Traditional Coronary Artery Bypass Grafting Research Articles

Abstract 4137855: Hybrid Coronary Revascularization versus Traditional Coronary Artery Bypass Grafting for Left Main Disease

Background: The current guideline-recommended intervention for left main (LM) disease is coronary artery bypass grafting (CABG). Hybrid coronary revascularization (HCR) combines robotic coronary artery bypass and percutaneous coronary intervention (PCI) and offers a less invasive approach for patients with LM and multivessel coronary artery disease. We aim to compare clinical outcomes at 30 days, 6 months and 1 year between HCR and CABG in patients with LM disease. Methods: We retrospectively screened 761 patients who underwent bypass for LM disease between 2019 and 2023 at a single institution. A total of 118 patients who underwent either HCR (n=59) or CABG (n=59) were included after propensity matching for baseline characteristics. The primary endpoint was major adverse cardiovascular events (MACE), defined as death, myocardial infarction, repeat revascularization and stroke, at 30 days, 6 months and 1 year, which was assessed using chi-squared tests. Secondary outcomes are individual components of MACE at 30 days, 6 months and 1 year. Kaplan-Meier curves were used to visualize the difference in 1-year cumulative MACE-free survival across groups coupled with a log-rank test. Results: The mean age was 68.93±11 years for HCR patients and 68.41±10.11 years for CABG patients (p=0.394). SYNTAX score was high (> 33) for 49.1% of HCR patients and 67.3% of CABG patients (p=0.15). Hospital length of stay was shorter for HCR compared to CABG (4.07 ± 1.21 days vs. 7.58 ± 7.71 days, p<0.001). MACE events were significantly lower in the HCR group at 30 days (0% vs 10.2%; p=0.01), 6 months (0% vs 17%; p=0.002) and 1 year (2.4% vs 20.5%; p=0.01). The cumulative MACE-free survival at 1 year was significantly higher in the HCR group (p=0.007). There were no significant differences in secondary outcomes at any time point with the exception of lower repeat revascularization at 6 months in the HCR group (0% vs 10.9%; p=0.02). Conclusion: This retrospective study demonstrates that HCR is a viable alternative to CABG for LM disease. While randomized clinical trial data is still needed, this less invasive approach is a promising treatment strategy for patients with high surgical risk.

Medium and long-term patency results of distal anastomosis connectors: a meta-analysis.

The difficulty of suturing perfect anastomoses in limited-access conditions prevents the transition of traditional coronary artery bypass grafting (CABG) to sternal-sparing approaches, even in the robotic era. Automated coronary anastomotic connector technologies may address these difficulties, but to date, none have achieved broad adoption. Besides versatility, ease-of-use and cost-effectiveness, the key performance parameter of such technology is anastomotic patency. In this meta-analysis, we aim to evaluate published connector devices by examining their patency outcomes in distal anastomoses. The literature was systematically searched for studies comparing the angiographic patency of connector constructed coronary anastomoses to handsewn (HS) connections in adult patients undergoing CABG. The primary outcome was anastomosis patency across early (<30 days), mid-term (30 days to 1 year) and long-term (>1 year) follow-up. Random-effects meta-analyses were employed to analyze and compare patency using pooled risk ratios (RR) with 95% confidence intervals (CI). The search yielded 14 studies concerning eight connector devices. In 4,311 patients, a total of 4,328 anastomoses were constructed, 674 with connector devices and 3,654 with a HS technique. The pooled device patency over all timeframes was non-inferior to the HS technique (RR 0.90, 95% CI: 0.56-1.44). Technologies having a relatively large blood-exposed non-intimal surface area (BENIS, >15 mm2) performed acceptably when applied to large target vessels [>2.0-2.5 mm inner diameter (ID)]. A tiny anastomotic orifice area (AOA, < ca. 4 mm2) appeared to adversely affect results. Technologies realizing a generous AOA in combination with a limited BENIS showed superior results and applicability by performing well across the entire range of target coronary artery diameters (>1.0-1.5 mm ID). The overall results suggest that connectors yield at least non-inferior anastomosis patency outcomes compared to HS techniques in all observed timeframes. Optimizing device characteristics like BENIS and AOA appear fundamental for broad applicability.

