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\begin{document}

\title{Comparison between Percutaneous Coronary Intervention versus Coronary
Artery Bypass Graft with Mitral Valve Replacement in Patients with
Single Vessel and Mitral Valve Disease}



\author[1]{Taher Abdelmoiem}%
\author[2]{Walaa Ahmed Saber}%
\author[2]{osama Abass}%
\author[2]{Moustafa Gamal ELBarbary}%
\affil[1]{National Heart Institute}%
\affil[2]{Ain Shams University Faculty of Medicine}%


\vspace{-1em}



  
  \date{May 28, 2024}


\begingroup
\let\center\flushleft
\let\endcenter\endflushleft
\maketitle
\endgroup





\selectlanguage{english}
\begin{abstract}
\emph{Background:} We compared staged percutaneous coronary intervention
(PCI) versus coronary artery bypass graft (CABG) with mitral valve
replacement (MVR) in patients with combined single vessel and rheumatic
mitral valve disease. \emph{Methods:} We prospectively evaluated 80
patients with combined single coronary artery (requiring
revascularization in non-LAD (Left Anterior Descending artery)
territory) and rheumatic mitral valve disease, divided into two groups;
Group I consisting of 40 patients who underwent staged PCI, and mitral
valve replacement 3 months later, and Group II consisting of 40 patients
who underwent combined CABG (using saphenous venous graft) and mitral
valve replacement. We compared between both groups. \emph{Results:} The
median aortic cross-clamp and cardiopulmonary bypass times were 44 and
62 minutes for Group I, versus 60.5 and 82 minutes for Group II, that
difference between groups is statistically significant. 8 patients
(20\%) in Group I needed inotropic support versus 12 patients (30\%) in
Group II, which is not statistically significant. No patients in both
groups did need any mechanical support in the form of intra-aortic
balloon pump (IABP). None of the patients in both groups had
intraoperative ECG (electrocardiogram) changes in the form of ischemia
or arrhythmias. The median intensive care unit (ICU) length of stay
(hours) and hospital length of stay (days) were 39 hours and 5.5 days
for Group I, versus 56.5 hours and 8.5 days for Group II, that
difference between groups is statistically significant. The median blood
loss (ml) postoperatively was 925 in group I versus 1075 in group II,
which is statistically significant. However, the rate of re-exploration
for bleeding did not differ significantly between both groups, with 1
case only (2.5\%) in group I versus 2 cases (5\%) in group II, and no
postoperative delayed cardiac tamponade noted in any of the two groups.
The post-operative complications for groups I and II included 0 (0\%)
versus 3 (7.5\%) prolonged mechanical ventilation (\textgreater{}24 h),
0 (0\%) versus 1 (2.5\%) respiratory complications, 0 (0\%) versus 2
(5\%) wound infection, 0 (0\%) versus 1 (2.5\%) cerebrovascular
accidents, 2 (5\%) versus 1 (2.5\%) acute kidney injury, respectively.
There is no statistically significant difference between both groups
regarding these previous post-operative complications. None of the
patients in both groups died within the first 30 days after surgery.
None of the patients in both groups had major cardiac events or CCU
(Cardiac Care Unit) admission. Regional wall motion abnormalities were
noted in 15 patients (37.5\%) of group I versus 17 patients (42.5\%) of
group II, who all undergone stress ECG, of whom 9 patients (22.5\%) in
group I versus 11 patients (27.5\%) in group II showed positive results,
and qualified for diagnostic coronary angiography, which confirmed the
need for reoperation for myocardial ischemia/infarction within the first
year of follow up post-operatively in 4 patients (10\%) of group I
versus 8 patients (20\%) of group II. All these follow up outcomes
showed no significant difference between both groups.
\emph{Conclusions:} A staged approach of PCI followed by MVR is an
alternative to the conventional combined CABG and MVR, can be performed
safely in some patients with single coronary artery and MV disease, and
is associated with good short and follow-up outcomes%
\end{abstract}%



