CORONARY ARTERY DISEASE

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1 C 2012, Wiley Periodicals, Inc. DOI: /j x CORONARY ARTERY DISEASE Comparative Study of Same Sitting Hybrid Coronary Artery Revascularization versus Off-Pump Coronary Artery Bypass in Multivessel Coronary Artery Disease WILLIAM B. BACHINSKY, M.D., F.A.C.C., MURAD ABDELSALAM, M.D., GOUTHAMI BOGA, M.D., LUKASZ KILJANEK, M.D., MUBASHIR MUMTAZ, M.D., and CHRISTINE MCCARTY, M.D. From the Writing Group on behalf of the Cardiac Surgery and Interventional Cardiology Groups, Pinnacle Health Cardiovascular Institute, Harrisburg Hospital, Harrisburg, Pennsylvania Objective: We compared the outcomes of same sitting robotic-assisted hybrid coronary artery revascularization (HCR) with off-pump coronary artery bypass grafting (OPCABG) in similar patients with multivessel coronary artery disease. Background: HCR is a novel procedure in selected patients with multivessel coronary artery disease (CAD). Although there are some data on staged HCR, the data on same sitting HCR are limited. Methods: We conducted a prospective study comparing same sitting robotic-assisted HCR patients (n = 25) to a group of consecutive low to moderate risk OPCABG patients (n = 27) during the study period. HCR patients underwent robotic internal mammary artery takedown followed by OPCABG via minithoracotomy. After confirming graft patency, immediate percutaneous coronary intervention on the nonbypass arteries was performed. Comparative analyses were performed on in-hospital and 30 day outcomes. Results: The baseline characteristics were similar for both groups including the severity of CAD (Syntax score 33.5+/ 8.2 vs / 8.2, P = 0.556). Overall MACE was similar between both groups; however, the HCR group showed improved hospital outcomes with lower need for postoperative transfusions (12% vs. 67%, P < 0.001), and shorter length of hospital stay (5.1+/ 2.8 vs. 8.2+/ 5.4 days, P < 0.01). Despite lower postoperative costs, the HCR group had higher overall hospital costs due to higher procedural costs ($33,984 +/ $4,806 vs. $27,816+/ $11,172, P < ). Propensity model analysis showed similar findings. The HCR group showed improved quality of life measures with shorter time to return to work (5.3+/ 3.0 vs. 8.2+/ 4.6 weeks, P = 0.01). Conclusions: Same sitting HCR appears to be feasible and may offer superior outcomes to standard OPCABG, further studies are warranted. (J Interven Cardiol 2012;25: ) Introduction Since its inception over 50 years ago, coronary artery bypass surgery (CABG) has evolved into a common, beneficial procedure with technical advances resulting in reduced risks despite increasing complexity of the patients. 1,2 Significant recent advances have included off-pump CABG and minimally invasive CABG which Address for reprints: William Bachinsky, M.D., F.A.C.C., Pinnacle Health Cardiovascular Institute, Moffitt Heart and Vascular Group, 1000 N. Front St., Wormleysburg, PA Fax: ; bachinsky@comcast.net allows bypass surgery through small anterior thoracotomy incisions. The concept of endoscopic, roboticassisted CABG is one of the newest of the minimally invasive procedures and theoretically imposes the least surgical trauma. 3 However, because of the difficulty in accessing the posterior and lateral aspects of the heart with current systems, complete revascularization is not achievable in many patients with concomitant right coronary artery (RCA) and/or left circumflex disease limiting minimally invasive CABG in patients with multivessel coronary artery disease (MVCAD). Recent advances in percutaneous coronary intervention (PCI) 460 Journal of Interventional Cardiology Vol. 25, No. 5, 2012

