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Pusca et al. Mini-invasive Surg 2021;5:51 https://dx.doi.org/10.20517/2574-1225.2021.45 Page 7 of 15

Figure 9. Hybrid coronary revascularization coronary angiogram: robotic left internal mammary artery to left anterior descending and
stenting of the distal circumflex artery.

TIMING OF HCR STEPS
It is important to understand that HCR has two components: minimally invasive or robotic-assisted CABG
and PCI. The sequence in which these two steps are performed matters and has clinical, scheduling, and
even financial consequences. A comparative summary of the advantages and disadvantages of each
sequence is presented in Table 1.

Our preference at Emory is to perform the LIMA-LAD first when possible. In patients with stable coronary
disease, this has several advantages, including the ability to perform the surgical procedure without
concerns for dual antiplatelet therapy and interrogate the anastomosis angiographically during the
subsequent cardiac catheterization. However, for patients that present to the hospital with an acute
coronary syndrome, the general rule is to treat the culprit lesion first.

The LIMA LAD anastomosis can be done during the same admission or staged 1-2 months later if the LAD
anatomy permits [13,17] . The most convenient option for the patient is a concomitant procedure in a hybrid
room where the PCI portion of the procedure can be performed immediately after the anastomosis.

The main advantage for the clinician is that graft patency can be confirmed immediately on the operating
table, and any technical complications can be addressed while still in the operating room.

However, the logistical challenges of scheduling for both surgeons and interventionalists can make this
difficult.