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\begin{document}

\title{Long-Term Survival in Triple-Vessel Disease: Hybrid Coronary
Revascularization Compared to Contemporary Revascularization Methods}



\author[1]{Craig Basman}%
\author[2]{Jonathan Hemli}%
\author[1]{Michael Kim}%
\author[1]{Karthik Seetharam}%
\author[1]{Derek Brinster}%
\author[1]{Luigi Pirelli}%
\author[1]{Chad Kliger}%
\author[1]{S Scheinerman}%
\author[1]{Varinder Singh}%
\author[1]{Nirav Patel}%
\affil[1]{Lenox Hill Hospital}%
\affil[2]{Affiliation not available}%


\vspace{-1em}



  
  \date{May 23, 2024}


\begingroup
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\selectlanguage{english}
\begin{abstract}
Background: Hybrid coronary revascularization (HCR) constitutes a left
internal mammary artery (LIMA) graft to the left anterior descending
(LAD) coronary artery, coupled with percutaneous coronary intervention
(PCI) for non-LAD lesions. This management strategy is not commonly
offered to patients with complex multi-vessel disease. Our objective was
to evaluate 8-year survival in patients with triple-vessel disease (TVD)
treated by HCR, compared with that of concurrent matched patients
managed by traditional coronary artery bypass grafting (CABG) or
multi-vessel PCI. Methods: A retrospective review was undertaken of 4805
patients with TVD who presented between January 2009 and December 2016.
A cohort of 100 patients who underwent HCR were propensity-matched with
patients treated by CABG or multi-vessel PCI. The primary end-point was
all-cause mortality at 8 years. Results: Patients with TVD who underwent
HCR had similar 8-year mortality (5.0\%) as did those with CABG (4.0\%)
or multi-vessel PCI (9.0\%). A composite end-point of death, repeat
revascularization, and new myocardial infarction, was not significantly
different between patient groups (HCR 21.0\% vs. CABG 15.0\%, p = 0.36;
HCR 21.0\% vs. PCI 25.0\%, p = 0.60). Despite a higher baseline SYNTAX
score, HCR was able to achieve a lower residual SYNTAX score than
multi-vessel PCI (p = 0.001). Conclusions: In select patients with TVD,
long-term survival and freedom from major adverse cardiovascular events
(MACE) after HCR are similar to that seen after traditional CABG or
multi-vessel PCI. HCR should be considered for patients with
multi-vessel disease, presuming a low residual SYNTAX score can be
achieved.%
\end{abstract}%



\sloppy


\textbf{ABBREVIATIONS}

ACCF = American College of Cardiology Foundation

AHA = American Heart Association

BMI = body mass index

CABG = coronary artery bypass grafting

CHF = congestive heart failure

COPD = chronic obstructive pulmonary disease

DES = drug-eluting stent

ESRD = end-stage (dialysis-dependent) renal disease

FREEDOM = Future Revascularization Evaluation in Patients with Diabetes

Mellitus: Optimal Management of Multivessel Disease

HCR = hybrid coronary revascularization

IQR = interquartile range

ISR = in-stent restenosis

LAD = left anterior descending coronary artery

LIMA = left internal mammary artery

LVEF = left ventricular ejection fraction

MACE = major adverse cardiovascular events

MI = myocardial infarction

MIDCAB = minimally-invasive direct coronary artery bypass

n/a = not applicable

NYHA = New York Heart Association

PCI = percutaneous coronary intervention

RCA = right coronary artery

SYNTAX = SYNergy between percutaneous coronary intervention with TAXus

and cardiac surgery

SD = standard deviation

SEM = standard error of the mean

TVD = triple-vessel (coronary artery) disease

\textbf{INTRODUCTION:}

Landmark trials have suggested that coronary artery bypass grafting
(CABG) should be considered the revascularization method of choice in
patients with multi-vessel disease (1, 2). The benefits of CABG in these
patients are largely accrued by the unique advantages of the left
internal mammary artery (LIMA) to left anterior descending (LAD) bypass
graft, which, in itself, affords a significant long-term survival
advantage, and which has consistently demonstrated 10-year patency rates
well above 90\% (3). On the other hand, saphenous venous grafts to
non-LAD targets are more prone to atherosclerotic degeneration and
failure, and have been observed to occlude as early as 1 year
postoperatively in 6 - 32\% of cases (4, 5). By contrast, angiographic
surveillance has demonstrated that rates of clinically relevant in-stent
restenosis (ISR) after percutaneous coronary intervention (PCI) are less
than 5\% at 1 year follow-up, especially with the increasing utilization
of newer generation drug-eluting stents (DES) (6). One further potential
pitfall of traditional CABG is an increased incidence of stroke, as
compared to PCI (1, 2).

Hybrid coronary revascularization (HCR) affords the patient the
advantages of the LIMA to LAD graft, usually completed via a
minimally-invasive approach, coupled with PCI for all non-LAD lesions.
Utilizing a minimal access, `off-pump' technique to complete the LIMA to
LAD bypass virtually negates the risk of stroke that is associated with
traditional CABG, whilst also reducing the infection rate and the
perioperative transfusion rate, and hastening recovery time by avoiding
a median sternotomy (7, 8).