2 COMPARATIVE STUDY OF SAME SITTING HYBRID CORONARY ARTERY REVASCULARIZATION including the use of drug-eluting stents have expanded the ability to treat more complex disease and avoidance of CABG in many patients. 4 However, the limitations of PCI compared to left internal mammary artery (LIMA) bypass grafting include possibly reduced longterm patency when applied to the left anterior descending, higher acute and long-term complication rates in some complex subsets, and inability to open some chronically occluded arteries. 5 Hybrid coronary artery revascularization (HCR) potentially offers the best of both worlds. Under this paradigm, patients who are in need of CABG are treated with minimally invasive CABG and PCI in an attempt to avoid standard thoracotomy. Typically, the LIMA is anastomosed to the surgically accessible left anterior descending and/or diagonal artery, and the RCA and/or left circumflex disease are treated with PCI in a staged manner. Patients benefit with smaller incisions, less morbidity, and possibly improved outcomes including earlier hospital discharge and recovery. 6 However, patients often require 2 separate procedures and/or hospitalizations using this stage hybrid method adding to patient inconvenience and hospital/procedural costs. The advent of hybrid operating suites in recent years has allowed for same sitting surgical and endovascular procedures. In a same sitting HCR procedure, depending on coronary anatomy and other factors, the minimally invasive CABG is completed first followed by immediate PCI of the nonbypassed coronary arteries. Several small case series have been published suggesting potential benefit of same sitting HCR procedures This current study attempts to add to the experience assessing the safety and effectiveness of same sitting robotic-assisted minimally invasive CABG performed first followed by immediate PCI. Secondarily, we compared the clinical and quality of life outcomes in-hospital and at 30 days to patients undergoing standard off-pump CABG (OPCBG) during a similar period of time. Methods The study was conducted at a single center with enrollment occurring from September 2009 to March Both HCR and control patients had symptomatic MVCAD (>2 or more major coronary arteries with >50% stenosis) or asymptomatic MVCAD with abnormal stress test. The HCR group met one of the following criteria: 1) complex left anterior descending artery (LAD) and/or diagonal disease that was not amendable to PCI, but suitable for bypass and left circumflex artery (LCx) and/or RCA disease that was amendable to PCI or 2) left main disease with LAD and/or diagonal artery suitable for bypass and LCx and/or RCA disease amenable to PCI. The protocol was approved by the local institutional board and all the patients provided written informed consent. Off-Pump Coronary Artery Bypass Grafting (OPCABG) (Control) Patients. The control group consisted of consecutively treated patients with MV- CAD who underwent OPCABG with standard thoracotomy by the same surgeons performing HCR during the same time period. OPCABG was performed according to practice of health care facility. Control patients with hemodynamic instability need for emergent CABG, or Syntax scores above 60 were excluded from analysis to prospectively control for differences in severity of CAD between patients typically considered for HCR versus OPCABG. Control group patients received antithrombotic medications at the discretion of the treating physician. HCR Patients. HCR patients received Aspirin 325 mg daily prior to the procedure. A 4F common femoral arterial sheath was placed in preparation for the PCI to follow. Heparinized patients (activated clotting time [ACT] above 400 seconds) underwent roboticassisted takedown of the LIMA and/or right internal mammary artery (RIMA) using the Da Vinci Surgical System (Intuitive Surgical, Inc., Mountain View, CA, USA). The target artery for bypass and its collateral branches were identified via extending the anterior chest wall incision. Coronary arteriotomy and bypass graft anastomosis were performed using off-pump CABG techniques according to standard practice. After closure of surgical incisions, an ACT was obtained and heparin or protamine was administered to achieve ACT of approximately 250 seconds. Via the common femoral artery sheath, LIMA