Robotic-assisted coronary artery bypass grafting: how I teach it.

The first robotic cardiac operation was performed more than two decades ago. This paper describes the distinct steps and components necessary for teaching robotic-assisted minimally invasive direct coronary artery bypass (R-MIDCAB). It also provides a general overview of the surgical robotic setup and ways to troubleshoot potential complications. The focus of robotic training is not only on the surgeon but includes an entire dedicated cardiac team and administrative institutional support. This team approach ensures that R-MIDCAB can be performed safely and reproducibly. Meticulous planning, incremental learning, and teamwork are the main factors leading to program success and optimal patient outcomes. Robotic-assisted internal mammary artery (IMA) harvesting and coronary revascularization via a small, anterior mini-thoracotomy has provided an alternative to sternotomy in selected patients with coronary artery disease (CAD). Benefits include less postoperative atrial fibrillation, fewer blood transfusion, less time in the operating room (OR), less ventilatory support, fewer strokes, decreased intensive care unit stay and shortened postoperative length of stay all of which manifests as a decrease in institutional resource utilization. Recent data show that R-MIDCAB and hybrid coronary revascularization provides good long-term outcomes. In addition to patient satisfaction, there is an additional overall cost benefit to R-MIDCAB over traditional sternotomy coronary artery bypass grafting (CABG), secondary to decreased hospital length of stay. Robotically harvesting the IMA, operating on a beating heart, and performing anastomoses through a small incision all require advanced training and incremental learning. Increased experience generally leads to shortened surgical times and fewer complications.

EARLY RESULTS OF MINIMALLY INVASIVE CORONARY ARTERY BYPASS GRAFTING

Abstract Coronary artery bypass grafting (CABG) is the benchmark in elective revascularization for Coronary Artery Disease (CAD), particularly for complex or multivessel CAD, left main coronary involvement, diabetes, or impaired heart function. Traditional CABG, via median sternotomy using cardiopulmonary bypass (CPB), has limitations like CPB–related morbidity and sternal complications. Alternatives like Minimally Invasive Cardiac Surgery (MICS CABG) and Hybrid Revascularization (HR) aim to address these drawbacks. We present a series of 215 consecutive patients (mean age 67±9 years, 27.9% females, EuroSCORE II 1.5±1.3%) between 2017–2023 who underwent elective minimally invasive surgical revascularization. Among the cohort, 164 (76.3%) had Minimally Invasive Direct Coronary Artery Bypass (MIDCAB) via anterolateral left mini–thoracotomy (ALMT) at the fifth intercostal space (IS), with 140 (85.4%) receiving a single left internal thoracic artery (LITA) graft to the left anterior descending (LAD) artery and 24 (14.6%) an additional distal anastomosis. Thirty–four (20.7%) had HR via percutaneous coronary intervention (PCI) on the right coronary artery (RCA). Of the total cohort, 35/215 patients (16.3%) underwent multivessel MICS CABG via ALMT, with mean 2.3±0.5 distal anastomoses using LITA, right ITA, radial artery, or saphenous vein. Heart manipulation was via a subxiphoid device. Four MICS CABG patients (11.4%) had HR. More than half of MICS CABG cases were performed with planned peripheral CPB, without cross–clamping the Aorta. Of the total cohort, 16/215 patients (7.4%) received MICS CABG in an endoscopic fashion, using 3D thoracoscopy for LITA and RITA harvesting via bilateral ports in the 2nd, 3rd, and 4th IS, employing peripheral CPB and aortic clamping by Chitwood clamp at the second IS, with cardioplegia delivery via a 4 cm right anterior MT. Distal anastomoses were performed via left anterior MT, with easy subxiphoid manipulation of the emptied heart. Transit time flowmetry was used in all cases. Conversion to sternotomy was needed in 3 cases, all were MIDCAB. Thirty–day mortality was 1.4%, median ventilation was 4 [2–5] hours, and Intensive Care Unit–stay was 1 [1–2] days. All patients received graft evaluation via computerized tomography before hospital discharge. Mean follow–up was 2.9±1.9 years (max 5 years), with no deaths and 4 (1.9%) requiring follow–up PCI. MICS CABG is a promising future technique for heart revascularization by dedicated teams.

