undergoing percutaneous coronary intervention (PCI) with drug eluting stents (DESs) (7). However, the long-term outcomes of PCI were not superior to those of CABG in patients with intermediate or high SYNTAX scores (>22) (8, 9).

Hybrid coronary revascularization (HCR) was first introduced by Angelini in 1996 and consisted of LIMA-LAD anastomosis using a minimally invasive left thoracotomy approach and PCI procedure for non-LAD lesions (10). HCR combines the advantages of CABG and PCI, avoids their relative deficiencies, and achieves complete revascularization. The HYBRID trial and several observational studies have shown similar short and long-term outcomes compared with off-pump or on-pump CABG (11–14). Nevertheless, data comparing HCR and off-pump CABG (OPCAB) are still limited, and the safety and efficacy of HCR in multivessel coronary artery disease have not been completely indicated, especially for one-stop HCR patients, due to the majority composition of staged HCR in these studies. Considering the potentially different strengths and disadvantages between one-stop and staged HCR, the results of one-stop HCR need to be separately evaluated.

Therefore, we sought to investigate the early and midterm outcomes of one-stop HCR compared with OPCAB in patients with multivessel coronary artery disease to evaluate the safety and effectiveness of this procedure.

Minimally invasive techniques for surgical myocardial revascularization have received much attention in recent years, especially the HCR technique (17). Compared with staged HCR, one-stop HCR can achieve complete revascularization in a single procedure, which avoids ischemic events during the waiting period caused by incomplete revascularization in staged HCR. Furthermore, LIMA-LAD anastomosis can be evaluated by angiography immediately before PCI, and grafts can be revised if there are any major issues (18). Additionally, high-risk non-LAD PCI is performed with a protected LAD territory, and surgical bailout can be performed for any possible complication or unsuccessful PCI with a surgical team in a hybrid suite. Finally, this single-step procedure reduces hospital stay and readmission, provides convenience for patients, and improves patient satisfaction (19).

On the other hand, the simultaneous procedure requires a costly hybrid room featuring advanced surgical and interventional equipment. In addition, adopting an appropriate antiplatelet therapy strategy to balance the risk of bleeding and stent thrombosis is a major challenge (20).

To date, a series of published data comparing HCR with conventional CABG and OPCAB from different centers with variable surgical techniques and study methodologies have demonstrated limited conclusions (11, 12, 21, 22). Most of the patients involved in these studies underwent staged HCR, and the one-stop HCR approach accounted for only 15% of all HCR procedures in the United States (23). Outcomes of one-stop HCR should be proven, particularly due to their different natural attributes.

The present study compared early and midterm results between one-stop HCR and standard OPCAB, which revealed similar excellent in-hospital and midterm outcomes. In addition, the HCR group was associated with a lower rate of perioperative transfusion (23.8 vs. 53.0%), new-onset AF (5.3 vs. 15.2%), shorter time of mechanical ventilation, and LOS in the hospital. Consistent with our results, Reynolds et al. (24) evaluated a total of 4,260 patients (1,350 of whom underwent HCR) in a meta-analysis. They confirmed that HCR had a significantly lower rate of blood transfusion than CABG (22.8 vs. 46.1%) and a shorter time of mechanical ventilation and LOS in the hospital, but no significant differences were found in ICU stay, postoperative atrial fibrillation, renal failure, perioperative myocardial infarction, or death. Similar conclusions were also investigated by Sardar et al. (25). These findings indicated the advantages of minimally invasive and rapid recovery of HCR.

Another particular potential benefit of HCR procedures is completely avoiding manipulation of the aorta, which could theoretically reduce the risk of neurological events. However, in our study, the incidence of in-hospital stroke was low and was comparable between the two groups. Three (HCR group) and two (OPCAB group) patients developed stroke. Among the stroke patients in the HCR group, two patients had a history of cerebral infarction, and one stroke patient was caused by atherosclerotic plaques detached from the left subclavian artery in selective LIMA angiography. Meanwhile, in the OPCAB group, using proximal anastomosis devices (Heartstring or Enclose) was a routine procedure in our center. This surgical approach reduced aortic manipulation and was associated with a lower risk of perioperative stroke (26). Nevertheless, HCR is still an optimal strategy for patients with severe aortic atherosclerosis.