In the American College of Cardiology Foundation/American Heart
Association (ACCF/AHA) Guidelines for Coronary Artery Bypass Graft
Surgery, HCR, for the treatment of triple vessel disease (TVD), was
denoted a Class IIb recommendation as an alternative method of
revascularization to PCI or CABG, in an attempt to improve the overall
risk-benefit ratio of the procedures (9). Despite the fact that the
first HCR was performed more than two decades ago, this treatment option
has constituted less than 0.5\% of all CABG volume in the United States
(10). A paucity of long-term data has undoubtedly contributed, at least
in part, to the relative under-utilization of HCR. Consequently, we
sought to evaluate the 8-year survival data after HCR for TVD, and we
compared it with that of concurrent matched patients who had either
traditional CABG via sternotomy or multi-vessel PCI.

\textbf{METHODS}

\textbf{Patients and Definitions}

A review was undertaken of all patients who underwent myocardial
revascularization at our institution between January 2009 and December
2016. Of these patients, those who had intervention for TVD were
selected for analysis.

We used the same definitions for stroke and myocardial infarction
(long-term) as the SYNTAX trial (1). However, for periprocedural
myocardial infarction (short-term outcome) we only included Type 1 MI
(using the Third Universal Definition of Myocardial Infarction) that
occurred on index hospital admission, which explains our low event rate
(11). New-onset renal failure was defined as a non-dialysis dependent
patient requiring one or more hemodialysis sessions post-procedure.
Target vessel revascularization was defined as a repeat intervention for
a prior stented lesion, either within the stent itself or within 5 mm of
the stent, and/or a repeat procedure for a lesion that was previously
surgically bypassed. We also included major adverse cardiovascular
events (MACE) as a long-term clinical endpoint. Our definition of MACE
denotes a composite end-point encompassing death, repeat
revascularization and/or myocardial infarction. We did not include major
adverse cardiovascular and cerebrovascular evens (MACCE) as a long-term
clinical outcome. Instead we included stroke as a short-term clinical
endpoint, as we felt that stroke 30 days post-revascularization is
unlikely related to the revascularization method. For patients that
underwent HCR, length of stay included the total hospital stay for both
the MIDCAB and PCI. Our preferred method is to perform a MIDCAB-first
approach, followed by interval PCI, typically within 4 to 6 weeks of
surgery. However, select situations require a PCI-first approach. Among
the PCI cohort in which revascularization was often performed on
separate admissions, we defined length of stay as the days admitted for
all hospitalizations combined. All clinical events were adjudicated by
an independent clinical event committee (involving a cardiothoracic
surgeon and interventional cardiologist).

The relative contraindications to HCR were the need for emergency
revascularization, and/or severe pulmonary disease rendering the patient
unable to tolerate single-lung ventilation. Patients with high BMI have
been regarded by some investigators as being unsuitable for HCR; we did
not withhold HCR from these patients, and, indeed, our experience with
minimally-invasive direct coronary artery bypass (MIDCAB) in this
patient population has been reported previously (12).

We analyzed propensity-matched patients who underwent HCR, CABG, or
multi-vessel PCI for triple-vessel disease. Any patients who required
concomitant non-coronary surgery, in addition to their revascularization
procedure, were also excluded, as were patients who required emergency
or salvage intervention, as well as patients who had prior cardiac
and/or thoracic surgery.

\textbf{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 (\textasciitilde{}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.

\textbf{Calculation of SYNTAX Scores}

All baseline SYNTAX scores were calculated by an experienced
interventional cardiologist who was blinded as to the treatment modality
that was to be assigned to any particular patient. Baseline SYNTAX
scores were derived from the initial coronary angiogram, prior to any
intervention.

For those patients who underwent coronary artery bypass grafting
(standard or hybrid coronary revascularization) the SYNTAX scores were
calculated based on Farooq V et al's methodology for the calculation of
residual SYNTAX score (16). In those patients that underwent
MIDCAB-first HCR or multi-vessel PCI, the residual SYNTAX score was
based on the final angiogram, obtained after the last stents were
placed. In those patients who had PCI-first HCR, the residual SYNTAX
score was calculated assuming patency of the LIMA to LAD graft. For the
CABG cohort, residual SYNTAX score was calculated based on the
combination of the initial angiogram together with the operation report,
assuming patency of the bypass grafts to the target vessels.

\textbf{Data Analysis}

Study data were collected and managed using REDCap electronic data
capture tools hosted at Lenox Hill Hospital (17). REDCap (Research
Electronic Data Capture) is a secure, web-based application designed to
support data capture for research studies.

Observed covariates at baseline included age, gender, body mass index,
diabetes mellitus, cerebrovascular disease, chronic lung disease,
peripheral vascular disease, dialysis-dependent renal failure, history
of prior myocardial infarction, congestive heart failure, and left
ventricular ejection fraction. To control for these confounding
influences, we calculated propensity scores (or the probability of
assignment to HCR, CABG, or multi-vessel PCI) using multivariable
logistic regression for each patient. Patients who underwent HCR were
matched with patients who underwent conventional CABG and with those who
had multi-vessel PCI in a 1:1 ratio through a nearest neighbor-matching
algorithm. In order to exclude bad matches, we instituted a caliper of
0.2 of the standard deviation of the logit of the propensity score. The
Area Under the Curve for the ROC of the propensity model 0.74. The
matched sample included a total of 300 patients, evenly distributed in
each group

Longitudinal outcomes and survival to 8 years was estimated using
Kaplan-Meier analysis and Cox proportional hazard regression. Patient
characteristics and outcomes were compared using chi-square, Fisher's
exact test, Student's t-test, or Wilcoxon-Mann-Whitney test, as
appropriate. A chi-square test was used for categorical variables~where
the expected value for each cell was 5 or higher; if this assumption was
not met, then Fisher's exact test was used. A \emph{p} value of less
than 0.05 was considered to be statistically significant. Statistical
analyses were performed with the IBM Statistical Package for the Social
Sciences (SPSS) for Windows, version 22.0 (IBM Corporation, Armonk, NY,
USA).