Comparison of On-Pump Beating Heart Surgery Versus Conventional Bypass Surgery in Patients with Acute Myocardial Infarction Requiring Urgent Revascularization

Background: The objective of our study was to provide the initial outcomes of the traditional coronary artery surgery approach and the on-pump beating heart surgery in terms of survival and morbidity in patients who needed emergency surgery for acute myocardial infarction. Methods: A single-center retrospective study was performed from November 2013 to September 2023 on a total of 212 patients requiring emergency coronary artery surgery. Group I patients (n = 108) received traditional coronary artery bypass grafting with cross-clamping, while Group II patients (n = 104) underwent on-pump coronary surgery on the beating heart. Results: There were no disparities observed in the preoperative left ventricular function, percutaneous coronary intervention, intra-aortic balloon usage, or clinical-hemodynamic characteristics. Group I patients had significantly higher rates of postoperative mortality and low cardiac output syndrome, as well as a greater utilization of intra-aortic balloons and a higher requirement for extracorporeal membrane oxygenation (p &lt; 0.001). Conclusions: Ultimately, the on-pump beating heart approach could serve as a viable alternative to enhance the preservation of cardiac function and decrease postoperative complications and mortality rates in patients with acute myocardial infarction who require emergency surgery.

Fifteen-year results of bilateral and unilateral internal mammary artery grafting

To evaluate the clinical effectiveness of bilateral internal mammary artery grafting over long-term (15 years) postoperative period. There were 276 patients divided into two groups: 135 patients (group A) underwent bilateral internal mammary artery grafting and 141 patients (group B) underwent unilateral internal mammary artery grafting together with venous bypass grafts. On-pump surgeries and cardioplegia, parallel CPB and on-pump procedures were performed in equal proportions. Mean age of patients was 57.3±7.6 years. Diabetes mellitus was detected in 21 (15.5%) and 24 (19.1%) patients, respectively (p>0.05). Mean LV ejection fraction was 55.4±9.9%, revascularization index - 3.1±0.8 and 3.0±0.7, respectively. In the 1st group, 43 patients underwent bilateral internal mammary artery grafting alone. Autovenous grafts were additionally used in other 84 patients. Ten-year survival exceeded 90% in both groups. Freedom from adverse cardiac events after 15 years was significantly higher in group A (77.3% vs. 59.3%, p=0.018). In group A, 16 patients died throughout this period due to cancer (50%), myocardial infarction (12.5%), stroke (18.8%) and complications of diabetes mellitus (6.3%). In group B, 22 patients died mainly from cardiac causes (myocardial infarction - 40.9%, cancer - 27.3%). Bilateral internal mammary artery grafting has obvious advantages over traditional coronary artery bypass grafting. If we take into account higher proportion of cardiac causes in structure of mortality in group B, we can talk about positive impact of bilateral internal mammary artery grafting not only on the quality of life, but also on life expectancy in long-term postoperative period.

Long-term clinical outcomes of robotic-assisted surgical coronary artery revascularisation.

Patients who are not candidates for traditional coronary artery bypass grafting (CABG) and amenable only for percutaneous coronary intervention (PCI) with stents can receive the "gold standard" left internal thoracic artery (LITA) to left anterior descending artery (LAD) anastomosis through robotic-assisted CABG and PCI to non-LAD coronary targets. We aimed to analyse clinical outcomes of robotic-assisted CABG. A total of 2,280 consecutive patients who had undergone robotic-assisted CABG between May 2005 and June 2021 were included in our study. Robotic-assisted LITA harvest was followed by LITA-LAD manual anastomosis through a 4 cm left thoracotomy. Hybrid coronary intervention (HCR) consists of stent implantation in a non-LAD coronary artery performed within 7 days after robotic-assisted LITA-LAD. We performed a propensity-adjusted analysis comparison after dividing all robotic-assisted CABG patients into three time periods: 2005-2010, 615 patients; 2011-2016, 904 patients; and 2017-2021, 761 patients. The mean age increased from 64.5 years in the first time period to 65.8 years in the second time period to 68.1 years in the third (p<0.0001). Operative time was progressively reduced in the three periods (6.4; 6.2; 5.5 hours; p<0.001). The incidence of conversion to sternotomy remained similar for each period (1.8%; 1.7%; 1.5%; p=0.53). Thirty-day mortality in the three periods included 9 (1.4%), 9 (1.0%), and 7 (0.9%) patients, respectively (p=0.91), while 8 (0.3%) patients had PCI with stents in the entire group. The mean follow-up for the entire population was 4.2 years. At follow-up, the rates of all-cause death, major adverse cardiac and cerebrovascular events, non-fatal stroke, and repeat revascularisation with stents were significantly decreased from the first to the last period (pË0.0001). Robotic-assisted CABG and HCR provides good long-term outcomes in patients who are not candidates for conventional CABG.

