Robot-assisted minimally invasive coronary artery bypass in treating multi-vessel coronary artery disease: A retrospective study in a single center / 中国胸心血管外科临床杂志

@#Objective    To evaluate the early and mid-term results of robot-assisted coronary artery bypass grafting (RACAB) in the treatment of multi-vessel coronary artery disease (MV-CAD). Methods     Patients with MV-CAD who underwent RACAB from April 2018 to December 2021 in our hospital were included. Patients who underwent hybrid coronary revascularization (HCR) which combined RACAB with percutaneous coronary intervention were allocated to a HCR-RACAB group, and patients who underwent multi-vessel RACAB were allocated to a MV-RACAB group. Perioperative and follow-up data were collected and compared between the two groups. Results     A total of 102 patients were included, including 81 males and 21 females with a mean age of 61.7±10.8 years. Two (2.0%) patients were transferred to conventional CABG due to sudden ventricular fibrillation and pleura adhesion. In the remaining 100 patients who underwent RACAB, 100 left internal mammary arteries (LIMA) and 46 right internal mammary arteries (RIMA) were harvested with a 100.0% success rate. Besides, all patients undergoing RACAB achieved LIMA/RIMA-left anterior descending branch reconstruction, with an average number of 2.5±0.6 target vessels revascularized by stent or graft. One patient had perioperative myocardial infarction with an outcome of death. The incidence of major perioperative adverse events was 1.0%. There was no perioperative stroke or re-sternotomy for hemostasis. The mean follow-up time was 28.2 months, with a follow-up rate of 99.0% and an overall major adverse cardiac and cerebrovascular event (MACCE) rate of 7.0%, including 3 all-cause deaths (3.0%), 2 strokes (2.0%) and 3 re-revascularizations (3.0%). The HCR-RACAB group had fewer red blood cell transfusion (P=0.030) and intraoperative blood loss (P=0.037) compared with the MV-RACAB group, and there was no statistical difference in the incidence of major perioperative adverse events or MACCE between the two groups during the follow-up period (P>0.05). Conclusion    RACAB can be safely applied in the treatment of MV-CAD with good early and mid-term outcomes. High-quality harvesting of LIMA/RIMA and aortic no-touch technique are crucial to achieve these results.

Retrospective cohort study of early and mid-term results of HCR and MICS-CABG in coronary artery disease patients with low ejection fraction and non diabetes mellitus / 中华胸心血管外科杂志

Objective:To compare the early and mid-term results of hybrid coronary revascularization (HCR) and minimally invasive multivessel coronary artery bypass grafting (MICS-CABG) in coronary artery disease patients with low left ventricular ejection fraction and non diabetes mellitus, and to explore the indication of HCR and MICS-CABG.Methods:A retrospective cohort analysis of HCR and MICS-CABG cases with preoperative left ventricular ejection fraction less than 0.40, and without diabetes mellitus were conducted in Xijing Hospital from January 2015 to December 2019. 36 cases in HCR group and 17 cases in MICS group were included in this study. For HCR procedure, minimally invasive left internal mammary artery(LIMA) to the left anterior descending artery (LAD) bypass surgery were performed, and followed by percutaneous coronary intervention (PCI) to treat non LAD lesion 1 to 4 weeks later. MICS-CABG procedure was performed through left anterior small thoracotomy minimally invasive direct coronary artery bypass grafting for multiple diseased vessels.Results:The preoperative SYNTAX score in MICS group was significantly higher than that in HCR group ( P<0.05). There was no perioperative death in both groups. Troponin I, postoperative drainage volume, blood transfusion volume and ventilator ventilation time in MICS group were significantly higher than those in HCR group ( P<0.05). After 12 months follow-up, no patient died in both groups. Furthermore, all LIMA grafts were patency. The stenosis rate of drug-eluting stents in HCR group was similar to that of great saphenous vein grafts in MICS group. LVEF and left ventricular end diastolic diameter of both groups were significantly improved 12 months after operation ( P<0.05). Conclusion:HCR and MICS-CABG are minimally invasive and safe treatment for multivessel coronary artery disease patients with low ejection fraction and non diabetese mellitus. The early and mid-term therapeutic effects are satisfactory. If coronary artery lesions other than LAD are suitable for PCI, HCR should be the preferred treatment.

