Clinical outcomes after hybrid coronary revascularization versus coronary artery bypass surgery: a meta-analysis of 1,190 patients Ralf E. Harskamp, MD, a,b Akshay Bagai, MD, MHS, c Michael E. Halkos, MD, MSc, d Sunil V. Rao, MD, MHS, a William B. Bachinsky, MD, e Manesh R. Patel, MD, a Robbert J. de Winter, MD, PhD, b Eric D. Peterson, MD, MPH, a John H. Alexander, MD, MHS, a and Renato D. Lopes, MD, PhD, MHS a Durham, NC; Amsterdam, The Netherlands; Ontario, Canada; Atlanta, GA; and Harrisburg, PA
Background Hybrid coronary revascularization (HCR) represents a minimally invasive revascularization strategy in which the durability of the internal mammary artery to left anterior descending artery graft is combined with percutaneous coronary intervention to treat remaining lesions. We performed a systematic review and meta-analysis to compare clinical outcomes after HCR with conventional coronary artery bypass graft (CABG) surgery. Methods A comprehensive EMBASE and PUBMED search was performed for comparative studies evaluating in-hospital and 1-year death, myocardial infarction (MI), stroke, and repeat revascularization. Results Six observational studies (1 case control, 5 propensity adjusted) comprising 1,190 patients were included; 366 (30.8%) patients underwent HCR (185 staged and 181 concurrent), and 824 (69.2%) were treated with CABG (786 offpump, 38 on-pump). Drug-eluting stents were used in 328 (89.6%) patients undergoing HCR. Hybrid coronary revascularization was associated with lower in-hospital need for blood transfusions, shorter length of stay, and faster return to work. No significant differences were found for the composite of death, MI, stroke, or repeat revascularization during hospitalization (odds ratio 0.63, 95% CI 0.25-1.58, P = .33) and at 1-year follow-up (odds ratio 0.49, 95% CI 0.20-1.24, P = .13). Comparisons of individual components showed no difference in all-cause mortality, MI, or stroke, but higher repeat revascularization among patients treated with HCR. Conclusions Hybrid coronary revascularization is associated with lower morbidity and similar in-hospital and 1-year major adverse cerebrovascular or cardiac events rates, but greater requirement for repeat revascularization compared with CABG. Further exploration of this strategy with adequately powered randomized trials is warranted. (Am Heart J 2014;167:585-92.)
Hybrid coronary revascularization (HCR) refers to the use of surgical and percutaneous techniques that are combined to establish complete coronary revascularization in patients with multivessel coronary artery disease (CAD). According to the latest revascularization guidelines, HCR with the use of the internal mammary artery (IMA) for bypassing the left anterior descending (LAD) and percutaneous coronary intervention (PCI) of non-LAD coronary
From the aDuke Clinical Research Institute and Duke University Medical Center, Durham, NC, bAcademic Medical Center–University of Amsterdam, Amsterdam, The Netherlands, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada, dEmory University School of Medicine, Atlanta, GA, and ePinnacle Health Cardiovascular Institute, Harrisburg Hospital, Harrisburg, PA. Marc Cohen, MD, served as guest editor for this article. Submitted November 25, 2013; accepted January 10, 2014. Reprint requests: Ralf E. Harskamp, MD, 2400 Pratt St, Durham, NC 27707. c
E-mail:
[email protected] 0002-8703/$ - see front matter © 2014, Mosby, Inc. All rights reserved. http://dx.doi.org/10.1016/j.ahj.2014.01.006
lesions has been recognized as a feasible alternative to coronary artery bypass grafting (CABG) surgery in selected patients. 1–3 In theory, the use of HCR may have a number of advantages over CABG surgery: (1) minimal invasive techniques may lead to faster recovery and fewer inhospital complications; (2) avoidance of saphenous vein grafts for non-LAD disease, which carry additional procedural risk and have poor patency rates when compared with the latest drug-eluting stents (DES). 4,5 In the present study, our goals are to provide an overview of evidence for the use of HCR as an alternative for CABG and to gain insights for future randomized clinical trials that involve HCR in patients with multivessel CAD.