Robotic-Assisted Versus Traditional Full-Sternotomy Coronary Artery Bypass Grafting Procedures: A Propensity-Matched Analysis of Hospital Costs

We aim to compare hospital costs of robotic-assisted coronary artery bypass grafting (CABG) versus conventional CABG. All consecutive 1,173 patients who underwent conventional and robotic-assisted CABG between January 2018 and June 2021 were included. After propensity-matching, 267 patients in each group (robotic-assisted vs conventional) were included in the study. Patient selection for each group was decided by a treating surgeon with a heart team based on clinical factors. Syntax score was not assessed. Total costs (direct+indirect hospital costs) of patients who underwent robotic-assisted and conventional CABG were compared. Direct cost expenses included surgical operating time, hospital stay, surgical implants and supplies, catheterization laboratory, pharmacy, radiology and ultrasound imaging, blood bank, cardiology, and so on. Indirect cost expenses included general administration medical records, and so on. Using the propensity-matched groups (n=267), we summed the total cost by year. Results for 267 propensity-matched patients (each group) evidenced that total conventional CABG costs were $9.5 million (average of $35,580/patient), whereas robotic-assisted CABG costs were $5 million ($18,726/patient). Therefore, the differences between robotic-assisted and conventional CABG costs were $4.5 million ($16,853/patient), favoring robotic-assisted over conventional CABG. Differences in direct and indirect costs were $2.2 million and $1.8 million, respectively. When the cost of the Da Vinci robot was added ($1,200,000), the total cost was $3.3 million ($12,359×patient) lower in the robotic-assisted CABG group. Multivariate analysis showed that, mainly, the shorter hospital length of stay (7 vs 5days) accounts for the reduced costs observed in the robotic-assisted CABG group. In conclusion, in a mature practice, robotic-assisted CABG decreases hospital length of stay, leading to reduced hospital costs compared with conventional CABG.

TCT-450 Robotic-Assisted vs Traditional Coronary Artery Bypass Grafting Procedures: A Propensity-Matched Analysis of Hospital Costs

TCT-450 Robotic-Assisted vs Traditional Coronary Artery Bypass Grafting Procedures: A Propensity-Matched Analysis of Hospital Costs

Coronary artery bypass grafting in left ventricular dysfunction: when and how.

The surgical management of patients undergoing coronary artery bypass grafting (CABG) with low ejection fraction presents unique challenges that require meticulous attention to details and good surgical technique and judgement. This review details the latest evidence and best practices in the care of such patients. CABG in patients with low ejection fraction carries a significant risk of perioperative mortality and morbidity related to the development of postcardiotomy shock. Preoperative optimization with pharmacological or mechanical support is required, especially in patients with cardiogenic shock. Rapid and complete revascularization is what CABG surgeons aim to achieve. Multiple arterial revascularization should be reserved to selected patients. Off-pump CABG, on-pump breathing heart CABG, and new cardioplegic solutions remain of uncertain benefit compared with traditional CABG. Tremendous advancements in CABG allowed surgeons to offer revascularization to patients with severe left ventricular dysfunction and multivessel disease with acceptable risk. Despite that, there is a lack of comprehensive and robust studies particularly on long-term outcomes. Individualized patient assessment and a heart team approach should be used to determine the optimal surgical strategy for each patient.

