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Pusca et al. Mini-invasive Surg 2021;5:51 https://dx.doi.org/10.20517/2574-1225.2021.45 Page 11 of 15

functional evaluation (fractional flow reserve calculations - iFR/RFR); however, technical issues that can
occur in attempts to cross a fresh anastomosis with a wire could be a problem. Our experience, which we
are in the process of analyzing for mid and longer-term results, has been that the majority of these should
not be intervened on early, particularly if there is TIMI 3 flow distal to the anastomosis. Instead, repeat
angiography in 6-8 weeks, and possible iFR/RFR is recommended, and if necessary, intervention can then
be performed.

Major adverse cardiac and cerebrovascular events (MACCE - death, myocardial infarction, and
stroke)
In most published series, there are no statistically significant differences in hospital MACCE between the
HCR group when compared to our conventional sternotomy patients [14,18-22] . However, our current
experience suggests a low risk-adjusted mortality rate < 1% and a stroke rate that is comparable to PCI at
approximately 0.5%.

One important finding was that the incidence of perioperative myocardial infarction was not statistically
[14]
different (0.7% vs. 0.5% in the HCR vs. the conventional group, P = 0.8) . This alleviates concerns that
partial revascularization, either by single vessel CABG or PCI, during the initial part of the procedure would
increase the risk of perioperative myocardial infarction due to increased risk of perioperative demand
ischemia during the interim period between both procedures [18-22] .

In general, if patients present with an acute coronary syndrome secondary to a non-LAD culprit lesion, they
should undergo PCI of the non-LAD culprit lesion first. If the LAD lesion is not critical, it can be staged 4-6
weeks later.

If the LAD lesion and the non-LAD lesion(s) are both critical, LIMA LAD grafting should be done first, and
PCI should be done postoperatively during the same hospital stay. For non-critical lesions, the procedures
can be staged over weeks.

The goals of HCR should be the same as for CABG and multivessel PCI - complete revascularization for all
patients.

Risk of bleeding
An important question about HCR is the risk of bleeding due to the mandatory need for antiplatelet agents
in the perioperative period. A pivotal role in the success of HCR is played by the use of DES. Such stents
have a long-term patency rate comparable to vein grafts, and second-generation DES are less thrombogenic
compared to bare metal stents; however, early thrombosis due to delayed endothelialization can still be an
issue. Dual antiplatelet therapy is mandatory after DES, and the risk of stent thrombosis, with associated
myocardial infarction or sudden death, doubles for the first generation stents if that therapy is stopped [7,8,23] .
Even with the second-generation DES, permanent discontinuation of dual antiplatelet therapy before thirty
days from stent insertion results in a high risk of stent thrombosis (hazard ratio = 26.8, 95% confidence
interval: 8.4-85.4, P < 0.0001); permanent discontinuation after 90 days does not seem to be associated with
[23]
a higher risk of stent thrombosis .

For patients that have undergone a PCI first strategy for HCR, we recommend the continuation of DAPT
even for their surgery. Modifications of these recommendations will depend on guideline changes for the
duration of DAPT for the latest generation of DES.