Current application status and prospect of hybrid coronary revascularization / 中国胸心血管外科临床杂志

@#Hybrid coronary revascularization (HCR) combining with coronary artery bypass grafting (CABG) has a long-term patency of left internal mammary artery to left anterior descending artery (LIMA-LAD) grafting, and the percutaneous coronary intervention (PCI) has a minimal invasiveness. It provides an alternative revascularization for patients with coronary heart disease. For patients who meet the HCR indications, most studies suggest that HCR can significantly reduce perioperative trauma, and offer favorable mid- and long-term prognosis, which is comparable with traditional revascularization strategies. Based on the major research results in this field in the past 10 years, we review the current application status and discuss the potential future direction of HCR in this paper.

Research progress on clinical outcomes of hybrid coronary revascularization / 中国胸心血管外科临床杂志

@#Hybrid coronary revascularization (HCR) combines the advantages of minimally invasive direct coronary artery bypass grafting (MIDCAB) and percutaneous coronary intervention (PCI), and avoids its relative shortcomings, which has received particular attention in recent years. HCR seems to have become the third revascularization strategy for multi-vessel disease in coronary heart diseases. However, the clinical researches on HCR are still limited. This article will systematically review the comparison of HCR with coronary artery bypass grafting (CABG) and PCI, the results of HCR in specific patients, and the clinical results of different HCR strategies.

Revascularización coronaria híbrida: un punto de encuentro entre cardiólogos intervencionistas y cirujanos cardíacos / Hybrid coronary revascularization: a meeting point between interventional cardiologists and cardiac surgeons

Resumen: La revascularización coronaria híbrida busca combinar el beneficio de las técnicas quirúrgicas y percutáneas para un manejo óptimo de pacientes seleccionados con enfermedad coronaria obstructiva multivaso. Esto permite asociar el beneficio del puente de arteria mamaria interna izquierda a la arteria descendente anterior (ADA) y combinarlo con el implante de stents en lesiones no-ADA. El objetivo de este trabajo es hacer una revisión de la literatura disponible con énfasis en sus resultados clínicos comparados con la estrategia convencional.

Abstract: Hybrid coronary revascularization seeks to combine the benefit of surgical and percutaneous techniques for optimal management of selected patients with multivessel coronary artery disease. This allows combining the benefit of the left internal mammary artery bypass to the anterior descending artery (LAD) and stent deployment in non-LAD lesions. The objective of this manuscript is to review the available literature with emphasis on its clinical results compared to the conventional strategy.

Long-term results of minimally invasive direct coronary artery bypass / 上海交通大学学报（医学版）

Objective • To summarize the experiences and follow-up results of minimally invasive direct coronary artery bypass (MIDCAB) for treating coronary atherosclerotic cardiopathy for 10 years and to evaluate the long-term effects of MIDCAB. Methods • The patients who underwent MIDCAB at Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, from February 2009 to May 2019 were collected. According to whether the patients achieved complete revascularization (CR) or underwent hybrid coronary revascularization (HCR), the cases were divided into 3 groups: incomplete revascularization (IR) + optimal medical therapy (OMT) group, MIDCAB (CR) group and HCR (CR) group. The Kaplan-Meier (K-M) curve was used to analyze the long-term survival and the freedom from major adverse cardiac and cerebrovascular events (MACCE) of patients. Results • A total of 425 patients were enrolled in the study, with a median follow-up of 39.9 months (18.2-81.1 months). The hospital stay in the HCR (CR) group was significantly prolonged compared with the other two groups (P=0.000). The perioperative mortality (P=0.000), perioperative myocardial infarction (MI) rate (P=0.000), perioperative MACCE rate (P=0.000), cardiac troponin I (cTnI) levels in 48 h (P=0.011), long-term mortality (P=0.000), long-term MI rate (P=0.002), and long-term MACCE rate (P=0.005) in the IR + OMT group were significantly higher than those in the other two groups of patients who had CR. The overall 10-year survival rate and freedom from MACCE estimated by K-M curves were 80.9% (95%CI 73.1%-88.7%) and 70.5% (95%CI 62.1%-78.9%), respectively. The long-term survival (P=0.000) and freedom from MACCE (P=0.001) in IR+OMT group were significantly lower than those in the other two groups. Conclusion • MIDCAB has good long-term effects on patients with coronary atherosclerotic cardiopathy. Patients undergoing MIDCAB should complete CR, and IR can significantly affect the long-term prognosis of patients.