Urgent robotic coronary revascularization in a pregnant woman

Outcomes of robotic-assisted coronary artery bypass grafting in pregnant women have not been assessed. This study aimed to understand the importance of minimally invasive robotic-assisted coronary artery bypass grafting in pregnant woman with coronary artery disease. We describe the case of a G3P1011 woman at 19+6 weeks' gestation presenting with a non-ST myocardial infarction treated with off-pump hybrid robotic-assisted revascularization. This study describes the surgical approach for a pregnant woman presenting with non-ST myocardial infarction treated with hybrid robotic-assisted revascularization. A coronary angiography demonstrated a culprit lesion of 90% stenosis in the left anterior descending coronary artery and an 80% stenosis in the right coronary artery. Because of the high rate of complications with traditional coronary artery bypass grafting, the heart team opted for hybrid robotic-assisted revascularization and the postoperative recovery was uneventful. Robotic coronary artery bypass grafting can be the preferred surgical choice to decrease maternal and fetal mortality in patients undergoing coronary artery bypass grafting, and it is an important tool in the surgical armamentarium.

Comparison of Sternal Wound Complication after Off-Pump CABG between Skeletonized and Pedicled LIMA Harvesting: A Single Centre Experience in Bangladesh

Background: Off-pump coronary artery bypass grafting (OPCAB) is a surgical procedure that has gained popularity due to its potential benefits over traditional coronary artery bypass grafting, including reduced morbidity and mortality. However, sternal wound complication (SWC) remains challenging following the procedure. The technique of left internal mammary artery (LIMA) harvesting has been shown to impact the incidence of SWC. This study aimed to compare the incidence of SWC between two techniques of LIMA harvesting, i.e., skeletonized and pedicled. Methods: The study was conducted at the Department of Cardiac Surgery, Bangabandhu Sheikh Mujib Medical University, and included 60 patients who underwent OPCAB. The patients were divided into two groups of 30 each based on the technique of LIMA harvesting used, i.e., skeletonized (group A) or pedicled (group B). The postoperative ICU care was given to each patient as per the protocol. The statistical analysis was conducted using the SPSS version 26.0 for Windows software. Results: The results showed that 5 (8.33%) patients developed SWC, with 1 (1.67%) patient in group A and 4 (6.66%) patients in group B. However, the occurrence of SWC was not statistically significant between the two groups (p = 0.35). The mean age, gender distribution, and comorbidities such as hypertension, diabetes, dyslipidemia, and anemia were also not statistically significant between the two groups. The number of smokers was statistically significant between the two groups (p = 0.03), and the occurrence of SWC was found to be higher in smoker patients in group B (p = 0.04). Preoperative and postoperative parameters such as duration of operation, duration of mechanical ventilation, duration of chest drains, duration of the central venous line, and amount of postoperative mediastinal bleeding were also not statistically significant between the two groups. The distribution of wound complications, duration of ICU stays, and hospital stay between the two groups was also not statistically significant. Conclusion: In conclusion, this study found that the incidence of SWC was less in skeletonized LIMA harvesting than in pedicled LIMA harvesting after OPCAB. However, this finding was not statistically significant. Further studies with larger sample sizes may be needed to confirm these results and determine the appropriate technique of LIMA harvesting to decrease the incidence of SWC after OPCAB.

Hybrid coronary revascularization (HCR) versuscoronary artery bypass grafting (CABG) in multivessel coronary artery disease (MVCAD): A meta-analysis of 14 studies comprising 4226 patients.

