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\begin{document}

\title{First Report of Totally Robotically-Assisted Hybrid Coronary Artery
Revascularization Combining RE-MIDCAB and R-PCI: Case Report}



\author[1]{Dario Tino Bertolone}%
\author[1]{Konstantinos Bermpeis}%
\author[1]{Emanuele Gallinoro}%
\author[1]{Giuseppe Esposito}%
\author[1]{Pasquale Paolisso}%
\author[1]{Cristina De Colle}%
\author[1]{Jeroen Sonck}%
\author[1]{Carlos Collet}%
\author[1]{Bernard De Bruyne}%
\author[1]{Emanuele Barbato}%
\author[1]{Frank Van Praet}%
\author[1]{Eric Wyffels}%
\affil[1]{Hartcentrum OLV Aalst}%


\vspace{-1em}



  
  \date{June 15, 2024}


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\selectlanguage{english}
\begin{abstract}
A 62-year-old man presents to the Cardiology Department with a two years
history of angina on exertion. Invasive coronary angiography revealed a
severe three vessels coronary artery disease. The ``Hybrid Heart Team''
successfully performed a fully robotically-assisted hybrid
revascularization combining RE-MIDCAB on the LAD and R-PCI on non-LAD
lesions.%
\end{abstract}%



\sloppy


\textbf{Introduction}

Hybrid Coronary Revascularization(HCR) with arterial grafts to the left
anterior descending artery (LAD) and percutaneous coronary interventions
for non-LAD lesions have been shown excellent graft patency rates and
long-term results. This approach is a feasible strategy in selected
patients with multivessel coronary artery disease\textsuperscript{1}.

Robotically enhanced-minimally invasive direct coronary artery bypass
(RE-MIDCAB) is an endoscopic approach with robotic harvesting of the
left internal mammary artery(LIMA) followed by hand-sewn anastomosis
under direct vision to the LAD on the beating heart \textbf{(Fig.1A)} .
Robotically-assisted PCI (R-PCI) is a novel approach in interventional
cardiology, where operators perform PCI controlling guidewires and
catheter devices remotely \textbf{(Fig.1B)} .

\textbf{Case Report}

This case report highlights the feasibility of treating a patient with a
full robotically hybrid revascularization strategy. We report, a case of
fully Robotically-Assisted HCR. RE-MIDCAB surgery, combined with R-PCI.

A 62-year-old man presents with a two years history of typical stable
angina on exertion.

The patient has a history of arterial hypertension, hyperlipidemia,
obesity (BMI 31kg/m\textsuperscript{2}), insulin-dependent diabetes
mellitus (hemoglobin A\textsubscript{1c} of 8.4\%), and previous smoking
until 2012.

Physical examination was normal. Resting echocardiography showed a
preserved left ventricular ejection fraction (biplane 60\%) without wall
motion abnormalities. A cycle ergometer stress test was submaximal and
hence inconclusive to rule out CAD.

Invasive Coronary Angiography (ICA) revealed a severe three-vessel
disease. Multiple atherosclerotic lesions were present with an 80\%
focal stenosis in the middle RCA \textbf{(Fig.2A)} , a 70-80\% focal
stenosis in the proximal LCx \textbf{(Fig.2B)} , and diffuse and
extensive lesions of the LAD \textbf{(Fig.2C)} . The anatomical SYNTAX
Score was 15.

A hemodynamic evaluation of the lesions was performed using a Fractional
Flow Reserve (FFR) with a pullback maneuver, in this way it is possible
to evaluate the distribution of epicardial resistance to determine CAD
pattern (focal or diffuse CAD)\textsuperscript{2}. The hyperemic
Pullback Pressure Gradient (PPG), was used to quantify the CAD
pattern\textsuperscript{3}. The FFR measurement in the LAD showed an FFR
value of 0.75 with a PPG value of 0.40(\textbf{Fig.2D} ).

\textbf{Management}

Following a discussion in the Heart team, a hybrid robotically-assisted
revascularization was proposed to the patient. First, the RE-MIDCAB
(DaVinci X Surgical System, Intuitive Surgical, Sunnyvale, USA),
robotically-assisted harvesting of a pedicled LIMA followed by an
end-to-side anastomosis to LAD, was performed via a left non-rib
spreading mini-thoracotomy \textbf{(Video 1)} . On the
2\textsuperscript{nd} post-operative day, the staged R-PCI
revascularization was performed. The LIMA-LAD anastomosis was assessed
by coronary angiography before PCI, confirming a good quality of the
bypass \textbf{(Fig.3A)} . Then, R-PCI was performed using the CorPath
GRX Robotic-PCI System \textbf{(Fig.3B)(Video 2)} . A Drug-Eluting Stent
(Abbott Sierra 3.0 x 33 mm) was placed on the RCA \textbf{(Fig.3C)} and
a long Drug-Eluting Stent (Biotronik, Orsiro Mission 3.0 x 40 mm) was
placed from LCx to the first obtuse marginal branch
(OM1)\textbf{(Fig.3D)(Video 3)} , achieving an excellent angiographic
result. The postoperative course was uneventful and the patient was
discharged on the 3\textsuperscript{rd} post-operative day.

