Robotic Totally Endoscopic Reverse Hybrid Coronary Revascularization: Early and Midterm Outcomes

Objective: Reverse hybrid coronary revascularization (RHCR) is the integration of percutaneous coronary intervention (PCI) followed by sternal-sparing coronary artery bypass grafting in patients with multivessel coronary artery disease (CAD). We sought to review our RHCR experience over a 10-year period using PCI first followed by robotic totally endoscopic coronary artery bypass (TECAB).Methods: We reviewed the indications and outcomes in patients who underwent RHCR (PCI with drug-eluting stents first, followed by TECAB).Results: From July 2013 to August 2024, 882 robotic TECAB procedures were performed at our institution. Of these, 60 patients underwent RHCR. The mean age of the patients was 66.7 +/- 10 years, and 74% were male patients. The target vessel stented was the right coronary artery in 52 patients (87%), circumflex coronary artery in 10 patients (17%), and diagonal in 4 patients (7%). The average time from PCI to TECAB was 3.8 +/- 1.64 months. A total of 35 patients (58%) underwent multivessel grafting, with 74% bilateral internal thoracic artery (ITA) use. The mean operative time was 253 +/- 88 min, and the mean hospital length of stay was 2 +/- 0.76 days. There were no conversions, perioperative strokes, or myocardial infarctions. At mean follow-up of 34 +/- 27 months, cardiac-related mortality occurred in 1 patient. Freedom from major adverse cardiac or cerebrovascular events including repeat revascularization was 93%.Conclusions: RHCR is safe and feasible in selected patients with multivessel CAD. In experienced hands, stenting first followed by robotic TECAB with left ITA or bilateral ITA grafts resulted in excellent early and midterm outcomes. Further studies are warranted.