The comparison of mid-and long-term follow-up between two-stage Hybrid coronary revascularization and off-pump coronary artery bypass for multi-vessel coronary artery disease / 中华胸心血管外科杂志

Objective To evaluate the mid-and long-term efficacy of Hybrid coronary revascularization (HCR) in the treatment of multi-vessel coronary artery disease for 5 years after operation,and to compare the operative effect with those of offpump coronary artery bypass grafting (OPCABG) for the same period.Methods From March 2010 to June 2013,37 patients underwent selective staging HCR surgery (HCR group) due to multi-vessel coronary artery disease in our hospital.All patients were treated by PCI and MIDCAB subsequently.148 patients with OPCABG completed by the same group of doctors at the same time were served as control group (OPCABG group),and the follow-up period was up to June 2018.The end point of the study was the incidence of major adverse cardiac or cerebrovascular events (MACCE) events in both groups,including cardiac death,new myocardial infarction,secondary coronary revascularization and cerebrovascular accident.Results The clinical baseline data of the two groups were basically matched.37 patients in HCR group were successfully operated on,and each patient was completed with LIMA-LAD bypass,72 drug-eluting stents were implanted.504 stents were bridged in 148 patients in OPCABG group,each patient was completed with LIMA-LAD bypass,the other target vessels were performed by sequential anastomosis with great saphenous vein as graft.The average follow-up time was 6.3 years (5.1-8.2 years).In HCR group,33 patients(89％)completed the follow-up,of which 6 (18％) had MACCE events.In OPCABG group,130 patients(88％)successfully completed the follow-up,of which 19 (15％) had MACCE events.There was no significant difference in MACCE-free survival rate between the two groups (HCR 81.8％ vs.OPCABG 73.8％,P ＞ 0.05).Conclusion The mid-and long-term effect of HCR is similar to that of OPCABG in the treatment of multi-vessel coronary artery disease,but it has the advantages of less traumatic,faster recovery and less use of blood products.It can be widely used in patients with selective multi-vessel coronary artery disease.

The comparison of mid- and long-term follow-up between two-stage Hybrid coronary revascularization and off-pump coronary artery bypass for multi-vessel coronary artery disease / 中华胸心血管外科杂志

Objective@#To evaluate the mid- and long-term efficacy of Hybrid coronary revascularization (HCR) in the treatment of multi-vessel coronary artery disease for 5 years after operation, and to compare the operative effect with those of off-pump coronary artery bypass grafting (OPCABG) for the same period.@*Methods@#From March 2010 to June 2013, 37 patients underwent selective staging HCR surgery (HCR group) due to multi-vessel coronary artery disease in our hospital. All patients were treated by PCI and MIDCAB subsequently. 148 patients with OPCABG completed by the same group of doctors at the same time were served as control group (OPCABG group), and the follow-up period was up to June 2018. The end point of the study was the incidence of major adverse cardiac or cerebrovascular events (MACCE) events in both groups, including cardiac death, new myocardial infarction, secondary coronary revascularization and cerebrovascular accident.@*Results@#The clinical baseline data of the two groups were basically matched. 37 patients in HCR group were successfully operated on, and each patient was completed with LIMA-LAD bypass, 72 drug-eluting stents were implanted. 504 stents were bridged in 148 patients in OPCABG group, each patient was completed with LIMA-LAD bypass, the other target vessels were performed by sequential anastomosis with great saphenous vein as graft. The average follow-up time was 6.3 years (5.1-8.2 years). In HCR group, 33 patients(89%)completed the follow-up, of which 6 (18%) had MACCE events. In OPCABG group, 130 patients(88%)successfully completed the follow-up, of which 19 (15%) had MACCE events. There was no significant difference in MACCE-free survival rate between the two groups (HCR 81.8% vs. OPCABG 73.8%, P>0.05).@*Conclusion@#The mid- and long-term effect of HCR is similar to that of OPCABG in the treatment of multi-vessel coronary artery disease, but it has the advantages of less traumatic, faster recovery and less use of blood products. It can be widely used in patients with selective multi-vessel coronary artery disease.