Methods Data source and exclusion criteria A comprehensive literature search was performed from electronic databases including Cochrane Library, EMBASE, and MEDLINE updated to June 26, 2013. The terms “hybrid coronary
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revascularization,” “hybrid myocardial revascularization,” “integrated myocardial revascularization,” and “coronary artery disease” and their variations were used as keywords in a PubMed search. The search was limited to records in humans. Both English and non-English language articles were included (n = 247). Two independent reviewers (R.E.H., A.B.) screened all citations by using a hierarchical approach of assessing the title, abstract, and the article. Studies of HCR for multivessel CAD, referred to the use of a combination of surgical and percutaneous techniques to establish coronary revascularization, performed either simultaneously in a single setting or in 2 stages within hours, days, or weeks were included. Bibliographies of all selected articles were reviewed to identify additional studies. Exclusion criteria were studies that did not have a comparison CABG group, included patients with concomitant hybrid valve procedures, or were review articles or commentaries. Data from abstracts and unpublished studies were not included. Quality of observational studies was determined based on completeness of reporting, reporting of adjusted risk of outcomes, use of propensity adjustment, or absence of differences between reported baseline variables in the 2 treatment groups—representing high-quality studies. Data were abstracted by 2 reviewers in a blinded manner, and discrepancies were resolved by consensus.
Figure 1
Definitions and study end points Hybrid coronary revascularization was defined as the use of a combination of surgical and percutaneous techniques that involved IMA-to-LAD and PCI of the non-LAD, which could have been performed consecutively in a single setting or staged in which PCI and CABG were performed separately within hours, days, or weeks. Coronary artery bypass grafting surgery was defined as the use of surgical techniques to establish coronary revascularization with the use of arterial and/or vein grafts using a trans-sternal approach with or without the use of cardiopulmonary bypass. In-hospital outcomes included death, stroke, myocardial infarction (MI), repeat revascularization, new onset of atrial fibrillation, significant bleeding, and hospital length of stay. Longer-term outcomes were defined as cumulative clinical events occurring for the complete follow-up duration. Because studies reported outcomes at various follow-up time intervals (1-5years), authors were contacted to provide 1-, 2-, and 3-year clinical follow-up data for the primary end point of death, MI, stroke, and repeat revascularization as well as individual components.
Statistical analysis Continuous data are expressed as mean ± SD, and dichotomous data are expressed as absolute value and percentages. Meta-analysis was performed per recommendations of the Cochrane Collaboration and the MOOSE statement. 6 Heterogeneity was assessed by means of the Cochran Q test. Statistical value I 2 represents the degree of inconsistency, with a score of 25%, 50%, and 75% indicating low, moderate, and high levels of inconsistency, respectively. P value for the test of heterogeneity of less than .05 was considered to indicate heterogeneity between studies. Differences between the 2 groups for inhospital and long-term outcomes were assessed by as the number of events and number of patients in each group and estimated by odds ratios (ORs) with 2-tailed 95% CIs. Random-
Flow diagram of study selection process.
effects models were used because heterogeneity among studies was expected. Studies with zero events in one group or total zero events were included, and a continuity correction of 0.5 was used. 7 Potential publication bias was assessed by funnel plots and adjusted using Duval and Tweedie's 8 trim-and-fill methodology. A sensitivity analysis was performed to compare HCR performed as a concurrent procedure or as a 2-stage procedure separately with CABG surgery. All statistical analyses were performed using the Comprehensive Meta-Analysis software package version 2.2 (Biostat, Englewood, NJ).
Results Studies selection The study selection process is illustrated in Figure 1. The search strategy identified 247 studies. After screening of titles and abstracts, we excluded nonoriginal studies, case reports, or small case series (b10) and unrelated studies on noncoronary hybrid surgical or imaging procedures. This resulted in 37 unique studies that were comprehensively reviewed. After critical appraisal, we excluded 27 studies because of the lack of a comparative study arm, clinical outcome was not provided, or outcome data were provided without adjustment for confounders. This led to a total of 6 studies, which were included in the meta-analysis, and data on in-hospital and/or long-term clinical outcomes were further scrutinized. 9–14
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Table I. Characteristics of the included studies
PSM
F/U (mo)
282
Yes
36
OPCAB
No
100
2012
52
No
1
OPCAB
No
71
USA
2011
735
Yes
60
OPCAB
Yes (N90%)
N90
France
2010
36
Yes
12
On-pump
Yes
94
USA
2008
45
Yes
12
OPCAB
No
100
Belgium
2001
40
Yes
24
On-pump
Yes
0
Author
Country
Year
N
Shen et al
China
2013
Bachinsky et al
USA
Halkos et al
Delhaye et al Kon et al de Cannière et al
CABG
Staged HCR
HCR DES (%)
HCR surgical approach Direct vision mini-sternotomy Robotic harvest, anastomosis mini-thoracotomy Robotic or thoracoscopic harvest, anastomosis mini-thoracotomy Full sternotomy Anterolateral thoracotomy Anterolateral thoracotomy
Clopidogrel
UFH
after confirmation LIMA-LAD patency when chest tube b100 mL/h
During PCI: ACT N250 s During PCI: ACT ≈250 s
when chest tube b100 mL/h
180 IU/kg
6 h before PCI
During PCI: 40-50 U/kg ACT N300 s and N2 IU/mL –
upon arrival at the ICU –
Abbreviations: PSM, propensity score matching; F/U, follow-up; UFH, unfractionated heparin; ACT, activated clotting time; ICU, intensive care unit.
