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Pusca et al. Mini-invasive Surg 2021;5:51 https://dx.doi.org/10.20517/2574-1225.2021.45 Page 9 of 15

Table 2. Relative indications and contraindications of HCR
Relative indications Relative contraindications
Low-intermediate SYNTAX score High SYNTAX score
Proximal focal coronary lesions Left thoracotomy, left lung surgery
Low burden of calcium in the coronary arteries Home oxygen requirements
Good target vessels (large LAD) Hemodynamic instability
Large pleural cavity Preoperative need for intraaortic balloon pump
Small heart Obese (particularly morbidly obese) patients
Thin, tall body habitus Suspicion of intramyocardial LAD

SYNTAX score: angiographic grading system that evaluates the complexity of lesions in coronary artery disease, ranging from 0 (least complex)
to 60 (most complex) and derived from the “SYNergy between percutaneous coronary intervention with TAXUS stent and cardiac surgery” trial.
HCR: Hybrid coronary revascularization.

HCR in patients with chronic obstructive pulmonary diseases
Chronic obstructive pulmonary diseases (COPD) poses an interesting challenge for the performance of
HCR. On one hand, increased lung volumes increase left pleural cavity size and improve visualization and
ability to harvest the mammary greatly. On the other hand, medium and small airway obstruction can trap
air and make visualization difficult. Our preference is to use double-lumen tubes versus bronchial blockers
in such patients as this allows better deflation of the left lung. The use of CO insufflation for robotic cases
2
can result in respiratory acidosis and hypotension much faster than in patients without COPD; the
anticipation of these issues, administration of bronchodilators, and frequent blood gas checks.

With CO insufflation, the other option is to use low tidal volume bilateral lung ventilation during the
2
LIMA harvest and deflate the left lung during the anastomosis. Intermittent bilateral lung ventilation can
also be used throughout the procedure. In general, we have found that almost all patients who are not on
home supplemental oxygen are able to tolerate either single or low-tidal volume bilateral lung ventilation
safely.

HCR in patients with chest wall deformities (prior trauma, chest wall radiation, kypho-scoliosis,
pectus deformities)
Such patients can pose substantial challenges for minimally invasive CABG because of difficult visualization
and possible unpredictable course or complete occlusion of the LIMA in case of prior trauma with rib
fractures or radiation. Thus, again, the decision should be made on a case-by-case basis, taking into account
the severity of the deformity, its particular location, the likelihood of direct interference with the operation,
and most important the experience of the operator with minimally invasive CABG procedures.

HCR for left main disease
CABG is considered the standard of care for left main disease (LMD). Recently, however, after the results of
the EXCEL trial, PCI has been upgraded as an acceptable alternative for LMD treatment. This has opened
the possibility for HCR as a solution for LMD. However, performing a “limited intervention” in cases of
LMD during the first step of the HCR can have adverse effects during the higher demands of postoperative
recovery after a minimally invasive CABG procedure and until the patient can get completely revascularized
with PCI. We compared 27 patients who had HCR with 81 contemporary patients treated with off-pump
CABG for LMD. In all but one HCR patient, the left main was stented into the circumflex after LIMA LAD
anastomosis. Immediate postoperative and medium-term outcomes were similar, except that the need for
perioperative blood transfusions was significantly lower in the HCR group than the sternotomy CABG
group. There was a trend towards a higher need for repeat revascularization at a median follow-up of 3.2
years, but not statistically significant - 2 patients in the HCR group vs. 1 patient in the CABG group,