g., valve repair or replacement), and decompensated congestive heart regardless failure are regarded as exclusion criteria [7, 17, 20, 22, 27, 28]. 3.2. Timing of the HCR Procedure The best timing of the interventions remains a matter of debate. Three HCR strategies can be distinguished: (I) performing PCI first, followed by LITA to LAD bypass grafting or (II) vice versa; (III) combining LITA to LAD bypass grafting and PCI in the same setting in a hybrid operative suite. In the included studies, staged HCR procedures (I and II) were applied much more frequently than simultaneous procedures (III). In a ��staged�� procedure, in which PCI and LITA to LAD bypass grafting are carried out at separate locations and/or different days, both interventions can be performed under ideal circumstances (in a modern catheterization laboratory and modern operating room, resp.
) [11, 18, 29]. However, patients have to undergo 2 procedures, while they remain incompletely revascularized and at risk for cardiovascular events for an extended period of time [14, 29]. When PCI is performed first, a staged procedure takes place with an unprotected anterior wall, which could pose serious health risks in case the LAD lesion is considered the culprit lesion [13]. In addition, LITA to LAD bypass grafting is performed after aggressive platelet inhibition for prevention of acute (stent) thrombosis, which might lead to unnecessary postponement of following operation or may cause a higher than expected rate of bleeding [12, 13, 21, 29].
Moreover, stent thrombosis is risked after reversal of surgical anticoagulation and is related to the inflammatory reaction after cardiac surgery [13]. Furthermore, the opportunity for quality control of the LITA to LAD bypass graft and anastomosis by a coronary angiogram is lost and, therefore, this strategy requires a reangiography [12, 13]. These repeat control angiograms increase overall healthcare costs unnecessarily and decrease cost effectiveness [12]. Nevertheless, the potential advantages of this strategy are threefold. First, revascularization of non-LAD vessels provides an optimized overall coronary flow reserve, thereby minimizing the potential risk of ischemia and myocardial infarction during the LAD occlusion for LITA to LAD bypass grafting [6, 12]. Second, it is possible for the interventional cardiologist to fall back on conventional CABG in case of a suboptimal PCI result or major PCI complications.
However, failure of PCI leading to emergency conventional CABG has become extremely rare with decreasing incidence Entinostat since the introduction of coronary artery stenting [12, 20, 29�C32]. Furthermore, this strategy allows HCR in patients with the immediate need for PCI in a non-LAD target and no immediate possibility for emergency bypass surgery [11, 24].