To compare the outcomes of hybrid coronary revascularization (HCR) with traditional coronary artery bypass grafting (CABG) in multivessel coronary artery disease (MVCAD). HCR has emerged as an alternative to CABG in patients with MVCAD. Through minimally invasive surgical techniques, HCR carries the potential for faster recovery postoperatively, fewer complications, and lower utilization of resources. Systematic search of electronic databases was conducted up to December 2021 and studies comparing HCR with CABG in the treatment of MVCAD were included in this meta-analysis. Primary outcomes of interest were incidence of 5-year mortality and major adverse cardiac and cerebral event (MACCE). Fourteen studies (12 observational studies and 2randomized controlled trials) comprising 4226 patients were included. The rates of 5-year mortality (odds ratios[OR]: 1.55; 95%confidence interval[CI]: 0.92-2.62; I2 = 83.0%) and long-term MACCE (OR: 0.97; 95%CI: 0.47-2.01; I2 = 74.7%) were comparable between HCR and CABG groups. HCR was associated with a significantly lower likelihood of perioperative blood transfusion (OR: 0.36; 95%CI: 0.25-0.51; I2 = 55.9%), shorter mean hospital stay (weighted mean difference: -2.04; 95%CI: -2.60 to -1.47; I2 = 54%), and risk of postoperative acute kidney injury (OR: 0.45; 95%CI: 0.23-0.88; p = 0.02). CABG demonstrated a lower likelihood of requiring long-term repeat revascularization (OR: 1.51; 95%CI: 1.03-2.20; I2 = 18%) over a follow-up duration of 29.14 ± 21.75 months. This meta-analysis suggests that HCR is feasible and safe for the treatment of MVCAD. However, benefits of HCR should be carefully weighed against the increased long-term risk of repeat-revascularization when selecting patients, and further studies evaluating differences in long-term mortality between HCR and CABG are required.

Repeat Revascularization Post Coronary Artery Bypass Grafting: Comparing Minimally Invasive and Traditional Sternotomy Techniques in 1468 Cases.

Background: Traditional open sternotomy coronary artery bypass grafting (CABG) utilizes highly invasive techniques that lead to several serious complications. In response, minimally invasive cardiac surgery CABG (MICS-CABG) was developed. MICS-CABG is safe, reproducible, and with fewer complications, while allowing for better postoperative recovery periods. There is a paucity of data exploring rates of repeat revascularization in patients post MICS-CABG compared to post traditional sternotomy CABG.Methods: This was a retrospective billing database review examining 1468 CABG patients at a large university medical center from January 2005 to December 2017. The primary objective was to compare the rate of repeat revascularization events between MICS-CABG and traditional open sternotomy CABG over an eight-year follow-up period.Results: Our study population consisted of 1468 patients, of whom 513 had MICS-CABG and 955 had traditional CABG. The number of patients undergoing repeat revascularization within the eight-year surveillance was 99 for MICS-CABG and 75 for traditional CABG. The Kaplan-Meier survival probability estimates for eight years were 0.86 for MICS-CABG and 0.91 for traditional CABG. The mean time until a repeat revascularization event was 84.1 months for MICS-CABG and 88.5 months for traditional CABG.Conclusions: Traditional CABG was found to have a statistically significantly longer time to repeat revascularization than MICS-CABG. Despite the technical challenges associated with MICS-CABG, the time to repeat revascularization was different by only about four months, which may not hold large clinical significance. This suggests that MICS-CABG may have a role to play due to previous findings showing a reduction in complications while allowing for better postoperative recovery periods.

C-8 | Hybrid Coronary Revascularization (HCR) vs. Coronary Artery Bypass Grafting (CABG) in Multivessel Coronary Artery Disease (MVCAD): A Meta-analysis of 14 Studies Comprising 4,226 Patients

Hybrid Coronary Revascularization(HCR) has emerged as a favorable technique over traditional CABG in selected patients with Multivessel Coronary Artery Disease(MVCAD). We conducted the following meta-analysis in order to compare the outcomes between these two interventions.

Hybrid Coronary Revascularization Vs Traditional Coronary Artery Bypass Graft: A Better Revascularization Modality

Background: Hybrid coronary revascularization (HCR) represents a minimally invasive revascularization strategy in which the durability of the internal mammary artery to left anterior descending combined with percutaneous coronary intervention with drug eluting stents(DES)to treat remaining lesions in different coronary arteries. Objective: To compare the complication like bleeding, nephropathy and hospital stay MACCE defined as death, stroke, myocardial infarction (MI), stroke, and repeat revascularization in hospital and one year follow up. Methods: It was correctional study done UAE in 2018- 2019 patient with multi vessel disease who consented with insurance approval were included and decision for which patient went HCR or CABG arm by heart team, patient underwent HCR we used stage manner first LIMA – LAD followed by multi vessel PCI after 24 hrs. And patient were discharged on day 5 of admission Results: 15 patients underwent hybrid revascularization bleeding rate was high with OR OF 1.0 with 95% C.I of 0.8-1.3 with p value of 0.03, risk of Nephropathy was higher in HCR group with odd ration 1.2 (0.6-1.5) with p value of 0.04 the mean length was 5 vs 7 Days One stroke in CABG group and MACE was HCR with ODD ratio of 1.2 (95% CI 0.8-1.5 with p value of 0.04 observed till one year no in hospital death one year follow up. Three patients died of MACE in CABG and one patient in HCR group.