Mean (\selectlanguage{ngerman}± SEM) follow-up was 7.14 ± 0.12 years for all patients. All-cause
mortality up to a maximum of 8 years was obtained by querying the
National Death Index (NDI) to determine dates of death up to December
31, 2016. Short-term outcomes, such as length of hospital stay,
peri-procedural stroke, myocardial infarction (MI) or new-onset renal
failure was evaluated via a retrospective chart review on our hospital
systems electronic medical records. The long-term follow up for repeat
revascularization, myocardial infarction and target vessel
revascularization was achieved through a chart review of our hospital
system and our referring hospital systems electronic medical records.
The majority of patients had follow up greater than 1 year, however
there were patients (18 total) that we were unable to find proper
follow-up after hospital discharge.

\textbf{RESULTS}

\textbf{Patient Characteristics}

Over the study period, a total of 4805 patients had treatment for
triple-vessel coronary artery disease at our institution. Of these, 826
patients (17.2\%) were excluded from analysis, for reasons as previously
stated. Of the remaining 3979 patients with `stable' TVD, 100
individuals (2.5\%) underwent HCR, 1258 (31.6\%) had classic CABG via
sternotomy, whereas the remaining 2621 patients (65.9\%) had
multi-vessel PCI. Our final study population comprised the 100 patients
who underwent HCR, propensity-matched with 100 patients each who
underwent CABG or multi-vessel PCI for triple-vessel disease (Figure 1).
Patient demographics are summarized in Tables 1 and 2.

The baseline SYNTAX score was significantly higher in the CABG cohort
than in the HCR group (32.2 ± 7.9 \emph{vs.} 28.9 ± 10.6,
respectively,\emph{p} = 0.018), and, similarly, it was higher in the HCR
patients than in those who underwent PCI only (28.9 ± 10.6 \emph{vs.}
22.1 ± 7.6,\emph{p} \textless{} 0.01).

\textbf{Short-Term Outcomes}

Thirty-day mortality was 0\% in all patient groups. There was no
peri-procedural stroke, myocardial infarction (MI) or new-onset renal
failure, regardless of the technique of myocardial revascularization
employed (Table 3). Hospital length of stay was shorter for those
patients that underwent HCR (5.7 ± 7.5 days) than for those who had CABG
(7.5 ± 3.4 days) (\emph{p} = 0.01), but was still longer than it was for
the PCI group (2.0 ± 2.2 days) (\emph{p} \textless{} 0.0001).

There was no significant difference in residual SYNTAX score between
those patients who had HCR (4.5 ± 4.4) and those who underwent CABG (5.2
± 4.7) (\emph{p} = 0.31). However, despite the HCR cohort having a
higher SYNTAX score at baseline than those patients who underwent
multi-vessel PCI, the residual SYNTAX score was significantly lower
after HCR than it was after PCI (4.5 ± 4.4 \emph{vs.} 7.1 ± 6.5,
respectively, \emph{p} = 0.001) (Table 3).

\textbf{Long-Term Outcomes}

The primary end-point of all-cause mortality at 8 years was not
significantly across any of the three treatment groups (HCR
5.0\%\emph{vs.} CABG 4.0\% \emph{vs} . PCI 9.0\%) (Figure 2). There was
also no significant difference in the incidence of repeat
revascularization between the three patient groups (HCR 16.0\%
\emph{vs.} CABG 11.0\%\emph{vs.} PCI 18.0\%) (Figure 3). Repeat
revascularization rates on a previously treated coronary artery (`target
vessel revascularization') were similarly comparable between patient
cohorts (HCR 6.0\% \emph{vs.}CABG 5.0\% \emph{vs.} PCI 10.0\%) (Table
4). A composite MACE end-point encompassing death, repeat
revascularization and new myocardial infarction did not demonstrate
significant difference at 8 years, regardless of the technique of
revascularization (Figure 4).



\textbf{DISCUSSION}

HCR has not, as yet, become widely employed as a mainstream option for
treating coronary artery disease, particularly for those patients who
have more than just an isolated LAD lesion. Published data on HCR is
relatively limited, with the majority of studies thus far being
primarily single-center, non-randomized reports, incorporating only
small to moderate patient numbers, with few exceptions (18, 19). At
present, no randomized trials specifically compare HCR with CABG. To the
best of our knowledge, there is only one other study to analyze
propensity-matched data, comparing HCR to both CABG and multi-vessel PCI
in patients with TVD (20). However, our study is thus far the only
propensity-matched study comparing long-term clinical endpoints for all
three revascularization methods.

For patients undergoing HCR, we prefer a MIDCAB-first approach, followed
by interval PCI, typically within 4 to 6 weeks of surgery. This allows
the surgical revascularization to be performed without concern for
potential bleeding that may be associated with the dual antiplatelet
therapy that is mandatory after PCI with DES. We have, nevertheless,
previously described our satisfactory experience with MIDCAB in patients
taking dual antiplatelet agents (21), results that have not necessarily
been consistent amongst all surgical groups (22). More importantly,
however, the MIDCAB-first approach allows the patency of the LIMA to LAD
bypass graft to be interrogated during the subsequent PCI procedure.

