title: Advanced hybrid closed chest revascularization: an innovative strategy for the treatment of multivessel coronary artery disease†.
abstract: OBJECTIVE
  Conventional hybrid revascularization (CHR) combines minimally invasive placement of an internal mammary artery graft to the anterior wall and percutaneous coronary intervention (PCI) of non-anterior wall targets. In this study we assess perioperative and midterm outcomes of advanced hybrid revascularization (AHR) defined as the combination of single or multivessel (MV) totally endoscopic coronary artery bypass grafting (TECAB) with single or multivessel PCI.
  
  
  METHODS
  In total, 90 AHR patients [median age 62 years (35-86)] were compared with 90 CHR patients [median age 60 years (35-85)] in terms of perioperative and mid-term outcomes. The outcomes of the three different AHR options (MV-TECAB + PCI, MV-PCI + TECAB, MV-TECAB + MV-PCI) as well as the sequence of the interventions were further compared. Risk factors for major adverse cardiac and cerebral events (MACCEs) related to the hybrid revascularization strategy were calculated.
  
  
  RESULTS
  No perioperative deaths occurred either in the AHR group or in the CHR group, rates of myocardial infarction (3.3% vs 3.3%, P = 0.196) were similar between CHR and AHR. Operative times were longer in the AHR group [337 (137-794) min vs 272 (148-550) min, P = 0.002] and conversion rates slightly higher (P = 0.060); however, intensive care unit length of stay (P = 0.162) and hospital length of stay (P = 0.238) were similar. There was no difference in the follow-up survival (P = 0.091), freedom from angina (P = 0.844), PCI target vessel revascularization (P = 0.563), TECAB target vessel revascularization (P = 0.135) and MACCEs (P = 0.601) between CHR and AHR at follow-up. No differences were detected between the three variations of AHR in perioperative outcome, mid-term survival, freedom from MACCEs and reintervention. Neither the number nor type of TECAB/PCI targets, nor the sequence of interventions were significant predictors for MACCEs at follow-up.
  
  
  CONCLUSIONS
  AHR yields comparable results with CHR and can be taken into consideration as a sternum-sparing technique for the treatment of MV-coronary artery disease in selected patients.
authors.affiliation: Department of Cardiac Surgery, Innsbruck Medical University, Innsbruck, Austria nikolaos.bonaros@i-med.ac.at.
authors.forename: Nikolaos
authors.initials: N
authors.lastname: Bonaros
authors.affiliation: Department of Cardiac Surgery, Innsbruck Medical University, Innsbruck, Austria.
authors.forename: Thomas
authors.initials: T
authors.lastname: Schachner
authors.affiliation: Department of Cardiac Surgery, Innsbruck Medical University, Innsbruck, Austria.
authors.forename: Markus
authors.initials: M
authors.lastname: Kofler
authors.affiliation: Department of Cardiac Surgery, Swedish Medical Center, Seattle, USA.
authors.forename: Eric
authors.initials: E
authors.lastname: Lehr
authors.affiliation: Department of Cardiac Surgery, University of Maryland, MD, USA.
authors.forename: Jeffrey
authors.initials: J
authors.lastname: Lee
authors.affiliation: Department of Cardiology, University of Maryland, MD, USA.
authors.forename: Mark
authors.initials: M
authors.lastname: Vesely
authors.affiliation: Department of Cardiology, University of Maryland, MD, USA.
authors.forename: David
authors.initials: D
authors.lastname: Zimrin
authors.affiliation: Department of Cardiology, Innsbruck Medical University, Innsbruck, Austria.
authors.forename: Gudrun
authors.initials: G
authors.lastname: Feuchtner
authors.affiliation: Department of Radiology, Innsbruck Medical University, Innsbruck, Austria.
authors.forename: Guy
authors.initials: G
authors.lastname: Friedrich
authors.affiliation: Heart and Vascular Institute Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE.
authors.forename: Johannes
authors.initials: J
authors.lastname: Bonatti
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003324:Coronary Artery Disease / Q000601:surgery*; D006801:Humans; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures / Q000009:adverse effects / Q000379:methods*; D062645:Percutaneous Coronary Intervention / Q000009:adverse effects / Q000379:methods*; D011183:Postoperative Complications / Q000209:etiology; D012189:Retrospective Studies; D012307:Risk Factors; D065287:Robotic Surgical Procedures / Q000009:adverse effects / Q000379:methods*; D016896:Treatment Outcome
keywords: Coronary artery disease; Hybrid coronary revascularization; Minimally invasive cardiac surgery; Percutaneous coronary intervention; Robotics