Hybrid revascularization vs. coronary bypass for coronary artery disease: a systematic review and meta-analysis.

Coronary artery bypass graft is the mainstay of treatment for multivessel coronary artery disease and is superior to percutaneous coronary intervention. Combined approaches such as hybrid coronary revascularization integrate coronary artery bypass grafting with percutaneous coronary intervention during the same procedure or weeks apart. These attempt to improve surgical morbidity and long-term outcomes. Per PRISMA criteria, a systematic review of keywords "Hybrid Revascularization," "Hybrid Coronary Revascularization," "Surgical," "Surgery," "Treatment," "CABG," "HCR" and "PCI" was conducted in PubMed, EMBASE and SCOPUS. Studies comparing this technique's performance on either single or two-stage approach against traditional multiple vessel coronary artery bypass grafting were screened and analyzed for our review. Twenty-two studies totaling 6981 participants were ultimately included for analysis. Mean differences in operative time, bleeding, ventilator time and length of stay were significantly lower in the hybrid coronary revascularization group. Odds ratios in transfusions and in-hospital myocardial infarction were also lower in the hybrid coronary revascularization group. Results for in-hospital and all-cause mortality, major adverse cardiac events (MACE), stroke, reintervention, and complete revascularization were not significantly different. Our analysis shows hybrid coronary revascularization is a feasible alternative to traditional coronary artery bypass grafting. Short-and long-term outcomes including mortality, MACE, and postoperative morbidity are similar between both groups, while hybrid approaches are associated with decreased perioperative morbidity.

Ten-Year Outcomes of Off-Pump vs On-Pump Coronary Artery Bypass Grafting in the Department of Veterans Affairs

The long-term benefits of off-pump ("beating heart") vs on-pump coronary artery bypass grafting (CABG) remain controversial. To evaluate the 10-year outcomes and costs of off-pump vs on-pump CABG in the Department of Veterans Affairs (VA) Randomized On/Off Bypass (ROOBY) trial. From February 27, 2002, to May 7, 2007, 2203 veterans in the ROOBY trial were randomly assigned to off-pump or on-pump CABG procedures at 18 participating VA medical centers. Per protocol, the veterans were observed for 10 years; the 10-year, post-CABG clinical outcomes and costs were assessed via centralized abstraction of electronic medical records combined with merges to VA and non-VA databases. With the use of an intention-to-treat approach, analyses were performed from May 7, 2017, to December 9, 2021. On-pump and off-pump CABG procedures. The 10-year coprimary end points included all-cause death and a composite end point identifying patients who had died or had undergone subsequent revascularization (ie, percutaneous coronary intervention [PCI] or repeated CABG); these 2 end points were measured dichotomously and as time-to-event variables (ie, time to death and time to composite end points). Secondary 10-year end points included PCIs, repeated CABG procedures, changes in cardiac symptoms, and 2018-adjusted VA estimated costs. Changes from baseline to 10 years in post-CABG, clinically relevant cardiac symptoms were evaluated for New York Heart Association functional class, Canadian Cardiovascular Society angina class, and atrial fibrillation. Outcome differences were adjudicated by an end points committee. Given that pre-CABG risks were balanced, the protocol-driven primary and secondary hypotheses directly compared 10-year treatment-related effects. A total of 1104 patients (1097 men [99.4%]; mean [SD] age, 63.0 [8.5] years) were enrolled in the off-pump group, and 1099 patients (1092 men [99.5%]; mean [SD] age, 62.5 [8.5] years) were enrolled in the on-pump group. The 10-year death rates were 34.2% (n = 378) for the off-pump group and 31.1% (n = 342) for the on-pump group (relative risk, 1.05; 95% CI, 0.99-1.11; P = .12). The median time to composite end point for the off-pump group (4.6 years; IQR, 1.4-7.5 years) was approximately 4.3 months shorter than that for the on-pump group (5.0 years; IQR, 1.8-7.9 years; P = .03). No significant 10-year treatment-related differences were documented for any other primary or secondary end points. After the removal of conversions, sensitivity analyses reconfirmed these findings. No off-pump CABG advantages were found for 10-year death or revascularization end points; the time to composite end point was lower in the off-pump group than in the on-pump group. For veterans, in the absence of on-pump contraindications, a case cannot be made for supplanting the traditional on-pump CABG technique with an off-pump approach. ClinicalTrials.gov Identifier: NCT01924442.

