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Robotically assisted hybrid coronary revascularization: does sequence of intervention matter?
Mukta C Srivastava1, Mark R Vesely, Jeffrey D Lee
1Division of Cardiology, University of Maryland Medical Center, Baltimore, MD 21201, USA. msrivast@medicine.umaryland.edu
Insights
Hybrid coronary revascularization sequence did not significantly alter patient outcomes. Performing percutaneous coronary intervention (PCI) before or during surgery led to shorter hospital stays, suggesting individualized treatment approaches for coronary artery disease.
Area of Science:
- Cardiology
- Cardiovascular Surgery
- Interventional Cardiology
Background:
- Hybrid coronary revascularization (HCR) combines minimally invasive surgery and percutaneous coronary intervention (PCI) for multivessel coronary disease.
- The optimal sequence for HCR procedures remains undetermined.
- Robotically assisted totally endoscopic coronary artery bypass (TECAB) is a surgical component of HCR.
Purpose of the Study:
- To investigate clinical outcomes based on the revascularization sequence in patients undergoing HCR.
- To compare outcomes between TECAB-first, PCI-first, and same-session HCR procedures.
Main Methods:
- An observational study of 238 patients planned for HCR between 2001 and 2011.
- Patients were grouped by revascularization sequence: TECAB before PCI, PCI before TECAB, or same-session.
- Clinical endpoints and procedural outcomes were compared up to 2 years post-procedure.
Main Results:
- 73.5% underwent TECAB before PCI, 16.0% PCI before TECAB, and 10.5% same-session.
- The PCI-first group had a higher incidence of previous myocardial infarction.
- Simultaneous revascularization was associated with shorter ICU length of stay (LOS), and PCI-first with shorter overall hospital LOS.
Conclusions:
- Revascularization sequence did not dramatically impact overall clinical outcomes in this observational study.
- PCI-first and same-session approaches resulted in shorter hospital and ICU LOS compared to surgery-first.
- Individualized HCR sequencing based on patient factors and anatomy is recommended.
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.
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