Study characteristics The characteristics of the 6 studies are presented in Table I. All studies were single-center registries. 9–14 Four studies reported data on the primary end point at 1 year of follow-up, 10,11,13,14 and 5 studies reported data on allcause mortality and repeat revascularization. 10–14 Angiographic criteria for patient selection were comparable among the various studies and included the following: symptoms or signs of ischemia, due to multivessel disease with high-grade proximal disease of the LAD or left main disease, along with lesions suitable for PCI in the left circumflex and/or right coronary artery territories. Adjustment for differences at baseline was performed either by propensity score matching 10–14 or using stringent inclusion criteria that would equal matching for clinical and angiographic parameters. 9 Four studies included patients with a clinical presentation of acute coronary syndrome (ACS). 9–12 No significant heterogeneity was present across studies, and there was no apparent systematic bias. Procedural characteristics Minimal invasive surgical techniques were used for IMA harvest and for performing the anastomosis in all but one study 11 (Table I). In the control CABG group, surgery was performed without the use of cardiopulmonary bypass (off-pump CABG [OPCAB]) in 4 of the 6 studies. 10,11 In 3 studies, 9,13,14 cases were performed in a hybrid operating room that allowed the surgical and percutaneous coronary revascularization procedures to be done concurrently. The antiplatelet and anticoagulant regimens varied among studies. None of the centers reported the use of glycoprotein IIb/IIIa inhibitors or new anticoagulants.
Patient characteristics All studies combined represent outcome data on 1,190 patients who underwent either HCR (n = 366) or CABG surgery (n = 824) from the late 1990s until present. Most patients were treated in the United States (n = 842), followed by China (n = 282) and Europe (n = 76). The clinical characteristics are presented in Table II. Median age varied slightly among studies from 62 to 67 years, and female patients were underrepresented in most studies. Diabetes ranged from 18% to 48%, with studies from Asian patient populations reporting lower incidences (b25%) compared with the Western study populations (≈40%). The clinical presentation of patients varied considerably, with ACS being reported from 0 to 72%, which is largely attributable to study exclusion criteria. Left ventricular function was similar across groups. Although the angiographic criteria were similar, the lesion complexity varied among studies. In-hospital and short-term clinical outcomes The composite of in-hospital death, MI, stroke, and repeat revascularization was reported in 1.4% (5/366) of patients after HCR and 2.9% (24/824) of patients who underwent CABG. As shown in Figure 2, there was no significant relationship between the in-hospital outcomes among studies that reported on HCR vs CABG (OR 0.63, 95% CI 0.25-1.58, P = .33). The event rates and ORs for the individual components of the composite in-hospital clinical end point were also comparable between HCR and CABG (Figure 3). As shown in Table II, the rates of inhospital complications, such as the need for blood transfusions, tended to be lower after HCR compared with CABG. In addition, studies showed shorter overall length of stay in the intensive care unit as well as in the
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– –
7 12 8 22
37 ± 22 63 ± 46 – 42 ± 10 32 ± 10 (SF-12) – 6±3 8±3 –
33 ± 11 27 ± 8 (QOL 6 wk)⁎
14 35 22 89 NR
0.2 ± 0.4 1.4 ± 1.4
NR
10 38 2 11 ± ± ± ± –
24 58 20 27
25 (22-38) 24 (18-30) –
de Cannière et al
Kon et al
Delhaye et al
Bachinsky et al Halkos et al
Data between parentheses represent median and 25th and 75th percentiles. Data with ± symbol represent mean and SD. Abbreviations: DM, diabetes mellitus; LVEF, left ventricular ejection fraction; ICU, intensive care unit; LOS, length of stay; VAS, visual analog scale; QOL, quality of life; NR, not reported. ⁎ Duke Activity Status Scale Index questionnaire.