A PCI-first HCR strategy was pursued in those patients who presented
with a coronary syndrome in which the culprit lesion was deemed to be
within one of the non-LAD vessels, or in those individuals in whom the
angiographic severity and clinical import of at least one of the non-LAD
stenoses was thought to be greater than that of the disease within the
LAD itself. For these patients, subsequent LIMA to LAD grafting was
undertaken on uninterrupted dual antiplatelet therapy.

Of the 100 patients in our final study population who underwent HCR, 72
had MIDCAB followed by PCI, whereas the remaining 28 had PCI prior to
MIDCAB. We did not perform any cases of simultaneous MIDCAB and PCI,
although this approach has been adopted by other investigators (23, 24).
None of our MIDCAB patients required intraoperative conversion to
sternotomy.

The primary end-point of our study, all-cause mortality at 8 years, was
not significantly different across the three revascularization cohorts.
Freedom from MACE at 8 years was also comparable between patient groups.
However, despite having a higher SYNTAX score at baseline, those
patients that underwent HCR ended up with a lower residual SYNTAX score
did those who had multi-vessel PCI, reflective of a significant
difference in the completeness of revascularization achieved. By
contrast, HCR patients had similar residual SYNTAX scores to those
patients managed by traditional CABG. Our data also shows that early
complications from HCR were infrequent. The HCR cohort did benefit from
a shorter length of hospital stay than did the CABG group.

The mean baseline SYNTAX score in our HCR cohort was 28.9 ± 10.6. In the
SYNTAX trial, patients with TVD with similar, intermediate, SYNTAX
scores demonstrated no significant difference in the incidence of MACE
at 12 months, when the PCI group was compared to CABG (1). When this
group was of patients was followed for 5 years, MACE rates were indeed
found to be higher in the PCI cohort, but there was no significant
mortality difference between treatment groups (25). Similarly, in
diabetic patients with intermediate SYNTAX scores, the FREEDOM trial
found that the composite end-point of death, MI and stroke at 5 years
favored CABG over PCI, again with no significant mortality difference
identified (2). These results suggest that, in the TVD patient
population with intermediate SYNTAX scores, although mid-term survival
is comparable across treatment arms, morbidity may be higher after PCI,
particularly with respect to the increased incidence of repeat
revascularization and new myocardial infarction. We suggest that it may
be this group of patients that may be ideally suited to benefit from
HCR.

The longer-term overall mortality rates in our patient groups were
slightly lower than that observed in comparable individuals in some of
the larger trials. It is our hypothesis that these low mortality rates
are attributable, at least in part, to the low residual SYNTAX scores
that were able to be achieved in each patient group, regardless of the
technique of revascularization. There is good data to support the
assertion that the completeness of revascularization (as quantified by
the residual SYNTAX score) is a predictor of short-to-medium term MACE
in patients with multi-vessel coronary artery disease undergoing PCI or
CABG (26 -- 28). Our group has previously reported that a low residual
SYNTAX score after HCR was associated with 8-year survival that was not
significantly different than that seen after traditional CABG in
patients with double-vessel coronary disease (29). Our current results
suggest that HCR is also associated with favorable long-term results in
patients with TVD, provided that the operators can achieve a low
residual SYTNAX score.

This study is also one of the first thus far to demonstrate that HCR may
be considered a reasonable method of revascularization in TVD patients
with left main-stem involvement. Of the 24 patients with left main
coronary disease who underwent HCR, there was only 1 death (4.2\%) at
long-term follow up.

Sixteen patients who underwent HCR required repeat revascularization by
8-year follow-up. Of these, only 6 (37.5\%) actually required a `target
vessel revascularization'. The remaining 10 patients (62.5\%) all
required intervention for \emph{de-novo} lesions. In those 6 HCR
individuals that required target vessel revascularization, 3 procedures
were performed due to problems with the LIMA to LAD graft, whereas 3
interventions were undertaken in non-LAD vessels. The incidence of
target vessel revascularization was not significantly different between
the HCR, CABG and multi-vessel PCI groups; in the CABG population, 2
patients required a re-intervention for the LIMA to LAD graft.

\textbf{STUDY LIMITATIONS}

Our study has several limitations to be acknowledged. Our data was
derived from a retrospective review in a single institution. A
multi-center approach, incorporating a larger sample size, would be more
adequately powered to analyze more subtle differences between outcomes.
Our patients were not randomized to a given revascularization strategy.
Although the impact of this may be somewhat mitigated by the fact that
the treatment for each patient was not selected by a single
practitioner, but rather by a multidisciplinary heart team, the fact
that the overwhelming majority of patients with TVD in our institution
were treated by either CABG or multi-vessel PCI reflects an intrinsic
selection bias for those individuals offered HCR.

Due to the differences in SYNTAX scores between patient groups, our data
cannot be used to comment on the superiority of one revascularization
strategy over another. The data does, however, afford us the opportunity
to evaluate the effectiveness of a `real-world' heart team approach to
the management of patients with TVD. Residual SYNTAX score calculations
in our CABG and PCI-first HCR patients assumed patency of all surgical
bypass grafts; although suboptimal, it was not deemed appropriate to
undertake formal angiography in asymptomatic patients for the sole
purpose of calculating a residual SYNTAX score.

