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Page 12 of 15 Pusca et al. Mini-invasive Surg 2021;5:51 https://dx.doi.org/10.20517/2574-1225.2021.45

At Emory, we use a staged strategy preferentially, performing the robotic LIMA LAD first, then the PCI,
unless the culprit vessel is a non-LAD vessel, in which case PCI is performed first. With this strategy, our
blood transfusion requirements have been statistically significantly less in the HCR group than in the
[17]
[14]
sternotomy CABG group (35.4% vs. 56%, P < 0.001) . Similar results have been confirmed by others .
However, a larger study is necessary to elucidate this issue, as it is possible that performing PCI routinely
first, before the portion of the procedure, can increase the risk of bleeding due to the more widespread use
of dual antiplatelet therapy. Our current transfusion rate for HCR procedures is approximately 15% of
patients undergoing robotic-assisted CABG, which is significantly less than sternotomy patients - 25%-30%.

A word of caution should also be said about the particular type of antiplatelet agents used: most of the
studies have been done with the combination of Aspirin and Plavix (Clopidogrel). Newer agents like
Brilinta (Ticagrelor) or Effient (Prasugrel) have not been studied extensively in this setting, and it is
possible, particularly if PCI is done first and particularly if Effient (which is much more potent at platelet
inhibition) is used, that the bleeding complications will be higher in the HCR group.

For patients on these newer generation antiplatelet agents, we usually transition them to clopidogrel if they
are sensitive to this agent 7 days before surgery to avoid performing surgery on ticagrelor or prasugrel.

Mistaking a diagonal branch for the LAD
Mistaking a diagonal branch for the LAD can occur at times, particularly if the LAD is small,
intramyocardial or the target LAD lesion is very distal, as mentioned above. If there is no stenosis between
the ostium of the diagonal and the LAD, grafting a LIMA to diagonal instead of the LAD has two main
drawbacks: the diagonals are much smaller vessels, and the diagonals lack septal perforators, which reduces
the vascular bed available for immediate perfusion substantially. Both of these factors can result in decrease
patency rates for the LIMA and inadequate long-term flow in the anterior region of the heart.

For these reasons, if the mistake is recognized intraoperatively, we recommend transecting the LIMA as
close as possible to the diagonal anastomosis after applying a small clip on the LIMA flush with the diagonal
and re-grafting the LAD with the LIMA. If this complication is recognized during the index procedure, it
almost always can be addressed during the same setting by dividing the LIMA at the diagonal anastomosis
and grafting it onto the LAD.

ADVANTAGES OF HCR: WHAT HCR CAN DO WELL AND WHAT IT DOES ONLY
MARGINALLY BETTER THAN CONVENTIONAL CABG
The main advantages to a hybrid approach are the following:

(1) The major benefit of CABG is still achieved with LIMA LAD grafting;
(2) There is a lower transfusion rate [14,17] compared to conventional CABG;
(3) Risk of stroke is lower because there is no aortic manipulation and no cardiopulmonary bypass;
(4) The risk of serious wound complications (mediastinitis) is avoided;
(5) Return to normal activity and recovery time are much quicker;
(6) Improved cosmesis.

The main goal with HCR is for patients with proximal LAD disease who may have otherwise been treated
with PCI to the LAD can derive the long-lasting benefits associated with LIMA LAD grafting. In addition,
most of the patients that undergo robotic-assisted CABG would have otherwise been treated with
multivessel PCI, not CABG.