\sloppy


\textbf{Comparison between Percutaneous Coronary Intervention versus
Coronary Artery Bypass Graft with Mitral Valve Replacement inPatients
with Single Vessel and Mitral Valve Disease}

Taher Mohamed Eid AbdelMoneim, Walaa Ahmed Saber, Osama Abbas
Abdelhamid, Moustafa Gamal ELBarbary

\textbf{Abstract}

Background: We compared staged percutaneous coronary intervention (PCI)
versus coronary artery bypass graft (CABG) with mitral valve replacement
(MVR) in patients with combined single vessel and rheumatic mitral valve
disease.

Methods: We prospectively evaluated 80 patients with combined single
coronary artery (requiring revascularization in non-LAD (Left Anterior
Descending artery) territory) and rheumatic mitral valve disease,
divided into two groups; Group I consisting of 40 patients who underwent
staged PCI, and mitral valve replacement 3 months later, and Group II
consisting of 40 patients who underwent combined CABG (using saphenous
venous graft) and mitral valve replacement. We compared between both
groups.

Results: The median aortic cross-clamp and cardiopulmonary bypass times
were 44 and 62 minutes for Group I, versus 60.5 and 82 minutes for Group
II, that difference between groups is statistically significant. 8
patients (20\%) in Group I needed inotropic support versus 12 patients
(30\%) in Group II, which is not statistically significant. No patients
in both groups did need any mechanical support in the form of
intra-aortic balloon pump (IABP). None of the patients in both groups
had intraoperative ECG (electrocardiogram) changes in the form of
ischemia or arrhythmias. The median intensive care unit (ICU) length of
stay (hours) and hospital length of stay (days) were 39 hours and 5.5
days for Group I, versus 56.5 hours and 8.5 days for Group II, that
difference between groups is statistically significant. The median blood
loss (ml) postoperatively was 925 in group I versus 1075 in group II,
which is statistically significant. However, the rate of re-exploration
for bleeding did not differ significantly between both groups, with 1
case only (2.5\%) in group I versus 2 cases (5\%) in group II, and no
postoperative delayed cardiac tamponade noted in any of the two groups.
The post-operative complications for groups I and II included 0 (0\%)
versus 3 (7.5\%) prolonged mechanical ventilation (\textgreater{}24 h),
0 (0\%) versus 1 (2.5\%) respiratory complications, 0 (0\%) versus 2
(5\%) wound infection, 0 (0\%) versus 1 (2.5\%) cerebrovascular
accidents, 2 (5\%) versus 1 (2.5\%) acute kidney injury, respectively.
There is no statistically significant difference between both groups
regarding these previous post-operative complications. None of the
patients in both groups died within the first 30 days after surgery.
None of the patients in both groups had major cardiac events or CCU
(Cardiac Care Unit) admission. Regional wall motion abnormalities were
noted in 15 patients (37.5\%) of group I versus 17 patients (42.5\%) of
group II, who all undergone stress ECG, of whom 9 patients (22.5\%) in
group I versus 11 patients (27.5\%) in group II showed positive results,
and qualified for diagnostic coronary angiography, which confirmed the
need for reoperation for myocardial ischemia/infarction within the first
year of follow up post-operatively in 4 patients (10\%) of group I
versus 8 patients (20\%) of group II. All these follow up outcomes
showed no significant difference between both groups.

Conclusions: A staged approach of PCI followed by MVR is an alternative
to the conventional combined CABG and MVR, can be performed safely in
some patients with single coronary artery and MV disease, and is
associated with good short and follow-up outcomes.

\textbf{Keywords:} PCI, CABG, MVR

\textbf{Background}

Combined coronary artery mitral valve disease is a major cause of
morbidity and mortality in the adult patient population. Traditional
treatment involves combined mitral valve and CABG surgery using a median
sternotomy. However, this combined surgical approach confers a higher
risk when compared with isolated MV surgery, the risks of such a
combined surgical procedure may outweigh the benefits. Thus, the concept
of parsing the total risk of a single major procedure to the lesser
individual and summed risks of 2 smaller procedures---percutaneous
coronary intervention (PCI) plus the mitral valve operation---has been
applied in clinical practice and reported by various groups.

