Midterm Clinical Outcomes of Robotic-Assisted Reverse Hybrid Coronary Revascularization: A Single-Center Experience.

Outcomes of robotic-assisted reverse hybrid coronary revascularization (HCR) remain hindered. We aimed to analyze midterm clinical outcomes of robotic-assisted reverse HCR. All consecutive 285 patients who underwent reverse robotic-assisted HCR between September 2005 and July 2021 were included. Reverse HCR comprises percutaneous coronary intervention with stent implantation in non-left anterior descending (LAD) coronary arteries was performed within 30 days before robotic-assisted left internal thoracic artery (LITA) harvesting and LITA-to-LAD manual anastomosis through a 4-cm left minithoracotomy. Dual antiplatelet therapy was not interrupted in any patient. Preoperatively, mean age was 70.2 years (±11.2). Before surgery, 168 patients received 1 stent, 112 patients 2 stents, and 5 patients 3 stents. Intraoperatively, mean operating room time was 5.9 hours (±1); no case was converted to full sternotomy, whereas 9 patients (3.1%) received intraoperative blood product transfusions. Postoperatively, a small incidence of stroke, 1 (0.3%), reoperation for bleeding, 7 (2.4%), blood product transfusions, 48 (16.8%), and hospital stay (4.8 days) was observed. At 30-day follow-up, 1 patient (0.3%) underwent percutaneous coronary intervention with stent on a surgical LITA-LAD anastomosis owing to graft failure. Mean follow-up was 4.2 years. Reported midterm outcomes included all-cause death in 31 patients (10.9%), major adverse cardiovascular and cerebrovascular events in 102 of 285 (35.9%), nonfatal stroke in 2 of 285 (0.7%), myocardial infarction in 17 of 285 (5.9%), and repeat intervention in 50 of 285 patients (17.5%). This single-center study reports effective and safe clinical outcomes at midterm follow-up of reverse HCR procedures for treating multivessel coronary artery disease.

Long-term clinical outcomes of robotic-assisted surgical coronary artery revascularisation.

BACKGROUND: Patients who are not candidates for traditional coronary artery bypass grafting (CABG) and amenable only for percutaneous coronary intervention (PCI) with stents can receive the "gold standard" left internal thoracic artery (LITA) to left anterior descending artery (LAD) anastomosis through robotic-assisted CABG and PCI to non-LAD coronary targets. AIMS: We aimed to analyse clinical outcomes of robotic-assisted CABG. METHODS: A total of 2,280 consecutive patients who had undergone robotic-assisted CABG between May 2005 and June 2021 were included in our study. Robotic-assisted LITA harvest was followed by LITA-LAD manual anastomosis through a 4 cm left thoracotomy. Hybrid coronary intervention (HCR) consists of stent implantation in a non-LAD coronary artery performed within 7 days after robotic-assisted LITA-LAD. We performed a propensity-adjusted analysis comparison after dividing all robotic-assisted CABG patients into three time periods: 2005-2010, 615 patients; 2011-2016, 904 patients; and 2017-2021, 761 patients. RESULTS: The mean age increased from 64.5 years in the first time period to 65.8 years in the second time period to 68.1 years in the third (p<0.0001). Operative time was progressively reduced in the three periods (6.4; 6.2; 5.5 hours; p<0.001). The incidence of conversion to sternotomy remained similar for each period (1.8%; 1.7%; 1.5%; p=0.53). Thirty-day mortality in the three periods included 9 (1.4%), 9 (1.0%), and 7 (0.9%) patients, respectively (p=0.91), while 8 (0.3%) patients had PCI with stents in the entire group. The mean follow-up for the entire population was 4.2 years. At follow-up, the rates of all-cause death, major adverse cardiac and cerebrovascular events, non-fatal stroke, and repeat revascularisation with stents were significantly decreased from the first to the last period (pË0.0001). CONCLUSIONS: Robotic-assisted CABG and HCR provide good long-term outcomes in patients who are not candidates for conventional CABG.

Hybrid Coronary Revascularization for the Treatment of Multivessel Coronary Artery Disease: A Multicenter Observational Study.