9 7 8 5
± ± ± ±
2 3 2 1
– NR
2.7 2.6 0 17 0 10 NR
0.2 ± 0.7 1.8 ± 2 NR
± ± ± ± ± ± 8 9 8 8
±7 ±8 ± 10 ± 12 ±9 ±9 (54-65) (55-65) ± 14 ± 14 ±5 ±7 63 63 55 51 55 55 60 60 47 45 56 55 0 0 32 37 14 12 56 72 0 0 10 10 26 18 36 48 40 29 45 39 27 40 20 25 89 90 80 59 62 71 78 78 73 63 80 75 ± 10 ±8 ± 11 ± 11 ± 13 ± 13 (55-70) (53-68) ± 10 ± 10 ±9 ± 13 62 62 63 67 64 64 62 62 61 65 62 63 HCR CABG HCR CABG HCR CABG HCR CABG HCR CABG HCR CABG Shen et al
141 141 25 27 147 588 18 18 15 30 20 20
Groups Author
N
hospital after HCR compared with CABG. Although postoperative pain appeared to be higher, quality of life assessment seemed to be more improved when measured within 6 weeks of hospital discharge.
± ± ± ±
– – –
0 0 NR NR
8±3 10 ± 5 5±3 8±5 7±7 6±4 10 (10-11) 11 (10-13) 4±1 6±2 7±1 9±1 35 55 29 58 57 53 – 28 ± 28 ± 34 ± 35 ± –
36 46 14 85 145 88
ICU LOS (h) ACS (%) DM (%) Male (%) Age (y)
Table II. Baseline characteristics and short-term outcomes of the study patients
LVEF (%)
SYNTAX
Hospital LOS (d)
Blood transfusion (%)
Renal failure (%)
Pain (VAS)
QOL
Return to work (wk)
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Clinical outcomes at follow-up The composite of death, MI, stroke, and repeat revascularization occurred in 4.1% (8/194) of patients after HCR and 9.1% (19/209) of patients with CABG at 1 year of follow-up. As shown in Figure 2, the ORs for the composite end point were not significantly different at 1 year of follow-up (OR 0.49 [0.20-1.24], P = 0.13). No significant heterogeneity or data inconsistency was seen for these comparisons. The funnel plot in the right-hand panel suggests only minimal publication bias favoring CABG. Comparisons among the individual components of the composite outcome at 1 year as well as up to 3 years for death and repeat revascularization are displayed in Figure 3. Overall, the outcomes for all-cause mortality, MI, and stroke were not statistically different, whereas repeat revascularization was clearly more common after HCR compared with CABG. Detailed information on the location of repeat revascularization was available from 2 studies at long-term follow-up, as shown in Figure 4. Overall, a greater need for LAD revascularization and repeat revascularization for nontarget lesion-related progression of native CAD was seen in patients who underwent HCR compared with CABG. 12,14 Comparison of single- vs dual-stage procedures As shown in Table III, there appeared to be no difference in in-hospital death, MI, stroke, and repeat revascularization when HCR was performed concurrent or as staged procedures (using CABG as the reference group). Data on long-term outcomes were available for 1year all-cause mortality and showed similar trends for both concurrent and staged HCR vs the reference CABG group.
Discussion In this meta-analysis of more than 1,100 patients from 6 observational cohort studies, we observed the following: (1) patients undergoing HCR with IMA-to-LAD grafting and PCI of non-LAD lesions have a similar risk of the composite of death, MI, stroke, and repeat revascularization than those treated with CABG during hospitalization and during follow-up; (2) although death, MI, and stroke rates were numerically but not statistically lower with HCR, the need for repeat revascularization occurred more frequently with HCR; and (3) these findings were similar when HCR was performed as a 1- or 2-stage procedure. Our study is the first meta-analysis on clinical outcomes after HCR compared with conventional surgical revascularization, and its findings support the current
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Figure 2
Forest and funnel plots for the in-hospital and 1-year composite of death, MI, stroke, and repeat revascularization for studies comparing HCR vs coronary artery bypass surgery.
Figure 3
Forest plot for the individual components at various time points for the comparisons HCR vs coronary artery bypass surgery.
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Figure 4
Localization of repeat revascularization for 2 studies with clinical follow-up of 3 years. Abbreviations: TLR, target lesion revascularization; TLR of non-LAD lesion involves PCI or CABG for vein graft failure or in-stent restenosis.
