Hybrid Coronary Revascularization in Multivessel Disease: The Ideal Strategy for Challenging Scenarios

The treatment of coronary artery disease (CAD) has considerably evolved over the last three decades thanks to innovations in percutaneous and surgical revascularization techniques. The demographic shift towards an aging population with complex coronary anatomy and multiple comorbidities necessitates a personalized approach. A primary challenge for Heart Teams is to integrate new strategies into their decision-making process. Hybrid coronary revascularization (HCR) combines the long-term benefits of coronary artery bypass grafting (CABG) with percutaneous coronary intervention (PCI) to treat complex coronary artery disease. Selection of the ideal candidate for HCR requires careful evaluation of anatomic challenges and risk profiles. Although recent evidence demonstrates the safety and efficacy of HCR and makes it a viable alternative to conventional methods, further large-scale randomized controlled trials (RCTs) are needed to establish its role in routine practice. In this manuscript, we have provided an overview of the major advances in both percutaneous and surgical techniques. In addition, we have addressed the innovative implications of robotic-assisted minimally invasive direct coronary artery bypass (RA-MIDCAB) and described the surgical procedure and postoperative care in detail. Finally, we have outlined the key principles that guide our clinical practice in selecting the appropriate approach for hybrid coronary revascularization.