Hybrid Revascularization With Robotic Totally Endoscopic Coronary Bypass and Stents: What Are the Outcomes When The Stent Does Not Happen?

Abstract

Hybrid coronary revascularization (HCR) combines minimally invasive coronary bypass with percutaneous coronary intervention (PCI) to achieve complete revascularization. However, in some patients, the PCI portion is not completed, resulting in incomplete HCR. Outcomes in this population are not well known. We sought to better understand this group of patients undergoing robotic beating-heart totally endoscopic coronary artery bypass (TECAB). We retrospectively analyzed 418 intent-to-treat HCR patients who underwent robotic TECAB between July 2013 and June 2025. Of these, 332 (80%) completed PCI and 85 (20%) did not. Propensity score matching yielded 82 well-balanced pairs. Early outcomes, perioperative variables, and midterm survival and freedom from major adverse cardiac and cerebrovascular events were compared. Intraoperative and early postoperative outcomes were similar between groups. Hospital length of stay was slightly longer in the complete PCI group (2.7 ± 0.9 days vs 2.3 ± 0.8 days; P = .004). At 5 years, cardiac survival was 95.7% in the complete PCI group vs 95.4% in the incomplete PCI group (log-rank P = .608). Freedom from cardiac mortality, myocardial infarction, repeated revascularization, and major adverse cardiac and cerebrovascular events was also not significantly different. Incomplete PCI most commonly involved right coronary artery or nondominant circumflex lesions; no patients had ungrafted left anterior descending coronary artery or other dominant left-sided targets. In a propensity score-matched cohort of patients undergoing robotic TECAB, omission of PCI as part of HCR did not have a negative impact on midterm survival, repeated revascularization, or major adverse events. Careful selection of patients and prioritization of dominant left-sided coronary targets are vital. Further studies with longer follow-up are warranted.