The emerging concept of hybrid coronary revascularization

Coronary artery disease (CAD) is the foremost single cause of morbidity and mortality globally even if their prevalence continues to fall in the last decades in Western countries. This may be due both to improved primary and secondary preventive measures and to effective treatment of the acute phase. Many of these patients with multivessel CAD need a staged treatment of their disease following the acute phase either by percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG), or both. In addition, the aging population, irrespective of additional bleeding risk criteria, warrant less intensive therapy. This subgroup of patients, with a higher prevalence of comorbidities including CAD, needs specific revascularization strategies taking into account the bleeding risk related to such procedures. In this setting less invasive strategies including the use of advanced endoscopic and robotic approaches led to a new concept of hybrid coronary revascularization (HCR) for CAD. The rationale of HCR lies in the wellestablished survival benefit conferred by left internal mammary artery to left anterior descending coronary artery (LIMA-to-LAD) grafting combined with PCI to non-LAD coronary vessels using contemporary stent platforms. HCR can be performed with different strategies which may have some advantages both in terms of clinical outcomes and in the management of bleeding risk. One-stop HCR is performed simultaneously, starting with surgery followed by PCI. Two-stage HCR consists of two different procedures: in the standard two-stage HCR, surgery is followed by PCI after 1–2 months; in the reverse twostage HCR, PCI is performed first. In this chapter we describe the different options and their possible clinical applications.