We were able to achieve 100\% follow up for our primary end-point,
namely, all-cause death at 8 years. We utilized the National Death Index
as our primary source for 8-year survival data; though this methodology
may somewhat underestimate true mortality (30). Patients that underwent
multi-vessel PCI had a numerically higher amount of death than CABG or
HCR, however this did not meet significance. We cannot exclude the
possibility of a type II error, as our study size was limited. With
respect to the other long-term outcomes that were reported, it is
important to note that there were 15 patients in the CABG arm, 5 in the
PCI group, and 3 in the HCR cohort, that were all lost to follow-up.
Furthermore, we are unable to correct for the use of DAPT which may
confound the long-term results of MACE.

Our institution has extensive experience with minimal-access,
robotic-assisted LIMA to LAD grafting, as well as with complex PCI. Our
results may, therefore, not be directly generalizable to other
institutions who have less experience with either revascularization
strategy. Similarly, the low perioperative stroke rate observed in our
sternotomy CABG cohort may not necessarily be translatable to other
patient populations, given that we perform the majority of these cases
`off-pump,' a practice pattern not currently adopted by most surgical
centers in the United States (31). Despite our center's surgical
experience, only 100 patients were treated with HCR, which reflects our
selectiveness of the revascularization strategy.



\textbf{CONCLUSIONS}

Our results confirm that HCR is associated with excellent short-term
outcomes, with a shorter length of hospital stay than traditional CABG.
A HCR strategy for patients with TVD is associated with similar
long-term survival and freedom from MACE to traditional CABG or
multi-vessel PCI. HCR should be considered a feasible option for select
patients with TVD, for those with intermediate SYNTAX scores and
appropriate coronary anatomy, a proposal echoed by others (23, 31),
presuming that a low residual SYNTAX score can be attained.

\textbf{Acknowledgements:} The authors are grateful to Efstathia A
Mihelis and to Sridhar Uttara for their assistance in data collection
and management.

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  Thygesen K, Alpert JS, Jaffe AS,~Simoons ML, Chaitman BR, White HD et
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  infarction. Circulation.~2012;~126:2020--35
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  Hillis LD, Smith PK, Anderson JL, Bittl JA, Bridges CR, Byrne JG et
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  practice guidelines. Circulation 2011; 124: e652-735.
\item
  Harskamp RE, Brennan JM, Xian Y, Halkos ME, Puskas JD, Thourani VH et
  al. Practice patterns and clinical outcomes after hybrid coronary
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\item
  Hemli JM, Darla LS, Panetta CR, Jennings J, Subramanian VA, Patel NC.
  Does body mass index affect outcomes in robotic-assisted coronary
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\item
  Hemli JM, Henn LW, Panetta CR. Defining the learning curve for
  robotic-assisted endoscopic harvesting of the left internal mammary
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\item
  Subramanian VA, Loulmet DF, Patel NC. Minimally invasive coronary
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\item
  Patel NC, Patel NU, Loulmet DF, McCabe JC, Subramanian VA. Emergency
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  Farooq V, Girasis C, Magro M, Onuma Y, Morel MA, Heo JH et al. The
  CABG SYNTAX Score - an angiographic tool to grade the complexity of
  coronary disease following coronary artery bypass graft surgery: from
  the SYNTAX Left Main Angiographic (SYNTAX-LE MANS) substudy.
  EuroIntervention. 2013 Mar;8(11):1277-85.
\item
  Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG.
  Research electronic data capture (REDCap) -- a metadata-driven
  methodology and workflow process for providing translational research
  informatics support. J Biomed Inform 2009; 42: 377-81.
\item
  Halkos ME, Rab ST, Vassiliades TA, Morris DC, Douglas JS, Kilgo PD et
  al. Hybrid coronary revascularization versus off-pump coronary artery
  bypass for the treatment of left main coronary stenosis. Ann Thorac
  Surg 2011; 92: 2155-60.
\item
  Puskas JD, Halkos ME, DeRose JJ, Bagiella E, Miller MA, Overbey J et
  al. Hybrid Coronary Revascularization for the Treatment of Multivessel
  Coronary Artery Disease: A Multicenter Observational Study. J Am Coll
  Cardiol. 2016 Jul 26;68(4):356-65.
\item
  Hemli JM, Darla LS, Panetta CR, Jennings J, Subramanian VA, Patel NC.
  Does dual antiplatelet therapy affect blood loss and transfusion
  requirements in robotic-assisted coronary artery surgery? Innovations
  (Phila) 2012; 7: 399-402.
\item
  Shen L, Hu S,~Wang H, Xiong H, Zheng Z, Li L et al. One-stop hybrid
  coronary revascularization versus coronary artery bypass grafting and
  percutaneous coronary intervention for the treatment of multivessel
  coronary artery disease: 3-year follow-up results from a single
  institution. J Am Coll Cardiol. 2013 Jun 25;61(25):2525-33)
\item
  Daneil WT, Liberman HA, Kilgo P, Puskas JD, Vassiliades TA, Devireddy
  C et al. The impact of clopidogrel therapy on postoperative bleeding
  after robotic-assisted coronary artery bypass surgery. Eur J
  Cardiothorac Surg 2014; 46: e8-13.
\item
  Bonatti J, Schachner T, Bonaros N, Jonetzko P, Ohlinger A, Ruetzler E
  et al. Simultaneous hybrid coronary revascularization using totally
  endoscopic left internal mammary artery bypass grafting and placement
  of rapamycin eluting stents in the same interventional session. The
  COMBINATION pilot study. Cardiology 2008; 110: 92-5.
\item
  Kon ZN, Brown EN, Tran R, Joshi A, Reicher B, Grant MC et al.
  Simultaneous hybrid coronary revascularization reduces postoperative
  morbidity compared with results from conventional off-pump coronary
  artery bypass. J Thorac Cardiovasc Surg 2008; 135: 367-75.
\item
  Mohr FW, Morice MC, Kappetein AP, Feldman TE, Ståhle E, Colombo A et
  al. Coronary artery bypass graft surgery versus percutaneous coronary
  intervention in patients with three-vessel disease and left main
  coronary disease: 5-year follow-up of the randomised, clinical SYNTAX
  trial. Lancet 2013; 381: 629-38.
\item
  Malkin CJ, George V, Ghobrial MS, Krishnan A, Siotia A, Raina T,
  Morton AC et al. Residual SYNTAX score after PCI for triple vessel
  coronary artery disease: quantifying the adverse effect of incomplete
  revascularisation. EuroIntervention 2013; 8: 1286-95.
\item
  Farooq V, Serruys PW, Bourantas CV, Zhang Y, Muramatsu T, Feldman T et
  al. Quantification of incomplete revascularization and its association
  with five-year mortality in the synergy between percutaneous coronary
  intervention with taxus and cardiac surgery (SYNTAX) trial: validation
  of the residual SYNTAX score. Circulation 2013; 128: 141-51.
\item
  Melina G, Angeloni E, Refice S, Benegiamo C, Lechiancole A, Matteucci
  M et al. Residual SYNTAX score following coronary artery bypass
  grafting. Eur J Cardiothorac Surg 2017; 51: 547-53.
\item
  Patel NC, Hemli JM, Kim MC, Seetharam K, Pirelli L, Brinster DR,
  Scheinerman SJ et al. Short and intermediate-term outcomes of hybrid
  coronary revascularization for double-vessel disease. J Thorac
  Cardiovasc Surg 2018; 156: 1799-1807.
\item
  Peterss S, Charilaou P, Ziganshin BA, Elefteriades JA. Assessment of
  survival in retrospective studies: the Social Security Death Index is
  not adequate for estimation. J Thorac Cardiovasc Surg 2017; 153:
  899-901.
\item
  Yanagawa B, Nedadur R, Puskas JD. The future of off-pump coronary
  artery bypass grafting: a North American perspective. J Thorac Dis
  2016; 8: S832-8.
\item
  Tajstra M, Hrapkowicz T, Hawranek M, Filipiak K, Gierlotka M, Zembala
  M et al; POL-MIDES Study Investigators. Hybrid coronary
  revascularization in selected patients with multivessel disease:
  5-year clinical outcomes of the prospective randomized pilot study. J
  Am Coll Cardiol Intv 2018; 11: 847-52.
\item
\end{enumerate}

