Surgical and Interventional Details
Our technique for robotic-assisted LIMA to LAD bypass, constituting the MIDCAB component of HCR, has been described previously (13, 14). Briefly, the da Vinci Intuitive robot system (Intuitive Surgical Inc, Sunnyvale, CA, USA) was utilized for LIMA harvest. The LIMA to LAD anastomosis was completed ‘off-pump’, through an anterior, muscle-sparing, non-rib spreading, mini-thoracotomy, facilitated by a low-profile compression myocardial stabilizer. An intra-coronary shunt was used in all cases. Graft flow characteristics were assessed in the operating room using the Medistim VeriQ transit-time flow measurement system (Medistim USA Inc, Plymouth, MN, USA).
The PCI components of the HCR cases, as well as the interventions in those patients treated by PCI alone, were performed using standard techniques (~50% radial approach). All patients received either second or third generation drug-eluting stents (DES). We did not deny HCR to those patients that required ‘complex PCI’ (as defined by the NCDR (National Cardiovascular Data Registry) CathPCI Registry: https://www.ncdr.com/WebNCDR/docs/default-source/public-data-collection-documents/cathpci_v4_codersdictionary_4-4.pdf?sfvrsn=2). All patients were maintained on dual antiplatelet therapy for at least one year after stent placement. The majority of our sternotomy CABG cases were completed ‘off-pump’, our technique for which has been previously reported (15). All patients received a LIMA graft to the LAD.