A first outpatient contact 6 weeks after the procedure the patient
remains free from angina and without any adverse event.

\textbf{Discussion}

Coronary artery bypass grafting (CABG), mainly utilizing multi-arterial
conduits, is the best therapeutic strategy for patients with diabetes
and multivessel CAD. The use of LIMA as a graft to the LAD has been
shown to have excellent long-term results in terms of patency,
event-free survival, and relief of angina in patients undergoing
coronary revascularization. On the other hand, the disadvantages of CABG
are epitomized by the invasiveness of the sternotomy, the use of
cardiopulmonary bypass, and other frequent complications (bleeding,
atrial fibrillation, and stroke) that results in prolonged
hospitalization\textsuperscript{4,5}.

As a result, the search towards more minimally invasive CABG techniques
has known a long history. Total endoscopic approach with
robotically-assisted harvesting of the internal mammary artery and
anastomosing to the LAD on beating heart through a mini-thoracotomy is a
well-known approach in expert centers. The main benefits of RE-MIDCAB
are related to the reduction of typical complications of surgery while
increasing patient satisfaction paired with excellent long-term graft
patency\textsuperscript{6}. If the advantages of using multi-arterial
conduits are well known, the use of saphenous vein grafts (SVGs) has
shown a high incidence of failure compared to ischemia-driven
multivessel PCI. PCI is less invasive and offers a reduced risk of
immediate complications coupled with a lessening of the length of
stay\textsuperscript{7}.

In the field of interventional cardiology, R-PCI is a novel and emerging
approach. The interventional cardiologist can perform PCI using controls
for rotational and longitudinal movements of the coronary guidewire,
guide catheter, and for advancement and retraction of balloons and
stents \textbf{(Video4)} . Several studies have corroborated the safety
and efficacy of R-PCI for the treatment of simple and complex lesions
(CORA-PCI study)\textsuperscript{8}.

\textbf{Conclusions}

This case shows the feasibility and safety of HCR in selected patients
with multivessel CAD, highlighting how this hybrid technique combines
the advantages of surgical and percutaneous revascularization, both
guided by robotic techniques, eliminating at the same time some of the
disadvantages of both procedures. Moreover, the use of RE-MIDCAB graft
of the LIMA to the LAD and R-PCI to treat non LAD lesions could lead to
additional benefits in optimizing patient outcomes.

This case report of robotically-enhanced hybrid revascularization is an
example of a search towards a ``value-based cardiovascular care'' in
which the enhanced outcome mattering to the patient together with the
cost reduction through shortening of hospitalization and reduction of
well-known complications are the capital elements of the equation.

\textbf{References}

\begin{enumerate}
\tightlist
\item
  Moreno PR, Stone GW, Gonzalez-Lengua CA, Puskas JD.The Hybrid Coronary
  Approach for Optimal Revascularization:JACC Review Topic of the Week.J
  Am Coll Cardiol 2020;76:321-333.
\item
  Collet C, Sonck J, Vandeloo B et al. Measurement of Hyperemic Pullback
  Pressure Gradients to Characterize Patterns of Coronary
  Atherosclerosis.J Am Coll Cardiol 2019;74:1772-1784.
\item
  Candreva A, Mizukami T, Sonck J et al. Hyperemic hemodynamic
  characteristics of serial coronary lesions assessed by pullback
  pressure gradients.Catheter Cardiovasc Interv 2021.
\item
  Fearon WF, Zimmermann FM, De Bruyne B et al. Fractional Flow
  Reserve-Guided PCI as Compared with Coronary Bypass Surgery.N Engl J
  Med 2021.
\item
  Neumann FJ, Sousa-Uva M, Ahlsson A et al.2018 ESC/EACTS Guidelines on
  myocardial revascularization.Eur Heart J 2019;40:87-165.
\item
  Davidavicius G, Van Praet F, Mansour S et al. Hybrid revascularization
  strategy: a pilot study on the association of robotically enhanced
  minimally invasive direct coronary artery bypass surgery and
  fractional-flow-reserve-guided percutaneous coronary
  intervention.Circulation 2005;112:I317-22.
\item
  Ganyukov V, Kochergin N, Shilov A et al. Randomized Clinical Trial of
  Surgical vs. Percutaneous vs. Hybrid Revascularization in Multivessel
  Coronary Artery Disease: Residual Myocardial Ischemia and Clinical
  Outcomes at One Year-Hybrid coronary REvascularization Versus Stenting
  or Surgery(HREVS).J Interv Cardiol 2020;2020:5458064.
\item
  Mahmud E, Naghi J, Ang L et al. Demonstration of the Safety and
  Feasibility of Robotically Assisted Percutaneous Coronary Intervention
  in~Complex Coronary Lesions:Results of the CORA-PCI Study. JACC
  Cardiovasc Interv 2017;10:1320-1327.
\end{enumerate}

\textbf{Figures}

\textbf{Figure 1}\selectlanguage{english}
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