angiography was performed to confirm patency. The femoral sheath was then exchanged for a larger sheath (6 8F) and PCI was performed using either Vision (bare metal) and/or Xience (drug-eluting) coronary stents (Abbott Vascular, Inc., Santa Clara, CA, USA) at the discretion of the investigators. At the conclusion of the PCI, protamine was administered if needed to achieve an ACT below 200 seconds in order to minimize postoperative bleeding. Clopidogrel mg (Ticlopidine or Prasagrel in clopidogrel allergic patients) was administered following PCI orally or via nasogastric tube, provided that the thoracic drainage outputs were <100 cc/hour. Vol. 25, No. 5, 2012 Journal of Interventional Cardiology 461

3 BACHINSKY, ET AL. Antiplatelet therapy consisted of an indefinite duration of aspirin, along with minimum of 1 month (for bare metal stents) or 12 months (for drug-eluting stents) of dual antiplatelet therapy at the discretion of the treating physician. Clinical Evaluation and Follow-Up. Prior to the procedures, all patients completed a SF-12 quality of life questionnaire. 11 Demographics, preoperative risk factors and medications, and intraoperative and postoperative events were recorded by research nurses/assistants. All patients were followed daily until the end of their hospital stay and 30-day clinical follow-up occurred via phone conversation or office visit at 30 days. A 10-point peak pain assessment was obtained as recorded by staff nursing and the patient at time of discharge (0 no pain to 10 worst pain ever experienced) along with a 6-point overall satisfaction score (0 dissatisfied to 6 completely satisfied) at discharge. SF-12 quality of life questionnaire was completed at 30 days and time to work/normal activities postdischarge was obtained. Coronary angiograms were analyzed for Syntax score 12 preprocedure. Patient mortality risk scores were calculated using the Society of Thoracic Surgeons Predicted Operative Mortality Score (STS Score). 13 End-Points. The primary end-point of this study was to test safety and effectiveness of same sitting HCR in the treatment of obstructive MVCAD. A secondary objective was a comparative study of consecutive patients undergoing nonemergent OPCABG during the study period with low to moderate Syntax scores including in-hospital and 30-day events of bleeding (defined as need for any postprocedure red blood cell transfusions), repeat revascularization, new postoperative atrial fibrillation, stroke, myocardial infarction (MI), and death. Postprocedure MI was defined as 5X upper limit of normal of either CK- MB or troponin I level or definitive new Q-waves on ECG. Stent thrombosis was defined by Academic Research Consortium criteria 14 and Fitzgibbon graft patency grading 15 was used to describe intraoperative LIMA patency ((A) patent, no obstruction, (B) mild obstruction, <50%, and (C) severe obstruction/occlusion) in the HCR group. Complete revascularization was defined as revascularization of all epicardial vessels ( 2.5 mm diameter with 50% diameter stenosis) supplying viable myocardium. Length of stay in the intensive care unit/hospital and intubation status postprocedure along with pain and satisfaction scoring in hospital and at 30 days were analyzed. Data Safety Monitoring Board was composed of an interventional cardiologist and cardiovascular surgeon who were independent and were not participating in the trial. Statistical Analysis. For comparison of continuous variables between the 2 treatment groups, the unpaired two-tailed Student s t-test was used. Those variables with normal distribution were expressed as mean ± SD. Those variables with skewed distribution were logarithmically transformed for statistical analysis and were expressed as medians and interquartile range. Comparison of categorical variables and the 30- day composite end-point between the 2 groups was expressed as proportion and percentages. All tests were two-tailed,andapvalueof <0.05 was considered to indicate statistical significance. Additional