title: Hybrid revascularization strategy: a pilot study on the association of robotically enhanced minimally invasive direct coronary artery bypass surgery and fractional-flow-reserve-guided percutaneous coronary intervention.
abstract: BACKGROUND
  Robotically enhanced minimally invasive direct coronary artery bypass (RE-MIDCAB) graft of the left internal mammary artery to the left anterior descending coronary artery (LAD) and/or the first diagonal branch might be the least traumatic surgical revascularization approach available so far. When combined with fractional flow reserve (FFR)-guided percutaneous coronary intervention (PCI) in the non-LAD vessels, this "hybrid" strategy takes advantage of the survival benefit conferred by the internal mammary artery graft to the LAD while providing the patients with a truly minimally invasive, functionally complete revascularization.
  
  
  RESULTS
  Twenty patients with multivessel disease were selected to undergo combined PCI and RE-MIDCAB because they had a lesion amenable to PCI in the right and/or the left circumflex coronary artery and a lesion in the LAD and/or the first diagonal branch that was considered less than ideal for PCI. PCI was actually performed only when FFR was <0.80 ("provisional PCI"). In 7 stenoses, FFR was >0.80 and the planned PCI was not performed. Surgery was performed before provisional PCI in 6 cases. An angiogram was obtained in all patients before discharge, and a complete clinical follow-up including a stress test was obtained in all patients after a mean of 12 months. There were no significant intraoperative complications, conversions to cardiopulmonary bypass, or reinterventions for bleeding. At early control angiogram, 2 moderate stenoses just proximal to anastomosis were observed, both with normal run-off. After 12 months there were no objective signs of ischemia at stress testing. After an average follow-up of 19+/-10 months there were no deaths, myocardial infarctions, or repeat revascularizations.
  
  
  CONCLUSIONS
  A hybrid strategy combining FFR-guided PCI and RE-MIDCAB seems safe and provides selected patients with a functionally complete revascularization with minimal surgical trauma and excellent clinical outcomes.
authors.affiliation: Department of Cardiovascular and Thoracic Surgery, OLV Clinic, Aalst, Belgium.
authors.forename: Giedrius
authors.initials: G
authors.lastname: Davidavicius
authors.forename: Frank
authors.initials: F
authors.lastname: Van Praet
authors.forename: Samer
authors.initials: S
authors.lastname: Mansour
authors.forename: Filip
authors.initials: F
authors.lastname: Casselman
authors.forename: Jozef
authors.initials: J
authors.lastname: Bartunek
authors.forename: Ivan
authors.initials: I
authors.lastname: Degrieck
authors.forename: Francis
authors.initials: F
authors.lastname: Wellens
authors.forename: Raf
authors.initials: R
authors.lastname: De Geest
authors.forename: Hugo
authors.initials: H
authors.lastname: Vanermen
authors.forename: William
authors.initials: W
authors.lastname: Wijns
authors.forename: Bernard
authors.initials: B
authors.lastname: De Bruyne
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D015906:Angioplasty, Balloon, Coronary / Q000379:methods*; D017023:Coronary Angiography; D003327:Coronary Disease / Q000601:surgery / Q000628:therapy*; D005080:Exercise Test; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007387:Internal Mammary-Coronary Artery Anastomosis / Q000295:instrumentation / Q000379:methods*; D008297:Male; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures; D010865:Pilot Projects; D011183:Postoperative Complications / Q000453:epidemiology; D012371:Robotics; D013908:Thoracotomy / Q000379:methods; D016896:Treatment Outcome