ABC | Volume 110, Nº4, April 2018

Original Article Dong et al Comparison between HCR and OPCAB Arq Bras Cardiol. 2018; 110(4):321-330 Figure 3 – Funnel plot shows the test for publication bias of short-term (in-hospital or 30-day) mortality and MACCE rate. MACCE: major adverse cardiac and cerebrovascular event, RR: relative risk, SE: standard error. 0 0.5 1 1.5 2 0.01 0.1 1 10 100 RR SE (log[RR]) Short-term MACCE rate no-touch OPCAB provided superior neurological outcomes than on-pump CABG and no-touch technique should be properly applied. Halbersma et al. 32 investigated the four-year clinical outcomes after OPCAB with no-touch technique and concluded that it was a safe and efficient choice for patients with multivessel or left main CAD. Compelling data have indicated that the combination of OPCAB and clampless strategies can reduce stroke risk. However, the major shortcoming of no-touch OPCAB is its greater technical requirement so that it is not applicable for every surgical team or every patient. 33 Nevertheless, further investigations should be still carried out to compare no-touch OPCAB and HCR. In the current analysis, neither staged HCR nor simultaneous HCR makes a difference to the short-term outcomes, which is consistent with former studies. 27 Commonly, there are three strategies for HCR: (1) performing LIMA-LAD grafting first and then followed by PCI, the interval varies from several hours to a few weeks; (2) vice versa; (3) combined LIMA-LAD grafting and PCI at the same time in a hybrid operative unit. The optimal sequence of LIMA-LAD grafting and PCI has been debated but still remains unclear. In fact, most centers choose their own surgical procedures mainly based on preferences of physicians, considerations of patients, economic issues and available resources. Although several studies have indicated that both simultaneous and staged HCR contribute to excellent results, most centers prefer to adopt the latter one with LIMA‑LAD grafting performed first. 34 The CABG‑first approach is recommended by the American College of Cardiology Foundation/American Heart Association 35 and it has some obvious advantages. It can reduce the overlapping from two different teams so that they can perform in their most familiar way and avoid to interacting with each other in operation room. Then antiplatelet and antithrombotic strategies can be well managed and adjusted according to physicians from different teams. 36 However, the disadvantages include that patients have to undergo at least two surgeries and needmore time to recover. Moreover, hemorrhagic tendency and overload of kidneys also deserve significant attention. Currently, no study has compared the clinical outcomes of staged HCR and simultaneous HCR directly, so further research should be placed on it. In the present analysis, we also confirm that HCR apparently decreases the ventilator time, ICU stay, hospital stay and blood transfusion rate comparing to OPCAB. Although these items may not directly influence the main outcomes, they are also important criteria to judge a surgical procedure. Several reasons may account for these advantages of HCR. With the development of surgical procedures, endoscopic technique and mini incision are widely utilized in HCR to help patients ease suffering and recover sooner. 37 And retractor‑stabilizer, such as robot, provides access that LIMA-LAD grafting can be performed with accuracy and precision with minimally invasive thoracotomy or sternotomy. 38 Practically, with the assistance of a surgical robot, it offers an excellent visual field and reduces operation time. However, some drawbacks of HCR also deserve our attention. Our study detects that the hybrid procedure required longer operation time and incurred much higher in-hospital costs than OPCAB. In Bachinsky`s study, 23 despite lower postoperative costs, the HCR group still needs more overall hospital costs owning to its higher procedural costs. Consequently, pros and cons of HCR should be weighed and considered carefully before operation. 327