\textbf{FIGURE LEGENDS}

\textbf{Figure 1.} Flow-chart of patient selection.

CABG = coronary artery bypass grafting; HCR = hybrid coronary
revascularization; PCI = percutaneous coronary intervention.

\textbf{Figure 2.} Kaplan-Meier estimates for long-term survival with
number of subjects at risk and 95\% Hall-Wellner Bands.

CABG = coronary artery bypass grafting; PCI = percutaneous coronary
intervention.

\textbf{Figure 3.} Kaplan-Meier estimates for freedom from repeat
revascularization with number of subjects at risk and 95\% Hall-Wellner
Bands.

CABG = coronary artery bypass grafting; PCI = percutaneous coronary
intervention.

\textbf{Figure 4.} Kaplan-Meier estimates for freedom from MACE with
number of subjects at risk and 95\% Hall-Wellner Bands.

CABG = coronary artery bypass grafting; MACE = major adverse
cardiovascular events; PCI = percutaneous coronary intervention.



\textbf{TABLES}

\textbf{Table 1.} Patient demographics (prior to propensity-matching).\selectlanguage{english}
\begin{longtable}[]{@{}llllll@{}}
\toprule
\begin{minipage}[b]{0.16\columnwidth}\raggedright\strut
\textbf{Variable}\strut
\end{minipage} & \begin{minipage}[b]{0.16\columnwidth}\raggedright\strut
\textbf{HCR} \textbf{(n = 100)}\strut
\end{minipage} & \begin{minipage}[b]{0.16\columnwidth}\raggedright\strut
\textbf{CABG} \textbf{(n = 1258)}\strut
\end{minipage} & \begin{minipage}[b]{0.16\columnwidth}\raggedright\strut
\textbf{PCI} \textbf{(n = 2621)}\strut
\end{minipage} & \begin{minipage}[b]{0.16\columnwidth}\raggedright\strut
\emph{p} \textbf{value} \textbf{(HCR \emph{vs.} CABG)}\strut
\end{minipage} & \begin{minipage}[b]{0.16\columnwidth}\raggedright\strut
\emph{p} \textbf{value} \textbf{(HCR \emph{vs.} PCI)}\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Age, years, mean \selectlanguage{ngerman}± SD\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
67.5 \selectlanguage{ngerman}± 10.1\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
65.8 \selectlanguage{ngerman}± 10.1\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
66.9 \selectlanguage{ngerman}± 11.8\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.11\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.63\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Female gender, n (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
16 (16)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
320 (25.4)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
771 (29.4)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.04\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.003\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
BMI, kg/m\textsuperscript{2}, mean \selectlanguage{ngerman}± SD\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
27.5 \selectlanguage{ngerman}± 3.6\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
28.2 \selectlanguage{ngerman}± 5.7\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
28.7 \selectlanguage{ngerman}± 5.5\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.20\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.023\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
LVEF, \%, mean \selectlanguage{ngerman}± SD\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
53.3 \selectlanguage{ngerman}± 11.0\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
48.8 \selectlanguage{ngerman}± 13.2\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
51 \selectlanguage{ngerman}± 14.4\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.001\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.11\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Diabetes mellitus, n (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
53 (53)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
700 (55.6)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
1281 (48.9)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.68\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.48\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Peripheral vascular disease, n (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
10 (10)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
155 (12.3)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
328 (12.5)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.63\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.54\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Cerebrovascular disease, n (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
10 (10)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
192 (15.3)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
298 (11.4)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.19\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.87\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
CHF (NYHA III/IV), n (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
16 (16)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
281 (22.3)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
343 (13.1)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.17\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.37\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Prior MI, n (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
28 (28)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
614 (48.8)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
1066 (40.7)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\textless{} 0.0001\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.012\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
COPD, n (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
2 (2)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
70 (5.6)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
52 (2.0)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.16\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
1.0\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
ESRD, n (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
3 (3)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
49 (3.9)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
89 (3.4)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
1.0\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
1.0\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

