Minimally invasive surgical techniques in the era of hybrid coronary revascularization: additional benefits for the elderly patients?

Geriatric patients affected by stable multi-vessel coronary artery disease (CAD) are at the crossroad: they can live with the risks of acute coronary syndrome, malignant arrhythmias or heart failure, or they can undergo a rapid evaluation for myocardial revascularization. It might be a common thought that the risks inherent the revascularization procedure outnumber the perceivable benefits in older patients, and the percutaneous or especially the surgical option tends to be abandoned. Those “high risk” patients are generally discharged with maximum tolerated medical therapy. All over the world, patients with multivessel CAD are becoming older and with a greater number of comorbidities, and it is important to point out that those patients should not be negated a revascularization procedure, which proved to prolong survival from cardiac-related events. Appropriate interventions for elderly patients should be delineated shortly, as the number of octogenarians is expected to quadruple in the next 50 years.  Complete myocardial revascularization (CMR) has been shown to provide a better recovery of ventricular function and protection against adverse ischemic and arrhythmic events, which results into a longer survival and freedom from reintervention. Surgical revascularization using coronary artery bypass graft (CABG) is known to provide a higher proportion of CMR of all diseased myocardial territories, and is generally the treatment of choice in patients with multivessel CAD. Using percutaneous coronary intervention (PCI), several barriers prevents CMR in a real-life scenario: patient-related factors and technical details of the procedure, such as chronic total occlusion. However, CMR compared with incomplete myocardial revascularization (IMR) is associated with longer duration of surgery and increased procedural risks. Those daunting issues are crucial when considering geriatric patients, and a