Cardiovascular Outcomes in High-Risk Patients Undergoing OPCAB Surgery Compared to Traditional CABG

The benefit of coronary artery bypass graft (CABG) for coronary artery disease (CAD) with Ejection Fraction (EF) 30% and ischemic burden (IB) 10% is still debatable. The objective of this study is to analyze mortality and morbidity in patients with EF 30% and ischemic burden 10% undergoing OPCAB compared to traditional CABG (TCABG). The retrospective analytic cohort study was performed using data from January 2015–November 2018 at National Cardiovascular Center Harapan Kita Jakarta, Indonesia. 109 patients were included. 35 patients undergoing OPCAB and 74 patients undergoing TCABG. The primary outcomes were mortality rate, morbidity rate, and length of stay. Arrhythmia is statistically lower in OPCAB compared to TCABG (8.6% vs 39.2%; p=0.001). Kidney injury is statistically lower in OPCAB (8.6% vs 27.0 %; p=0.027). Stroke is statistically lower in OPCAB (1.0 % vs 17.6%; p=0,032). There is no significant difference between OPCAB and TCABG in mortality, 5.7% vs 16.2%, (RR=3.20; CI 95%=0.67–15.12; p= 0.126). There was a statistically significant difference in the occurrence of postoperative morbidity in CAD patients with EF &lt;30% and IB&lt;10% who underwent OPCAB surgery compared with patients who underwent TCABG. Mortality that occurred after OPCAB procedure was lower in CAD patients with EF &lt; 30% and IB&lt;10% compared to TCABG although the statistical difference was not significant. Therefore, patients with this condition are more advisable to undergo OPCAB.

Is hybrid coronary revascularization really beneficial in the long term?

Abstract OBJECTIVES This analysis aimed to compare both short- and long-term outcomes of hybrid coronary revascularization (HCR) with different techniques and coronary artery bypass grafting (CABG). METHODS Twenty-three studies were included, covering 10 468 different patients, among whom 2403 patients underwent HCR with either simultaneous or staged method and 8065 patients underwent CABG. RESULTS Compared with CABG, HCR had a statistically significant lower risk of stroke [odds ratio (OR) = 0.55, P = 0.049], major adverse cardiac and cerebrovascular events (OR = 0.69, P = 0.024) and blood transfusion (BT) (OR = 0.39, P &amp;lt; 0.001), whereas no significant differences were detected in mortality, myocardial infarction and repeat revascularization. A network meta-analysis showed that simultaneous HCR had significantly better outcomes in stroke (OR = 0.24, P = 0.01) and major adverse cardiac and cerebrovascular events (OR = 0.29, P &amp;lt; 0.001), and staged HCR had a significantly better outcome in BT (OR = 0.31, P &amp;lt; 0.001). According to the frequentist statistic results, simultaneous HCR had the highest probability of being the best treatment in terms of mortality (84%), stroke (97%), myocardial infarction (88%) and major adverse cardiac and cerebrovascular events (99%), whereas staged HCR had the highest probability of being the best in postoperative repeat revascularization (59%) and BT (83%). However, long-term results showed no significant difference between the HCR and CABG techniques. CONCLUSIONS HCR appears to be a feasible option for multivessel coronary artery disease patients. Compared to traditional CABG, HCR had lower risk of adverse events in the short term, but in the long term, survival rate and freedom from major adverse cardiac and cerebrovascular events rate were similar between groups.