BMI = body mass index; CABG = coronary artery bypass grafting; CHF =
congestive heart failure; COPD = chronic obstructive pulmonary disease;
ESRD = end-stage (dialysis-dependent) renal disease; HCR = hybrid
coronary revascularization; LVEF = left ventricular ejection fraction;
MI = myocardial infarction; NYHA = New York Heart Association; PCI =
percutaneous coronary intervention; SD = standard deviation; SYNTAX =
SYNergy between percutaneous coronary intervention with TAXus and
cardiac surgery.

\textbf{Table 2.} Patient demographics (after propensity-matching).\selectlanguage{english}
\begin{longtable}[]{@{}llllll@{}}
\toprule
\begin{minipage}[b]{0.16\columnwidth}\raggedright\strut
\textbf{Variable}\strut
\end{minipage} & \begin{minipage}[b]{0.16\columnwidth}\raggedright\strut
\textbf{HCR} \textbf{(n = 100)}\strut
\end{minipage} & \begin{minipage}[b]{0.16\columnwidth}\raggedright\strut
\textbf{CABG} \textbf{(n = 100)}\strut
\end{minipage} & \begin{minipage}[b]{0.16\columnwidth}\raggedright\strut
\textbf{PCI} \textbf{(n = 100)}\strut
\end{minipage} & \begin{minipage}[b]{0.16\columnwidth}\raggedright\strut
\emph{p} \textbf{value} \textbf{(HCR \emph{vs.} CABG)}\strut
\end{minipage} & \begin{minipage}[b]{0.16\columnwidth}\raggedright\strut
\emph{p} \textbf{value} \textbf{(HCR \emph{vs.} PCI)}\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Age, years, mean \selectlanguage{ngerman}± SD\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
67.5 \selectlanguage{ngerman}± 10.1\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
67.0 \selectlanguage{ngerman}± 9.3\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
67.8 \selectlanguage{ngerman}± 10.5\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.97\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.80\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Female gender, n\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
16\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
11\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
16\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.41\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
1.0\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
BMI, kg/m\textsuperscript{2}, mean \selectlanguage{ngerman}± SD\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
27.5 \selectlanguage{ngerman}± 3.6\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
27.7 \selectlanguage{ngerman}± 5.0\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
27.5 \selectlanguage{ngerman}± 4.8\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.67\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.97\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
LVEF, \%, mean \selectlanguage{ngerman}± SD\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
53.3 \selectlanguage{ngerman}± 11.0\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
52.5 \selectlanguage{ngerman}± 10.7\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
54.5 \selectlanguage{ngerman}± 11.3\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.61\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.45\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
SYNTAX score, mean \selectlanguage{ngerman}± SD\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
28.9 \selectlanguage{ngerman}± 10.6\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
32.2 \selectlanguage{ngerman}± 7.9\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
22.1 \selectlanguage{ngerman}± 7.6\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.018\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\textless{} 0.01\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Diabetes mellitus, n\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
53\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
47\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
50\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.48\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.78\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Peripheral vascular disease, n\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
10\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
6\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
11\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.44\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
1.0\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Cerebrovascular disease, n\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
10\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
7\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
11\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.61\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
1.0\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
CHF (NYHA III/IV), n\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
16\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
13\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
13\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.69\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.69\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Prior MI, n\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
28\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
31\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
29\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.76\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.95\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
COPD, n\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
2\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
2\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
1.0\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.50\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
ESRD, n\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
3\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
3\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
3\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
1.0\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
1.0\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

BMI = body mass index; CABG = coronary artery bypass grafting; CHF =
congestive heart failure; COPD = chronic obstructive pulmonary disease;
ESRD = end-stage (dialysis-dependent) renal disease; HCR = hybrid
coronary revascularization; LVEF = left ventricular ejection fraction;
MI = myocardial infarction; NYHA = New York Heart Association; PCI =
percutaneous coronary intervention; SD = standard deviation; SYNTAX =
SYNergy between percutaneous coronary intervention with TAXus and
cardiac surgery.