Appropriate antiplatelet therapy to preserve stent patency and minimize the risk of postoperative bleeding is challenging in one-stop HCR procedures. Exposure to potent antiplatelet drugs may increase the risk of postoperative bleeding events. Coincidentally, in the present study, the reoperation rate for bleeding was higher in the HCR group (4.0 vs.0.7%), although the difference was not significant (p = 0.12), which is consistent with the rate of 3 to 6.8% reported by Zhao et al. and Harskamp et al. (18). Most of the reoperation cases occurred early after introducing one-stop HCR into our center, and the LIMA pedicle was harvested through direct vison at that time. Then, endoscopy was used in LIMA harvesting, which could reduce the trauma of the LIMA bed. We strengthened surgical hemostasis, such as by using the “LIMA bed closure” technique. As a consequence, few patients now develop major bleeding events requiring reoperation.

During midterm follow-up, we revealed no differences between the two groups in cumulative survival (94.9 vs. 92.9%, p = 0.91) or free from MACCE (84.1 vs. 86%, p = 0.59) after the procedure. These findings are consistent with recently published data. The HYBRID (POL-MIDES) trial (11), the largest prospective randomized study comparing HCR with conventional CABG, involved 98 HCR patients and 102 conventional CABG patients. The 5-year survival rates were 93.6% in the HCR group and 90.8% in the CABG group (p = 0.69), and the rates of freedom from MACCE were 45.2 and 53.4%, respectively (p = 0.39). No differences were found between the two groups. There were also no differences in the rates of MI, stroke, or repeat revascularization. Shen et al. (27) compared one-stop HCR, CABG, and PCI in an observational study. At the 3-year follow-up, actuarial survival was 99.3% in the HCR group and 97.2% in the CABG group, and the cumulative rate of freedom from MACCE was 93.6% after HCR and 86.5% after CABG (p = 0.14). In Shen's study, surgical revascularization was completed through a lower partial ministernotomy, which is different from the widely used technique through a small anterior thoracotomy.

In the present study, the rate of any repeat revascularization was comparable between the HCR and OPCAB groups (4.7 vs. 5.0%; OR.72; 95% CI.21–2.49; p = 0.61) during the follow-up. Hage et al. (12) compared HCR (n = 147, robotic-assisted minimally invasive direct CABG) and OPCAB (n = 216) using inverse-probability weighting. The HCR was associated with a higher in-hospital reintervention rate (HCR 3.4% vs. CABG 0%, p = 0.03). For long-term follow-up, freedom from any form of revascularization was similar between the two groups (91 vs. 92%; p = 0.80), which is consistent with our results. In contrast, a meta-analysis from Nolan et al. (28) found that HCR was also associated with a higher risk of long-term repeat target vessel revascularization (TVR) than CABG.

Several limitations need to be addressed. First, this study was a single-center retrospective study, and the risk of selection bias was inevitable despite the benefits of propensity score matching. Second, the sample size was limited. Finally, the follow-up time was short, and long-term follow-up to verify the effectiveness of one-stop HCR is warranted.

One-stop HCR is safe and efficacious with less invasiveness and faster postoperative recovery in selected patients with multivessel coronary artery disease. Compared with OPCAB, one-stop HCR is associated with a lower rate of perioperative transfusion and new-onset AF, shorter time of mechanical ventilation and LOS in the hospital, and excellent similar midterm outcomes. Randomized controlled trials with larger sample sizes and long-term follow-up are warranted to confirm these findings.

The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding authors.

The studies involving human participants were reviewed and approved by Research Ethics Board of Chaoyang Hospital. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.

DL, PS, and JG: conception and design. YL, JZ, and PS: administrative support. DL, JG, YGu, XA, and XZ: provision of study materials or patients. DL and YGa: collection and assembly of data. DL, JG, and SG: data analysis and interpretation. DL: manuscript writing. All authors read and approved the final manuscript.

This work was supported by Beijing Municipal Science and Technology Commission Foundation (No. Z191100006619036).

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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