analyses were carried out adjusting for baseline covariates for which significant between-group differences were observed with propensity score of case-controlled model. The SAS software (SAS Institute, Inc., Cary, NC, USA) was used and the authors vouch for the completeness and veracity of the data and data analyses. Results Baseline Characteristics. From September 2009 to March 2011, 25 patients underwent HCR during which time consecutively 27 patients underwent elective OPCABG (Syntax score of less than 60) with baseline characteristics, as shown in Table 1. The groups were similar in most of the baseline clinical categories including similar Syntax scores reflecting the severity of CAD (33.52 ± 8. vs ± 8.2, P = 0.556) and left ventricular function (55.3 ± 10.4 vs ± 12, P = 0.343). The predicated surgical mortality based on STS score was slightly lower in the HCR group versus OPCABG groups (0.46 ± 0.24 vs ± 0.93, P = 0.012), likely related to higher percentages of female gender and history of hypertension and/or previous MI in the control group. Revascularization Procedural Outcomes. The HCR procedure typically involved LIMA bypass to the LAD (and/or diagonal) with PCI of the non-laddiseased arteries, as seen in Figure 1. The HCR procedural outcomes were excellent with all cases performed at the same sitting and with 100% procedural success (Table 2). LCx lesions were the most commonly treated lesions (62%) during the HCR procedure. Approximately 70% of patients received at least one drug-eluting stent and the majority of the lesions 462 Journal of Interventional Cardiology Vol. 25, No. 5, 2012

4 COMPARATIVE STUDY OF SAME SITTING HYBRID CORONARY ARTERY REVASCULARIZATION Table 1. Preoperative Characteristics Hybrid Control N +/ SD N +/ SD Characteristics or N (%) or N (%) P value Patient N = 25 N = 27 demographic data Age (yrs) / / Male gender 20(80%) 16(59%) BMI (kg/m 2 ) / / Smoking 7(28%) 6(22%) Diabetes 9(36%) 13(48%) Dyslipidemia 20(80%) 23(85%) Pre-op creatinine 1 +/ / (mg/dl) Hypertension 18(72%) 26(96%) Chronic lung 0(0%) 2(7%) disease PVD 3(12%) 3(11%) CVD 1(4%) 4(15%) Previous PCI 5(20%) 6(22%) Previous MI 5(20%) 12(44%) Pre-op ejection / / fraction (%) CHF 0(0%) 5(19%) USA/MI 8(32%) 10(37%) Preoperative medications Beta blockers 23(92%) 23(85%) ACE-inhibitors 8(35%) 9(38%) Aspirin 23(92%) 25(93%) 0.99 Antilipids 16(64%) 20(74%) 0.55 Risk scores Syntax score / / STS score / / Data are presented as mean (SD) or N (%). Society of Thoracic Surgeons. BMI = Body mass index; PVD = peripheral vascular disease; CVD = cerebrovascular disease; CHF = congestive heart failure; MI = myocardial infarction; USA = unstable angina; PCI = percutaneous coronary intervention. treated were class B2 or lower. The majority of patients achieved grade A intraoperative LIMA patency. There were no observed acute or 30-day in-stent thrombosis events. In the OPCAB group, the mean number of grafts was 3.4 per patient and there were no obvious cases of acute graft thrombosis based on clinical evaluation as angiography was not performed. In-Hospital and 30-Day Clinical Outcomes. As seen in Table 3, there was no statistical significant difference between the groups in terms of Q-wave MI, CVA, repeat revascularization, and death, with similar achievement of complete revascularization (70% vs. 86%, P = 0.999). The operative times were longer in the HCR group (386 ± 49.4 vs. 261 ± 36.8 minutes, P < ) due to the robotic-assisted bypass portion of the procedure. The HCR group was more frequently extubated in the operating room (68% vs. 22%, P = ) and experienced shorter length of ICU and hospital days (28.5 ± 13.9 vs ± 84.7 hours, P = , 5.1± 2.8 vs ± 5.4 days, P = ), respectively. Postoperatively, non-qwave MI occurred more frequently in the control group (92% vs. 60%, P = ), with a trend toward higher incidence of new postoperative atrial fibrillation (30% vs. 16%, P = ) as well. HCR patients were less likely to require any blood products (12% vs. 67%, P = 0.002) despite