Table III. Sensitivity analysis among concurrent and staged HCR Outcome In-hospital MACCE 1-year death
Subgroup
Studies (n)
Patients (n)
Concurrent HCR Staged HCR Concurrent HCR Staged HCR
3 3 2 3
379 811 327 811
Random effects, OR (95% CI)⁎ 0.34 0.81 0.72 0.63
(0.06-1.89) (0.27-2.41) (0.09-5.71) (0.26-1.56)
P
I 2 (%)
Heterogeneity, P value
.22 .70 .78 .32
0.0 0.0 0.0 0.0
.54 .60 .56 .89
Abbreviation: MACE, major adverse cerebrovascular or cardiac events. ⁎ OR of HCR vs CABG.
guideline recommendations (level of recommendation: IIa/IIb, level of evidence: B). 1–3
Rationale for HCR The major advantages of HCR when compared with conventional CABG are the avoidance of cardiopulmonary bypass, aortic clamping, and complete sternotomy when using minimally invasive surgical techniques. 15 In studies where minimally invasive surgery was compared with conventional CABG, the avoidance of sternotomy resulted in shorter hospital stay and lower infection rates. 16 Theoretically, the avoidance of cardiopulmonary bypass and aortic clamping may also decrease the risk of stroke and renal failure. When femoral cannulation and techniques are used for
cardiopulmonary bypass, there is, however, still an increased chance of retrograde embolization from the descending aorta. Our data support that HCR performed without conventional sternotomy results in shorter duration of hospital stay, earlier return to work, and fewer in-hospital complications. From a patient's perspective, the use of minimal invasive techniques in HCR is promising because shorter postoperative recovery with fewer complications enables patients to recover much faster and to return to normal daily activities and work. In these studies, it was also shown that self-reported quality of life is significantly higher at follow-up. Although these findings are from small, nonrandomized studies, these findings indicate that factors to improve in-hospital recovery are issues that matter to patients even months after hospital discharge.
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Rationale against HCR The main concern about the use of minimal invasive surgical techniques in HCR vs conventional CABG for left IMA (LIMA)-to-LAD grafting is the quality of the anastomosis, particularly because LIMA failure has been associated with adverse long-term clinical outcomes. 17 For this reason, imaging for LIMA patency with coronary angiography during PCI is recommended and routinely applied in HCR where PCI is performed after surgical revascularization. 18 In this meta-analysis among highly specialized centers, patency rates were excellent (N95%). However, as shown in Figure 4, the rates of LIMA failure were significantly higher after HCR compared with CABG in 2 studies that reported long-term follow-up. 12,14 Most of these LIMA failures are due to asymptomatic defects that were detected during routine in-hospital angiography in the HCR group, which was not performed in the CABG group. A prior study by Zhao et al 18 showed that up to 7% of LIMA grafts have intraoperative angiographic defects in patients who underwent HCR using a conventional median sternotomy approach. As such, the advantage of angiographic confirmation of LIMA graft patency should be kept in mind when planning the sequence and timing of hybrid coronary procedures. Another concern is the greater need for non-LAD revascularization. As shown in Figure 4, the restenosis rates of coronary stents (primarily first-generation DES) appeared to be equal to vein graft failure rates. Future studies that include the use of newer stent platforms as well as refined antiplatelet regimens may help improve these outcomes. However, revascularization due to progression of native CAD was also markedly higher after HCR. Although incompletely understood, these data suggest that patients with HCR may either have more advanced CAD and/or are more frequently incompletely revascularized.
Hybrid coronary revascularization as a 1-stage or 2-staged procedure In this meta-analysis, we found that when HCR was performed as a 1-stage procedure, similar outcomes were observed as in studies in which staged HCR was performed, in which the CABG group served as reference. These findings require further exploration. One could imagine that concurrent HCR is likely to result in shorter length of stay, and because it allows for direct conversion to CABG when complications or PCI failure occurs, the procedural outcomes may be somewhat favorable. However, on the other hand, there may be higher risk for bleeding because of the use of dual antiplatelet therapy and incomplete heparin reversal, as well as acute stent thrombosis due to the proinflammatory milieu directly after surgery. 19 Also, differences in patient populations, whether its clinical presentation, frailty, diabetes, or other comorbidities, may
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affect HCR approach, as well as relative outcomes between HCR and CABG.