Interest in hybrid procedures, defined for the purpose of this thesis as
Mitral valve surgery and percutaneous coronary intervention (PCI), has
intensified with improved coronary stent technology, increased
collaboration between cardiac surgeons and interventional cardiologists,
and the introduction of hybrid operating suites. The complementary goals
of minimizing the morbidity of surgical procedures and optimizing
resource utilization have driven development of new solutions for
concurrent valvular and coronary heart disease (1).

\textbf{Methods}

The study was a prospective comparative review, of 2 years duration, of
80 patients with combined single coronary artery (requiring
revascularization in non-LAD territory) and rheumatic MV disease,
divided into two groups; Group I consisting of 40 patients who underwent
staged PCI, and mitral valve replacement 3 months later, and Group II
consisting of 40 patients who underwent combined CABG (using saphenous
venous graft) and mitral valve replacement. The study centers were
Cardiothoracic Surgery Department of Ain Shams University Hospitals, and
National Heart Institute (NHI). PCI was done at Cardiology Department of
Ain Shams University Hospitals, and National Heart Institute (NHI).

Included were patients with combined single vessel and mitral valve
disease, of age between 35 and 60 years old. Excluded were patients with
Ejection Fraction (EF) less than 45\%, concomitant aortic or tricuspid
valve disease requiring surgery, concomitant congenital heart disease
requiring surgical correction, redo cardiac surgery, acute coronary
syndrome requiring primary PCI together with mitral valve disease,
renal/hepatic failure, Chronic Obstructive Pulmonary Disease (COPD) or
other respiratory disease, any neurological deficit or previous
cerebrovascular event, or hematological disorders.

In all patients, the coronary and valvular lesions were documented by
diagnostic catheterization and echocardiography, respectively. Patients
were selected to undergo a hybrid approach after a comprehensive Heart
Team evaluation. Baseline variables, operative characteristics and
outcomes, and major adverse cardiovascular events during the follow-up
period were analyzed using our institutional medical records, outpatient
surgical and cardiology office visits, and a follow-up survey at 3-month
intervals within the first postoperative year.

All patients were clinically stable for both PCI and the operation.
Preoperative medication regimens were similar. Once the treatment plan
was established, the interventional cardiologist proceeded with PCI of
the significant lesion in the native vessel. Drug-eluting stents were
placed in all of Group I patients. A loading dose of 600 mg clopidogrel
and 325 mg aspirin was administered at the time of stent placement,
followed by clopidogrel 75 mg daily and aspirin 81 to 325 mg daily
thereafter (dual antiplatelet therapy). Management of antiplatelet
therapy between the PCI and the operation was at the discretion of the
interventional cardiologist. The patients had their antiplatelet agents
stopped 5 days before surgery. All patients resumed their antithrombotic
regimen within 24 to 48 hours after surgery, which comprised of single
antiplatelet (clopidogrel 75 mg daily) and an oral anticoagulant dose
adjusted according to target International Normalized Ratio (INR),
because of the mechanical mitral valve prosthesis inserted in all
patients.

In all patients, standard median sternotomy was performed, followed by
inverted T-shaped pericardiotomy, Aorto-bicaval cannulation, conduction
of cardiopulmonary bypass, and application of aortic cross-clamp. Warm
blood antegrade cardioplegia was given. Mitral valve was accessed
through left atriotomy via Sondergaard's groove, preservation of the
posterior leaflet was done, and the mechanical mitral prosthesis
inserted using 2-0 interrupted Ethibond sutures with pledgets sitting on
the atrial surface of the mitral valve. Closure of left atrium, deairing
through aortic root vent, and removal of aortic cross-clamp. Weaning off
bypass, hemostasis, and anatomical closure in layers. In group II
patients, the distal and proximal anastomoses using 7-0 and 6-0 Prolene
sutures, respectively, were done in addition to the previous steps of
mitral valve replacement, using the saphenous venous graft harvested
simultaneously with the median sternotomy at the start of the operation.