\textbf{Table 3.} Short-term outcomes\selectlanguage{english}
\begin{longtable}[]{@{}llllll@{}}
\toprule
\begin{minipage}[b]{0.16\columnwidth}\raggedright\strut
\textbf{Variable}\strut
\end{minipage} & \begin{minipage}[b]{0.16\columnwidth}\raggedright\strut
\textbf{HCR} \textbf{(n = 100)}\strut
\end{minipage} & \begin{minipage}[b]{0.16\columnwidth}\raggedright\strut
\textbf{CABG} \textbf{(n = 100)}\strut
\end{minipage} & \begin{minipage}[b]{0.16\columnwidth}\raggedright\strut
\textbf{PCI} \textbf{(n = 100)}\strut
\end{minipage} & \begin{minipage}[b]{0.16\columnwidth}\raggedright\strut
\emph{p} \textbf{value} \textbf{(HCR \emph{vs.} CABG)}\strut
\end{minipage} & \begin{minipage}[b]{0.16\columnwidth}\raggedright\strut
\emph{p} \textbf{value} \textbf{(HCR \emph{vs.} PCI)}\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
30-day mortality, n\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
1.0\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
1.0\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Stroke, n\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
1.0\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
1.0\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Peri-procedural MI, n\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
1.0\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
1.0\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
New-onset renal failure, n\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
1.0\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
1.0\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Length of stay, days, mean \selectlanguage{ngerman}± SD\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
5.7 \selectlanguage{ngerman}± 7.5\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
7.5 \selectlanguage{ngerman}± 3.4\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
2.0 \selectlanguage{ngerman}± 2.2\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.001\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\textless{} 0.0001\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Length of stay, days, median (IQR)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
5 (4 to 6)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
6 (5 to 9)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
1 (1 to 2)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
n/a\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
n/a\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Residual SYNTAX score, mean \selectlanguage{ngerman}± SD\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
4.5 \selectlanguage{ngerman}± 4.4\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
5.2 \selectlanguage{ngerman}± 4.7\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
7.1 \selectlanguage{ngerman}± 6.5\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.31\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.001\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

CABG = coronary artery bypass grafting; HCR = hybrid coronary
revascularization; IQR = interquartile range; MI = myocardial
infarction; n/a = not applicable; PCI = percutaneous coronary
intervention; SD = standard deviation; SYNTAX = SYNergy between
percutaneous coronary intervention with TAXus and cardiac surgery.

\textbf{Table 4.} Long-term outcomes\selectlanguage{english}
\begin{longtable}[]{@{}llllll@{}}
\toprule
\begin{minipage}[b]{0.16\columnwidth}\raggedright\strut
\textbf{Variable}\strut
\end{minipage} & \begin{minipage}[b]{0.16\columnwidth}\raggedright\strut
\textbf{HCR} \textbf{(n = 100)}\strut
\end{minipage} & \begin{minipage}[b]{0.16\columnwidth}\raggedright\strut
\textbf{CABG} \textbf{(n = 100)}\strut
\end{minipage} & \begin{minipage}[b]{0.16\columnwidth}\raggedright\strut
\textbf{PCI} \textbf{(n = 100)}\strut
\end{minipage} & \begin{minipage}[b]{0.16\columnwidth}\raggedright\strut
\emph{p} \textbf{value} \textbf{(HCR \emph{vs.} CABG)}\strut
\end{minipage} & \begin{minipage}[b]{0.16\columnwidth}\raggedright\strut
\emph{p} \textbf{value} \textbf{(HCR \emph{vs.} PCI)}\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Mortality, n\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
5\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
4\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
9\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
1.0\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.41\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Repeat revascularization, n\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
16\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
11\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
18\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.41\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.85\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Target vessel revascularization, n *\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
6\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
5\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
10\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
1.0\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.44\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Myocardial infarction, n\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
4\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
3\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
5\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
1.0\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
1.0\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
MACE, n +\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
21\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
15\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
25\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.36\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.61\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

CABG = coronary artery bypass grafting; HCR = hybrid coronary
revascularization; MACE = major adverse cardiovascular events; PCI =
percutaneous coronary intervention.

* Target vessel revascularization defined as repeat revascularization on
a coronary artery that has already been previously treated during the
index procedure.

+ MACE denotes a composite end-point encompassing death, repeat
revascularization, myocardial infarction.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure-1/Figure-1}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure-2/Figure-2}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure-3/Figure-3}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure-4/Figure-4}

\end{center}
\end{figure}

\textbf{Hosted file}

\verb`Table 1.docx`  available at \url{https://authorea.com/users/330607/articles/457403-long-term-survival-in-triple-vessel-disease-hybrid-coronary-revascularization-compared-to-contemporary-revascularization-methods}

\textbf{Hosted file}

\verb`Table 2.docx`  available at \url{https://authorea.com/users/330607/articles/457403-long-term-survival-in-triple-vessel-disease-hybrid-coronary-revascularization-compared-to-contemporary-revascularization-methods}

\textbf{Hosted file}

\verb`Table 3.docx`  available at \url{https://authorea.com/users/330607/articles/457403-long-term-survival-in-triple-vessel-disease-hybrid-coronary-revascularization-compared-to-contemporary-revascularization-methods}

\textbf{Hosted file}

\verb`Table 4.docx`  available at \url{https://authorea.com/users/330607/articles/457403-long-term-survival-in-triple-vessel-disease-hybrid-coronary-revascularization-compared-to-contemporary-revascularization-methods}

\selectlanguage{english}
\FloatBarrier
\end{document}