Study limitations This study has several limitations that should be acknowledged. First, the findings of this study are based on a limited number of observational studies, which are, by definition, subject to confounding. To limit confounding, we only included studies that used adjustment for differences in baseline characteristics. Second, the results of the included studies are from a few highly experienced centers and therefore do not necessarily represent “real-world practice.” Third, the duration of clinical follow-up was limited to 1 year in most studies, which did not allow us to assess longterm clinical follow-up. However, the observed difference in repeat revascularization between HCR and CABG did not change significantly between 1- and 3year follow-up. Fourth, the inclusion and exclusion criteria for the included studies varied, and as such, the risk profiles of patients varied. Fifth, HCR involves a heterogeneous group of procedures, and its outcomes may depend on the methods used, timing, and sequence of scheduled procedures and adjunctive pharmacologic therapies. Lastly, for planned 2-stage HCR, there is a possibility for survival bias because only patients who survive up to the second arm of the procedure are captured.
Conclusion In this contemporary meta-analysis of patients with multivessel CAD undergoing coronary revascularization, HCR was associated with similar rates of death, MI, stroke, and repeat revascularization during hospitalization and at follow-up, but with higher rates of repeat revascularization compared with conventional CABG. These findings seem to be similar irrespective of whether a 1-staged or 2-staged approach is used. Our findings may be used as reference for future clinical trials comparing HCR with CABG.
Disclosures Drs Harskamp, Bagai, Bachinsky, and de Winter do not report any relevant disclosures. Dr Rao receives research grants from Cordis Corportation, Ikaria, and Sanofi-Aventis and received consulting fees for Zoll, the Medicines Company, Terumo Medical, and Daiichi Sankyo Lilly. Dr Patel receives research funding from MAQUET Cardiovascular, Johnson & Johnson, The National Heart, Lung, and Blood Institute, and Agency for Healthcare Research and Quality's and consulting fees from Genzyme corporation. Dr Peterson receives research grants from Abbott Laboratories, Abiomed, Acorn Cardiovascular, and Aastrom Biosciences. Dr
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Alexander receives support from Bristol Myers Squibb, CLS Behring, the National Institutes of Health, and Regado Biosciences and consulting fees from Moerae Matrix and VA Cooperative Studies program. Dr Lopes receives research funding from Bristol Myers Squibb and Somahlution Inc.
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9. Bachinsky WB, Abdelsalam M, Boga G, et al. Comparative study of same sitting hybrid coronary artery revascularization versus off-pump coronary artery bypass in multivessel coronary artery disease. J Interv Cardiol 2012;25:460-8. 10. de Cannière D, Jansens JL, Goldschmidt-Clermont P, et al. Combination of minimally invasive coronary bypass and percutaneous transluminal coronary angioplasty in the treatment of double-vessel coronary disease: two-year follow-up of a new hybrid procedure compared with “on-pump” double bypass grafting. Am Heart J 2001; 142:563-70. 11. Delhaye C, Sudre A, Lemesle G, et al. Hybrid revascularization, comprising coronary artery bypass graft with exclusive arterial conduits followed by early drug-eluting stent implantation, in multivessel coronary artery disease. Arch Cardiovasc Dis 2010;103:502-11. 12. Halkos ME, Vassiliades TA, Douglas JS, et al. Hybrid coronary revascularization versus off-pump coronary artery bypass grafting for the treatment of multivessel coronary artery disease. Ann Thorac Surg 2011;92:1695-701. 13. Kon ZN, Brown EN, 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;135:367-75. 14. Shen L, Hu S, Wang H, et al. One-stop hybrid coronary revascularization versus coronary artery bypass graft and percutaneous coronary intervention for the treatment of multivessel coronary artery disease: three-year follow-up results from a single institution. J Am Coll Cardiol 2013;61:2525-33. 15. Diegeler A, Thiele H, Falk V, et al. Comparison of stenting with minimally invasive bypass surgery for stenosis of the left anterior descending coronary artery. N Engl J Med 2002;347: 561-6. 16. Iakovou I, Dangas G, Mehran R, et al. Minimally invasive direct coronary artery bypass (MIDCAB) versus coronary artery stenting for elective revascularization of the left anterior descending artery. Am J Cardiol 2002;90:885-7. 17. Mehta RH, Honeycutt E, Shaw LK, et al. Clinical and angiographic correlates of short- and long-term mortality in patients undergoing coronary artery bypass grafting. Am J Cardiol 2007;100:1538-42. 18. Zhao DX, Leacche M, Balaguer JM, et al. Routine intraoperative completion angiography after coronary artery bypass grafting and 1-stop hybrid revascularization results from a fully integrated hybrid catheterization laboratory/operating room. J Am Coll Cardiol 2009; 53:232-41. 19. Bonatti J, Schachner T, Bonaros N, et al. Technical challenges in totally endoscopic robotic coronary artery bypass grafting. J Thorac Cardiovasc Surg 2006;131:146-53.