the use of dual antiplatelet therapy in all patients following their procedure. When controlling for differences in baseline characteristics, time in the operating room and need for blood transfusions and non-q-wave MI remained significantly different between the 2 groups. Hospital Cost Data. There were significantly higher intraoperative costs among HCR group ($29,593 +/ $4,384 vs. $18,032 +/ $2,148, P < ), largely due to the PCI procedure and longer operative times (Fig. 2). However, postoperative costs were lower in the HCR group than OPCAB group ($4,391 +/ $1,726 vs. $9,783+/ $10,906, P < 0.001) due to shorter ICU and hospital stays. Despite these savings, there were higher total hospital costs in the HCR group ($33,984 +/ $4,806 vs. $27,816 +/ $11,172, P < ). Patient Satisfaction Data. Using a 10-point peak pain assessment, there was no statistically significant difference between HCR group and OPCABG group in pain severity both when assessed by nursing staff during hospitalization and by patients on discharge (7.58 ± 1.6 vs. 7.4 ± 1.8, P = 0.753, 7.48 ± 2.5 vs. 6.4 ± 2.6, P = 0.156), respectively (Table 4). Patient s satisfaction data were assessed using 6-point overall satisfaction scale at discharge and 30 days. There was no statistically significant difference between study groups (5.46 ± 0.7 vs. 5.8 ± 0.8, P = 0.577). However, quality of life using SF-12 at 30 days was better in the HCR group (physical QOL score 32.8 ± 10.4 vs ± 10.3, P = 0.009). Figure 3 illustrates the time to return to work and/or normal activity based on time quartiles. Forty percent of patients from the HCR group and only 22% of OPCABG patients were back at work and/or normal activity at the end of 4th week. The majority of HCR group (88%) achieved this goal by the end of 8th week in contrast to only 59% of the OPCABG Vol. 25, No. 5, 2012 Journal of Interventional Cardiology 463

5 BACHINSKY, ET AL. Figure 1. Patient with severe LAD/LCx disease and noncritical RCA disease (not shown) pre- and post-hcr procedure. (A) and (B) Preprocedure angiograms. (C) Immediate post-pci of LCx with mm Xience drug-eluting stent. (D) Sequential LIMA bypass graft to the DIAG-LAD intraoperative angiogram. group. The average times to return to work and/or normal activity were shorter in the HCR versus OPCABG patients (8.2 +/ 4.6 vs / 3.0 weeks, P = 0.01). Discussion The combination of coronary artery revascularization by both surgical and percutaneous intervention was first described in mid 1990s by Angelini and colleagues. 16 Since that time, recent advances in robotic technologies and increasing availability of hybridoperating facilities have made HCR procedures more feasible. Patients benefit with smaller incisions, less morbidity, and possibly improved outcomes including earlier hospital discharge and recovery. 6 However, patients often require 2 separate procedures and/or hospitalizations using this stage hybrid method adding to patient inconvenience, potential safety of delaying revascularization, lack of immediate confirmation of graft patency, and hospital/procedural costs. Same sitting HCR procedures offer patients a single intervention with reduced hospital stay compared to a staged HCR during a single hospital stay or a staged HCR procedure requiring 2 hospital stays We believe that this is the preferred approach as any issue with 464 Journal of Interventional Cardiology Vol. 25, No. 5, 2012