Efficacy and safety of "2-staged" Hybrid Coronary Revascularization Using Bilateral Internal Thoracic Artery Y Graft for Patients With Multivessel Coronary Artery Disease / 中国循环杂志

Objectives: To explore the feasibility and safety of "2-staged" hybrid coronary revascularization using bilateral internal thoracic artery (BITA) for the treatment of multivessel coronary artery disease. Methods: Data of 65 patients who underwent "2-staged" hybrid technique (HCR) using BITA (BITA-HCR group) in our heart center because of multivessel coronary artery lesions during 2014.05-2017.05 were retrospectively analyzed. Results were compared with 96 patients who underwent "2-staged" HCR with single ITA (SITA-HCR group) by the same surgeon over the same time period. Results: There was no significant difference of preoperative characteristics between two groups. Operation time was significantly longer [(204.6±28.7) min vs (147.9±31.6) min, P<0.05], number of distal anastomoses was significantly higher [(2.2±0.5) vs (1.0±0.0), P<0.05], number of stents was significantly lower [(1.90±0.67) vs (2.40±0.49), P<0.05] in BITA-HCR group than in SITA-HCR group. Bleeding volume [(520.1±120.3) ml vs (532.2±350.3)ml, P>0.05], mechanical ventilation time [(7.7±3.2) h vs (6.9±2.3) h, P>0.05] and blood transfusion required [5(7.7%)vs 8(8.3%), P>0.05] were similar between the two groups. Conclusions: The "2-staged" hybrid procedure using BITA is safe and feasible for the revascularization of multiple coronary artery lesions.

Comparison on 30-day Clinical Outcome Between Simultaneous Hybrid Coronary Revascularization and Off-pump Coronary Artery Bypass Grafting in Patients With Multivessel Coronary Artery Disease / 中国循环杂志

Objectives: The purpose of this study was to compare the 30-day clinical outcome after simultaneous hybrid coronary revascularization (HCR) with off-pump coronary artery bypass grafting (OPCABG) in patients with multivessel coronary artery disease and evaluate the safety and efficiency of simultaneous hybrid coronary revascularization strategy. Methods: Simultaneous HCR was performed in 533 patients with multivessel coronary artery disease at Fuwai hospital from January 2009 to January 2017. These patients were 1:1 matched with patients underwent OPCABG using propensity score matching method. The primary endpoint was major adverse cardiac or cerebrovascular events (MACCE) over the 30-day follow-up post-surgery, and the second endpoints were in-hospital outcomes, including chest tube drainage, transfusion rate, mechanical ventilation time and length of stay in intensive care unit. Results: Chest tube drainage post-surgery (ml)(714 [523, 971] vs 965 [716, 1 220], P<0.001),Blood transfusion rate (19.7% vs 34.0%, P=0.024), mechanical ventilation time (hours) (12.6[9.3, 15.7] vs 16.0 [12.8, 18.7], P<0.001), and stay in intensive care unit (hours) (21.7[19.8, 42.4] vs 41.6[23.6, 70.0], P<0.001) were all significantly reduced in the simultaneous HCR group than in OPCABG group. Mortality, myocardial infarction, stroke, repeat revascularization rate and accumulated MACCE rate during the 30-day follow-up were similar between HCR group and OPCABG group .Conclusions: For selected patients with multivessel coronary artery disease, simultaneous HCR provided a safe and effective alternative revascularization strategy. Simultaneous HCR is associated with less blood loss, faster recovery, and fewer perioperative complications and achieved similar and favorable early outcomes as compared with OPCABG strategy.

Clinical results of HCR compared with OPCABG on two-vessel coronary artery disease with proximal left anterior descending stenosis: a propensity-score-matched follow-up study / 上海交通大学学报（医学版）

Objective·To explore the difference between hybrid coronary revascularization (HCR) and off-pump coronary artery bypass grafting (OPCABG) on two-vessel coronary artery disease with proximal left anterior descending stenosis with propensity score matching.Methods·The patients with two-vessel coronary artery disease with proximal left anterior descending stenosis who underwent isolated HCR or OPCABG were selected in Ruijin Hospital from January 2009 to December 2016.The propensity score methodology was used to obtain risk-adjusted outcome.Kaplan-Meier analysis was applied to estimation of major adverse cardiac and cerebrovascular events (MACCE)-free survival rate and target vessel revascularization (TVR)-free survival rate.Results·The average follow-up time was 59 months (13-104 months).The length of hospital stay of HCR group was significantly shorter than that of OPCABG group [(15.3±4.5) d vs (17.6±5.4) d,P=0.027].There was no statistical difference in other short-term clinical endpoints in hospital.In midterm,there was no statistical difference in the rate of MACCE (11.4％ vs 13.3％,P=0.968),death (2.3％ vs 4.4％,P=0.984),myocardial infarction (2.3％ vs 2.2％,P=0.485),stroke (4.5％ vs 6.7％,P=0.979) and TVR (4.5％ vs 2.2％,P=0.984) between two groups.And there was no statistical difference in MACCE-free survival rate (P=0.906) and TVR-free survival rate (P=0.541) between two groups.Conclusion·HCR provides favorable midterm outcomes for selected patients with two-vessel coronary artery disease with proximal left anterior descending stenosis.It might provide a promising alternative to OPCABG.

