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Page 10 of 15 Pusca et al. Mini-invasive Surg 2021;5:51 https://dx.doi.org/10.20517/2574-1225.2021.45

[13]
P = 0.9 . Certainly, this study was small but shows that such an approach is feasible.

In general, this option can be considered in patients with either distal left main bifurcation lesion or any
lesion in the left main along with a proximal lad lesion. Isolated ostial or body lesions should not be
considered for HCR b/c; there will be significant competitive flow with the LIMA b/c; there will no longer
be a proximal lesion after PCI of the left main.

HCR for patients with a low ventricular ejection fraction
Poor contractility makes any cardiac intervention more difficult, and HCR is no exception. The challenge is
augmented by the fact that the heart cannot be fully visualized during the CABG part of the operation.
Nevertheless, such patients tend to tolerate poorly marginal oxygenation and ventilation that can occur with
single lung ventilation. As a general rule, if cardiopulmonary bypass assistance may be needed, our
preference is to perform median sternotomy.

HCR in patients with previous left lung surgery or who had previous left thoracotomies
In our experience, robotic HCR in those circumstances is generally contraindicated. The situation offers the
challenge of creating an adequate working space to harvest the LIMA and perform the LIMA to LAD
anastomosis because of previous adhesions. Equally challenging can be the fact that the heart can be
displaced much further to the left, particularly after left lower lobectomies. It is paramount, particularly in
situations of previous left anterolateral thoracotomies, to verify the patency of the LIMA at the time of
preoperative cardiac catheterization, as it could have been injured and ligated during the previous surgery.
Also, after left lung cancer surgery, it is possible that the patient had radiation to the chest wall on the left,
and this can make harvesting the LIMA exceedingly difficult. For all these reasons, the patient might be
better served with a conventional CABG and alternative arterial conduits, but these decisions should be
made on a case-by-case basis with considerations for the risks and benefits of each approach.

SAFETY OF HCR
Quality of the LIMA conduit and LIMA LAD anastomosis
One of the most important questions about HCR concerns exactly that topic: given the different
visualization during harvesting as well as limited exposure during the anastomosis, is this truly a
comparable end product to the well-established gold standard results of median sternotomy LIMA to LAD
operation? A comparison between our early HCR group versus median sternotomy off-pump CABG group
indicates that issues with either the LIMA or the LIMA to LAD anastomosis are potentially more prevalent
[14]
in the HCR group . However, these were rarely clinically driven ischemia events in the HCR group. In
addition, almost all of the patients in the hybrid group underwent LIMA angiography, and almost none of
the patients in the CABG group underwent postoperative angiography. Thus, the comparisons were not
standardized, and minor defects early after anastomosis are more likely to be identified.

Our recommendation is to perform completion or postoperative angiography during the surgeon’s early
experience with robotic-assisted CABG for quality control purposes. This was our model for almost all of
the first 3-400 cases. This provides opportunities for refinements in technique, ensures optimal quality
outcomes, and ensures that excellent results are achieved with minimally invasive approaches. Our current
patency rate approaches 98% for patients who underwent completion or postoperative catheterization.

One important question is what to do if a mild narrowing or physiologically insignificant defect is detected
at or near the distal anastomosis when PCI is performed during the second stage of HCR. There is no
compelling literature data about this issue. Certainly, an argument could be made about using invasive