6 COMPARATIVE STUDY OF SAME SITTING HYBRID CORONARY ARTERY REVASCULARIZATION Procedural Success Table 2. Hybrid Procedural Data # of lesions treated (n = 25) 1 56% (n = 14) 2 20% (n = 5) 3 24% (n = 6) Lesion location LAD 2% (n = 1) LCx 62% (n = 26) RCA 34% (n = 14) LM 2% (n = 1) Lesion type (n = 42) A 14% (n = 6) B1 26% (n = 11) B2 50% (n = 21) C 10% (n = 4) Total stent length/lesion 19.2 mm DES% (Xience V) 71% (n = 42) LIMA patency grade A 96% (n = 24) LAD = Left anterior descending artery; LM = left main coronary artery; LCx = left circumflex artery; RCA = right coronary artery; DES = drug-eluting stent(s); LIMA = left internal mammary artery. either revascularization procedure can be resolved in one setting. The largest reported experience with same sitting HCR has been published by Hu 10 on 104 patients compared with a propensity-matched subset of OPCABG patients. Patients underwent ministernotomy without robotic assistance, followed by immediate PCI after confirmation of LIMA patency. Compared with OP- CABG patients, the HCR group showed similar results to our current study with shorter hospital/icu stays, intubation times, and lower overall bleeding rates (28.8 vs. 51.9% of the HCR vs. OPCABG patients required blood transfusions). There were no acute/subacute stent thrombosis events, similar to our experience. Reicher 8 reported similar reduction in postoperative bleeding rates in 13 patients undergoing same sitting HCR with no reported acute stent thromboses. In contrast, Zhao and colleagues did report 1 episode of acute stent thrombosis in their series of 112 same sitting HCR procedures. 9 Thus far, the rates of acute/subacute stent thrombosis during same sitting HCR seem similar to the experience with PCI in patients with complex subsets. 4 The procedural outcomes in our current study were excellent with intraoperative angiographic patency grade A in 96% of the HCR patients and successful PCI procedures in all patients, similar to experience of other investigators The long-term benefits of a LIMA graft to the LAD have been well documented in patients with complex LAD disease. 2,5,17 However, whether non-lad vessels are best treated with saphenous vein grafts (SVGs), PCI or other modalities is controversial and likely depends on complex issues including lesion characteristics and vessel size. Failure rates for SVGs have been reported Table 3. Hospital and 30-Day Outcomes Hybrid Control Standard Propensity Model Outcome N +/ SD or % N +/ SD or % P Value Adjusted P Value Number of patients MACE (30 days) Q-wave MI 0 (0%) 0 (0%) CVA 0 (0%) 0 (0%) Revascularization 0 (0%) 0 (0%) Death 0 +/ 0% 1 (4%) Complete revascularization 17 (86%) 19 (70%) Total time in operating room (minutes) 386 +/ / 36.8 < < Extubated in operating room 17 (68%) 6 (22%) Length of ICU stay (hours) / / Length of hospitalization (days) 5.1 +/ / Need for any blood transfusion 3 (12%) 18 (67%) <0.001 <0.001 Blood transfusions (avg. units/patient) / / 2 < Troponin level POD #1 (mg/dl) 0.8 +/ / Non-Q-wave MI 15 (60%) 24 (92%) New postoperative atrial fibrillation 4 (16%) 8 (30%) Data are presented as mean (SD) or N (%). Adjusted for Syntax score, STS score, and comorbidities. MACE = Major adverse cardiovascular events; Q-wave MI = Q-wave myocardial infarction; CVA = cerebrovascular accident; POD = postoperative day. Vol. 25, No. 5, 2012 Journal of Interventional Cardiology 465

7 BACHINSKY, ET AL. Figure 2. Despite a significant decrease in postoperative costs in the hybrid group (P < 0.001), total average costs were lower in the OPCAB group ($33,984 +/ $4,806 vs. $27,816 +/ $11,172, P < ) due to higher operative costs incurred in the hybrid group. Table 4. Patient Satisfaction Data Control P value Parameter Hybrid N +/ SD N +/ SD Number of patients Peak pain assessed 7.4 +/ / by nursing Peak pain assessed 6.4 +/ / by patient Overall 5.5 +/ / days SF / / days (physical) SF days (mental) 52 +/ / Scale 0 10 (least->most); scale 0 6 (least->most). to range from 10 21% in some reports. 15,18,19 With appropriate case selection, restenosis rates in non-lad lesions have been acceptably low in patients treated with bare metal stents and DES including patients with diabetes and complex lesions. 