BACKGROUND: Hybrid coronary revascularization (HCR) combines minimally invasive surgical coronary artery bypass grafting of the left anterior descending artery with percutaneous coronary intervention (PCI) of non-left anterior descending vessels. HCR is increasingly used to treat multivessel coronary artery disease that includes stenoses in the proximal left anterior descending artery and at least 1 other vessel, but its effectiveness has not been rigorously evaluated. OBJECTIVES: This National Institutes of Health-funded, multicenter, observational study was conducted to explore the characteristics and outcomes of patients undergoing clinically indicated HCR and multivessel PCI for hybrid-eligible coronary artery disease, to inform the design of a confirmatory comparative effectiveness trial. METHODS: Over 18 months, 200 HCR and 98 multivessel PCI patients were enrolled at 11 sites. The primary outcome was major adverse cardiac and cerebrovascular events (MACCE) (i.e., death, stroke, myocardial infarction, repeat revascularization) within 12 months post-intervention. Cox proportional hazards models were used to model time to first MACCE event. Propensity scores were used to balance the groups. RESULTS: Mean age was 64.2 ± 11.5 years, 25.5% of patients were female, 38.6% were diabetic, and 4.7% had previous stroke. Thirty-eight percent had 3-vessel coronary artery disease, and the mean SYNTAX (Synergy Between PCI With Taxus and Cardiac Surgery) score was 19.7 ± 9.6. Adjusted for baseline risk, MACCE rates were similar between groups within 12 months post-intervention (hazard ratio [HR]: 1.063; p = 0.80) and during a median 17.6 months of follow-up (HR: 0.868; p = 0.53). CONCLUSIONS: These observational data from this first multicenter study of HCR suggest that there is no significant difference in MACCE rates over 12 months between patients treated with multivessel PCI or HCR, an emerging modality. A randomized trial with long-term outcomes is needed to definitively compare the effectiveness of these 2 revascularization strategies. (Hybrid Revascularization Observational Study; NCT01121263).

Unanswered questions in patients with concurrent atrial fibrillation and acute coronary syndrome.

The best regimen for the long-term management of patients with atrial fibrillation who present with an acute coronary syndrome or require placement of a coronary stent remains unclear. Clinicians need to understand the risk of stroke, stent thrombosis, and major bleeding associated with treating these patients. Numerous studies and risk assessment schemes provide clinicians with an estimation of the risk of stroke, stent thrombosis, and major bleeding that may be associated with the use or avoidance of dual antiplatelet therapy with concurrent anticoagulation therapy (triple therapy). This review discusses the special antithrombotic needs in patients who have atrial fibrillation and either acute coronary syndrome or a requirement for percutaneous coronary intervention, including the published evidence for non-vitamin K oral anticoagulants, and the unanswered questions in this patient population. In conclusion, until the results of additional ongoing or planned randomized trials are known, clinicians must continue to rely on expert opinion and their own clinical judgment when treating these patients.

Incredibly late thromboses in first generation drug eluting stents: a case series.

BACKGROUND: The drug-eluting stents have decreased the incidence of instent restenosis compared to bare metal stents. But, the incidence of late and very late stent thrombosis has increased with the drug-eluting stents. CASE PRESENTATION: We are here, reporting three cases of incredibly late instent thrombosis, each one occurring after more than 50 months of drug-eluting stent placement. CONCLUSION: The occurrence of stent thrombosis as late as 5 years has been reported in literature. This highlights the importance that there may be no limit to the time duration to the occurrence of very late stent thrombosis and dual antiplatelet therapy with aspirin and clopidogrel may have to be continued indefinitely in patients with drug-eluting stents.

The relationship of obesity to ischemic outcomes following coronary stent placement in contemporary practice.

OBJECTIVES: We analyzed the relationship of obesity, determined by body mass index (BMI), to short- and long-term outcomes in the TARGET trial. BACKGROUND: : Previous studies have conflicting findings regarding the relationship of BMI to outcomes following percutaneous coronary intervention (PCI). METHODS: The TARGET trial studied the use of glycoprotein (GP) IIb/IIIa inhibition in patients undergoing planned coronary stent placement. RESULTS: Eighty-one percent of all patients were overweight (BMI > 25), 36% were obese (BMI > 30), and United States patients were more frequently obese (38.7% vs. 25.8%, P < 0.001). Obese patients had a similar 30-day ischemic event rate compared with nonobese patients, but less major bleeding (0.4% vs. 1.1%, P = 0.013). Six-month death and myocardial infarction rates were similar in obese and nonobese patients. There was a J-shaped relationship between 6-month target vessel revascularization (TVR) and BMI with the lowest incidence of TVR at BMI 27.5. Six-month TVR was higher in the morbidly (BMI > 35) obese (12.4% vs 8.7%, P < 0.05). In extremely (BMI > 32) obese patients, this relationship was more significant (TVR 11.3% vs. 8.5%, P = 0.007), particularly in patients <65 years of age (TVR 12.3% vs. 8.4%, P = 0.003). CONCLUSION: The majority of patients undergoing PCI are overweight, especially in the United States. Extreme obesity is associated with a significant increase in TVR following intent-to-stent PCI, especially in patients <65 years of age. With routine use of GP IIb/IIIa inhibitors, other long- and short-term ischemic events are similar in obese and nonobese patients. However, obese patients have significantly less major bleeding.