title: Robotically assisted hybrid coronary revascularization: does sequence of intervention matter?
abstract: OBJECTIVE
  Hybrid coronary revascularization (HCR) is a treatment strategy for the revascularization of multivessel coronary disease that combines the advantages of both minimally invasive surgical techniques and percutaneous coronary intervention (PCI). The optimal sequence by which revascularization should be accomplished has not been determined. We investigated clinical outcomes in a series of patients planned for HCR via robotically assisted totally endoscopic coronary artery bypass (TECAB) and standard PCI based on revascularization sequence.
  
  
  METHODS
  A total of 238 patients planned for HCR between 2001 and 2011 were divided into three groups based on treatment sequence: (a) TECAB before PCI, (b) PCI before TECAB, and (c) same-session procedure. Multiple procedural and clinical end points before discharge and up to 2 years after the procedure were compared between the three groups in an intention-to-treat analysis. Demographic features were reviewed to determine baseline differences between each group.
  
  
  RESULTS
  Of the 238 patients, 175 (73.5%) underwent TECAB before PCI, 38 patients (16.0%) underwent PCI before TECAB, and 25 (10.5%) underwent a simultaneous revascularization procedure. At baseline, the patients undergoing TECAB before PCI were significantly older. There was a significantly higher incidence of previous myocardial infarction in the PCI-first group (P < 0.001). There was a significant difference in intensive care unit (ICU) length of stay (LOS), with shorter ICU stays in the simultaneous revascularization group (P = 0.031) and shorter hospital LOS in the PCI before TECAB group (P = 0.021).
  
  
  CONCLUSIONS
  In conclusion, revascularization sequence did not dramatically impact clinical outcomes in our observational study. The patients undergoing PCI-first and same-session interventions had shorter hospital and ICU LOS compared with the patients undergoing surgery first. Our findings suggest that no revascularization approach is arbitrarily superior and that revascularization sequence should be individualized on the basis of patient presentation and anatomical considerations.
authors.affiliation: Division of Cardiology, University of Maryland Medical Center, Baltimore, MD 21201, USA. msrivast@medicine.umaryland.edu
authors.forename: Mukta C
authors.initials: MC
authors.lastname: Srivastava
authors.forename: Mark R
authors.initials: MR
authors.lastname: Vesely
authors.forename: Jeffrey D
authors.initials: JD
authors.lastname: Lee
authors.forename: Eric J
authors.initials: EJ
authors.lastname: Lehr
authors.forename: Brody
authors.initials: B
authors.lastname: Wehman
authors.forename: Nikolaos
authors.initials: N
authors.lastname: Bonaros
authors.forename: Thomas
authors.initials: T
authors.lastname: Schachner
authors.forename: Guy J
authors.initials: GJ
authors.lastname: Friedrich
authors.forename: David A
authors.initials: DA
authors.lastname: Zimrin
authors.forename: Johannes O
authors.initials: JO
authors.lastname: Bonatti
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001026:Coronary Artery Bypass / Q000379:methods*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures / Q000379:methods; D062645:Percutaneous Coronary Intervention / Q000379:methods*; D012371:Robotics / Q000379:methods*; D016896:Treatment Outcome