4,20,21 Furthermore, SVG failure is often not treatable, whereas repeat PCI is an option in most patients with restenosis of a stent. These potential advantages of PCI form the fundamental basis for HCR in the treatment of multivessel CAD. As expected, the low-risk OPCABG patients had similar MACE to the HCR group in our study. Although the rates of Q-wave MI were not different between the 2 groups in our study, we did find significantly lower cardiac enzyme elevation along with postoperative atrial fibrillation possibly related to the less invasive nature of HCR. In the series by Kon and colleagues, 7 the same sitting HCR group had significantly lower levels of prothrombin fragment 1.2, activated Factor X11, myoglobin, and interleukin 8, suggesting lower levels of thrombin formation, intrinsic coagulation, ischemia, and inflammation, respectively, compared with the control OPCABG group. However, rates of postoperative atrial fibrillation were not lower in the same sitting HCR group versus standard OP- CABG patients in the study by Hu. 10 Reicher and colleagues 8 reported similar hospitalization cost data to our HCR group in their same sitting HCR study. However, the OPCAB group in their study had substantially higher postoperative costs resulting in a nonsignificant increase in total costs among both groups. We believe that as the surgical experience increases, operative costs in the HCR group will decline over time due to reduction in OR times. This, coupled with shorter hospital stays, will likely result in cost benefit in the HCR-treated patients. 466 Journal of Interventional Cardiology Vol. 25, No. 5, 2012

8 COMPARATIVE STUDY OF SAME SITTING HYBRID CORONARY ARTERY REVASCULARIZATION Figure 3. Time to return to work and/or normal activity. Cochran Armitage exact trend test. Regarding patient satisfaction, previous studies have suggested that patients undergoing MIDCAB procedures experience no advantage with regard to postoperative pain compared to conventional CABG. 22 This was similar to our pain score data between the 2 groups. Nevertheless, HCR patients in our study demonstrated superior satisfaction data and returned to work and/or normal activity several weeks sooner than the OP- CABG controls. This is similar to the experience of Kon 7 who found HCR patients returned to these activities, on average, 2.1 months sooner than matched control OPCABG patients. There are several important limitations of our current study. First, the findings are based on a small number of patients in this nonrandomized, observational study. Second, despite the control group consisting of consecutive, nonemergent, and low-risk OPCABG patients, the overall STS scores were higher than the HCR group likely having some effect on outcomes. Third, the perception both among patients and hospital staff that quicker recovery is expected in patients undergoing less invasive surgeries could possibly lead to different expectations postoperatively compared to patients undergoing the conventional OPCABG. Finally, these results cannot be extrapolated to patients undergoing HCR in a staged fashion. In conclusion, our report supports that same sitting hybrid robotic-assisted CABG and percutaneous coronary intervention in the treatment of obstructive MV- CAD is a potentially safe and effective option in selected patients with multivessel CAD. HCR may offer superior clinical and patient satisfaction outcomes to conventional CABG. Further prospective randomized studies are needed to help identify the ideal candidates for this hybrid approach and assess the long-term outcomes of this relatively new method of revascularization in patients with MVCAD. Acknowledgments: The authors would like to thank the following contributing authors: Michael Bosak, M.D., F.A.C.C.; David Chang, M.D., F.A.C.C.; Felix Gutierrez, M.D., F.A.C.C.; C. Randolph Hubbard, M.D., F.A.C.C.; Steven Jones, M.D., F.A.C.C.; Brij Maini, M.D., F.A.C.C.; Arthur Martella, M.D.; Kenneth May, M.D., F.A.C.C.; Robert Martin, M.D., F.A.C.C.; Thach Nguyen, M.D., F.A.C.C.; Keith Rice, M.D., F.A.C.C.; Alymer Tang, M.D., F.A.C.C.; Andreas Wali, M.D., F.A.C.C.; Susan Reilly, R.N., B.S.N.; Anita Todd, R.N., C.C.R.C.; Tammy Whitaker, N.R.