Robotic off-pump hybrid coronary revascularization - a niche area in need for objective data.

Hybrid coronary revascularization (HCR) consists of left internal thoracic artery (LITA) graft to the left anterior descending (LAD) artery and transcatheter revascularization of the non-LAD stenosis in specific settings to achieve complete coronary revascularization. Technique to perform the LITA to LAD graft has ranged from median sternotomy with cardiopulmonary bypass to robotically assisted totally endoscopic coronary bypass surgery using beating heart revascularization.

Hybrid coronary revascularization in multivessel coronary artery disease: a systematic review

Aim: Hybrid coronary revascularization (HCR) for multivessel coronary artery disease (CAD) integrates coronary artery bypass grafting (CABG) and percutaneous intervention in a planned revascularization strategy. This systematic review summarizes the state of this art of this technique. Methods: Major databases searched until October 2021. Results: The available literature on HCR includes three randomized trials, ten meta-analysis and 27 retrospective studies. The greatest benefits are observed in patients with low-to-intermediate risk and less complex coronary anatomy; highly complex disease and the presence of risk factors favored conventional CABG in terms of adverse events and survival. Conclusion: HCR is an interesting approach for multivessel CAD but should not be considered a ‘one-size-fits-all’ procedure. Further studies will specify the subset of patients likely to benefit most from this hybrid approach.

Robotic Hybrid Coronary Revascularization - a need for strategy specific data.

Robotic totally endoscopic techniques to perform the LITA to LAD graft, coupled with PCI, provides the least invasive option to achieve hybrid coronary revascularization (HCR). Shorter hospital stay and reduced need for blood transfusions have been consistently being reported by several studies along with similar long-term outcomes. Considerable variations exist in the definition of HCR which can be single or two-staged with surgical revascularization being carried out after PCI or vice versa. Variations also exist with respect to usage of cardiopulmonary bypass, surgical incisions, and use of minimally invasive robotic techniques. The different strategies of HCR do not lead to similar outcomes and the findings of one strategy cannot be extrapolated to the entire group. Studies reporting different strategies of HCR, should ideally provide more granular data when reporting outcomes.

Clopidogrel Loading Dose 300 vs. 600 mg in Patients Undergoing One-Stop Hybrid Coronary Revascularization: A Prospective Single-Center Randomized Pilot Study

Background: The optimal loading dose of clopidogrel in one-stop hybrid coronary revascularization (HCR) remains an “evidence-free” zone. This study aimed to compare the major bleeding and ischemic thrombotic events between different clopidogrel loading doses (300 vs. 600 mg) in one-stop HCR.Methods: In this prospective, single-center, randomized, and parallel pilot study, 100 patients receiving one-stop HCR were randomly assigned to the clopidogrel loading dose 300-mg group or 600-mg group in a 1:1 ratio. Major bleeding events and composite in-hospital ischemic thrombotic and adverse complications were evaluated after the procedure.Results: The results showed that postoperative mean chest drainage of the first 4 days and total drainage were comparable between the two groups. No differences were found in Bleeding Academic Research Consortium (BARC) coronary artery bypass grafting (CABG) related bleeding (4 vs. 2%, P = 1), PLATelet inhibition and patient Outcomes (PLATO) life-threatening bleeding (20 vs. 26%, P = 0.48), and PLATO major bleeding (70 vs. 76%, P = 0.5) in the two groups. The composite ischemic thrombotic and adverse events were also similar.Conclusions: In patients receiving one-stop HCR, clopidogrel 600 mg loading dose did not increase major bleeding events compared with 300 mg. More sufficient data is necessary to evaluate the potential benefits of 600 mg loading dose in one-stop HCR.

Five-Year Outcomes After Hybrid Coronary Revascularization: A Single Center Experience

Objective Hybrid coronary revascularization (HCR) combines both surgical and percutaneous coronary revascularization procedures. It offers a minimally invasive strategy for multivessel coronary artery disease and combines the advantages of both. However, quantitative long-term patency and clinical outcomes remain understudied. The objective of this study was to assess clinical outcomes and graft and stent patency at 5-year follow-up. Methods From January 2004 to January 2015, 120 patients were enrolled in this study. They underwent robotically assisted minimally invasive coronary artery bypass grafting of left internal thoracic artery (LITA) to the left descending artery (LAD) and percutaneous coronary intervention of non-LAD vessels. Primary outcome was graft (LITA-LAD) patency determined at 5 years of follow-up, assessed by computed tomography angiography and rest and stress myocardial perfusion scintigraphy (MPS-MIBI). Secondary outcomes were stent patency and major adverse major cardiac and cerebrovascular events (MACCE). Also, freedom from recurrence of angina was assessed. Results At follow-up, 18 of 120 patients (15%) had died (in 5 patients the cause of death was cardiovascular). Among survivors, follow-up was achieved in 83 of 102 (81%). In 76 of 83 patients (92%) there was a patent LITA-LAD graft and in 75 of 83 (90%) a patent stent was demonstrated. MACCE occurred in 36 of 120 patients (30%). Freedom from recurrence of angina occurred in 92 of 120 patients (77%). Conclusions HCR is a safe and a promising procedure. It provides a minimally invasive approach and results in complete revascularization with good 5-year patency and clinical outcomes.