Clinical results of HCR compared with OPCABG on two-vessel coronary artery disease with proximal left anterior descending stenosis: a propensity-score-matched follow-up study / 上海交通大学学报（医学版）

Objective: To explore the difference between hybrid coronary revascularization (HCR) and off-pump coronary artery bypass grafting (OPCABG) on two-vessel coronary artery disease with proximal left anterior descending stenosis with propensity score matching. Methods: The patients with two-vessel coronary artery disease with proximal left anterior descending stenosis who underwent isolated HCR or OPCABG were selected in Ruijin Hospital from January 2009 to December 2016. The propensity score methodology was used to obtain risk-adjusted outcome. Kaplan-Meier analysis was applied to estimation of major adverse cardiac and cerebrovascular events (MACCE)-free survival rate and target vessel revascularization (TVR)-free survival rate. Results: The average follow-up time was 59 months (13-104 months). The length of hospital stay of HCR group was significantly shorter than that of OPCABG group [(15.3±4.5) d vs (17.6±5.4) d, P=0.027]. There was no statistical difference in other short-term clinical endpoints in hospital. In midterm, there was no statistical difference in the rate of MACCE (11.4% vs 13.3%, P=0.968), death (2.3% vs 4.4%, P=0.984), myocardial infarction (2.3% vs 2.2%, P=0.485), stroke (4.5% vs 6.7%, P=0.979) and TVR (4.5% vs 2.2%, P=0.984) between two groups. And there was no statistical difference in MACCE-free survival rate (P=0.906) and TVR-free survival rate (P=0.541) between two groups. Conclusion: HCR provides favorable midterm outcomes for selected patients with two-vessel coronary artery disease with proximal left anterior descending stenosis. It might provide a promising alternative to OPCABG.

Simultaneous hybrid coronary revascularization versus off-pump coronary artery bypass grafting for diabetic patients with multivessel coronary artery disease / 中国胸心血管外科临床杂志

@#Objective    To compare the in-hospital and midterm outcomes after simultaneous hybrid coronary revascularization (HCR) with off-pump coronary artery bypass grafting (OPCAB) in diabetic patients with multivessel coronary artery disease. Methods    One hundred thirty-two diabetic patients with multivessel coronary artery disease underwent one-stop HCR at Fuwai Hospital from January 2010 to January 2015. These patients were 1∶2 matched with those who underwent OPCAB using propensity score matching. Results    Simultaneous HCR had less chest tube drainage (618 (420, 811) ml vs. 969 (711, 1 213)ml, P<0.001), lower transfusion rate (19.7% vs. 34.1%, P=0.026), shorter mechanical ventilation time (11.6 (8.2, 14.8) h vs. 16.0 (12.1, 18.7) h, P<0.001), and shorter stay in intensive care unit (21.5 (18.8, 42.0)   h vs. 44.6 (23.7, 70.1) h, P<0.001) than OPCAB. During over median 40 months follow-up, simultaneous HCR offered similar major adverse cardiac or cerebrovascular events (MACCE) rate (6.8% vs 9.0%, P=0.826), but lower stroke rate (0%vs 3.0%, P=0.029), compared with OPCAB. Conclusion    For selected patients with diabetes, simultaneous HCR provides a safe and effective revascularization alternative. It decreases perioperative invasiveness and incurred similar and favorable midterm outcomes with OPCAB.

The Current Situation and Progress of Minimally Invasive Integrated Coronary Revascularization / 中国微创外科杂志

[Summary] Minimally invasive hybrid coronary revascularization ( MIHCR) represents a minimally invasive revascularization strategy that combines coronary artery bypass graft ( CABG) surgery with percutaneous coronary intervention ( PCI) .Although MIHCR is better than coronary artery bypass graft surgery in theory , there is no useful randomized controlled trial to prove the advantage of MIHCR in recent medical papers .In this paper , we reviewed different aspects of MIHCR , such as basic definitions , basic rationale , indications , operation selection and current problems .