-C.M.A., C.C.R.C.; and Grants: Investigator sponsored study grant from Abbott Vascular, Santa Clara, CA. References 1. Mueller RL, Rosengart TK, Isom OW. The history of surgery for ischemic heart disease. Ann Thorac Surg 1997;63: Mohan R, Amsel BJ, Walter PJ. Coronary artery bypass grafting in the elderly: A review of studies on patients older than 64, 69 or 74 years. Cardiology 2002;80: LaPietra A, Grossi EA, Derivaux CC, et al. Robotic-assisted instruments enhance minimally invasive mitral valve surgery. Ann Thorac Surg 2000;70: King SB, Smith SC, Hirshfeld JW, et al focused update of the ACC/AHA/SCAI 2005 guideline update for percutaneous coronary intervention. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2008;117: Etienne P, Glineur D, Papadatos S, et al. Comparison of minimally invasive direct coronary artery bypass surgery with implantation of drug-eluting stents in patients with left anterior descending coronary artery disease. Innovations 2009;4(6): Bonatti J, Lehr E, Vesely MR, et al. Hybrid coronary revascularization techniques and outcome. Eur Surg 2011;43(4): Vol. 25, No. 5, 2012 Journal of Interventional Cardiology 467

9 BACHINSKY, ET AL. 7. Kon Z, Brown E, Tran R, et al. Simultaneous hybrid coronary revascularization reduces postoperative morbidity compared with results from conventional off-pump coronary artery bypass. J Thorac Cardiovasc Surg 2008;135: Reicher B, Poston RS, Mehra MR, et al. Simultaneous hybrid percutaneous coronary intervention and minimally invasive surgical bypass grafting: Feasibility, safety, and clinical outcomes. Am Heart J 2008;155(4): Zhao D, Leacche M, Balaguer JM, et al. Routine intraoperative completion angiography after coronary artery bypass grafting and 1-stop hybrid revascularization. J Am Coll Cardiol 2009;69: Hu S, Li Q, Gao P, et al. Simultaneous hybrid revascularization versus off-pump coronary artery bypass for multivessel coronary artery disease. Ann Thorac Surg 2010;91: Spertus JA, Winder JA, Dewhurst TA, et al. Development and evaluation of the Seattle Angina questionaire: A new functional status measure for coronary artery disease. J Am Coll Cardiol 1995;25: Sianos G, Morel MA, Kappetein AP, et al. The SYNTAX score: An angiographic tool grading the complexity of coronary artery disease. Eurointervention 2005;1: Edwards FH, Grover FL, Shroyer AL, et al. The Society of Thoracic Surgeons National Cardiac Surgery Database: Current risk assessment. Ann Thorac Surg 1997;63: Mauri L, Hsieh WH, Massaro JM, et al. Stent thrombosis in randomized clinical trials of drug-eluting stents. N Engl J Med 2007;356: Fitzgibbon GM, Burton JR, Leach AJ, et al. Coronary bypass graft fate: Angiographic grading of 1400 consecutive grafts early after operation and of 1132 after one year. Circulation 1978;57(6): Angelini GD, Wilde P, Salerno TA, et al. Integrated left small thoracotomy and angioplasty for multivessel coronary artery revascularization. Lancet 1996;347: Loop FD, Lytle BW, Cosgrove DM, et al. Influence of the internal-mammary-artery graft on 10-year survival and other cardiac events. N Engl J Med 1986;314: Desai ND, Cohen EA, Naylor CD, et al. A randomized comparison of radial artery and saphenous vein coronary bypass grafts. N Engl J Med 2004;351: Yun KL, Wu Y, Aharonian V, et al. Randomized trial of endoscopic versus open vein harvest for coronary artery bypass grafting: Six-month patency rates. J Thorac Cardiovasc Surg 2005;129: Wiemer M, Serrys P, Miquel-Hebert K, et al. Five-year longterm clinical follow-up of the XIENCE V everolimus eluting coronary stent system in the treatment of patients with de novo coronary artery lesions: The SPIRIT FIRST trial. Catheter Cardiovasc Interv 2010;75: Kappetein AP, Feldman TE, Mack MJ, et al. Comparision of coronary bypass surgery with drug-eluting stenting for the treatment of left main and/or three-vessel disease: 3-year follow-up of the SYNTAX trial. Eur Heart J 2011;32: Diegeler A, Walther T, Metz S, et al. Comparison of MIDCAB versus conventional CABG surgery regarding pain and quality of life. Heart Surg Forum 1999;2(4): Journal of Interventional Cardiology Vol. 25, No. 5, 2012

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