The intraoperative variables prospectively assessed as per our study
included total cardiopulmonary bypass time, total cross-clamp time, the
need for inotropic support, and ECG changes in the form of ischemia or
arrhythmias. The postoperative outcomes included bleeding,
cerebrovascular accidents, renal failure, respiratory complications,
duration of mechanical ventilation, duration of ICU stay, wound
infection, duration of hospital stay, and 30-day mortality. All patients
underwent postoperative routine trans-thoracic echo (TTE) follow up upon
discharge, after 3 months, 6 months, and 1 year, postoperative stress
ECG and/or coronary angiography if needed. The follow-up outcomes
included major cardiac events or CCU admission within first year, and
the need for reoperation for myocardial infarction or ischemia within
first year.

\textbf{Statistical Analysis}

The Community, Environmental and Occupational Medicine Department of Ain
Shams University suggested a minimum sample size of 36 patients in each
group to get reliable results. The collected data was revised, coded,
tabulated, and introduced to a PC using the Statistical Package for the
Social Sciences (SPSS 15.0.1 for windows; SPSS Inc, Chicago, IL, 2001).
The variables are reported as mean \selectlanguage{ngerman}± standard deviation (SD), median and
interquartile range (IQR), or number (N) and percentage. Suitable
analysis is done according to the type of data obtained. An independent
t-test, chi-square test, and Mann-Whitney U test are used to analyze
data accordingly. P-value \textless{}0.05 is considered statistically
significant.

\textbf{Results}

Baseline demographic, clinical, angiographic, and echocardiographic
information was prospectively collected for all patients. There was no
statistically significant difference between both groups in the baseline
characteristics, including age, sex, BMI, hypertension, diabetes
mellitus, and dyslipidemia (Table 1). There were 23 (57.5 \%) men in the
staged PCI + MVR group (Group I) and 25 (62.5 \%) in the CABG + MVR
group (Group II) (P= 0.648), with a mean age of 51.1±3.2 and 52.1±4.6
years (P= 1.000), and body mass index (BMI) of 27.2 ± 1.7 and 27.3 ± 2.1
(P= 0.819), respectively. The incidence of hypertension, diabetes
mellitus, and dyslipidemia for both groups were 82.5 versus 87.5\% (P=
0.531), 37.5 versus 42.5\% (P= 0.648), and 77.5 versus 82.5\% (P=
0.576), respectively.

\textbf{Table (1)}\selectlanguage{english}
\begin{longtable}[]{@{}lllllllllllllll@{}}
\toprule
\textbf{Characteristic} & \textbf{Group I (n=40)} & \textbf{Group I
(n=40)} & \textbf{Group I (n=40)} & \textbf{Group I (n=40)} &
\textbf{Group I (n=40)} & \textbf{Group I (n=40)} & \textbf{Group I
(n=40)} & \textbf{Group II (n=40)} & \textbf{Group II (n=40)} &
\textbf{Group II (n=40)} & \textbf{Group II (n=40)} & \textbf{Group II
(n=40)} & \textbf{Sig.} & \textbf{P}\tabularnewline
\midrule
\endhead
\textbf{Age} & & & & & & & & & & & & & \textbf{t*} &\tabularnewline
Mean\selectlanguage{ngerman}± S.D. & 51.1 & \selectlanguage{ngerman}± & \selectlanguage{ngerman}± & \selectlanguage{ngerman}± & 3.2 & 3.2 & 3.2 & 52.1 & \selectlanguage{ngerman}± & \selectlanguage{ngerman}± & \selectlanguage{ngerman}± & 4.6
& \textbf{0.001} & \textbf{1.000}\tabularnewline
Range & 45.0 & - & - & - & 56.0 & 56.0 & 56.0 & 45.0 & - & - & - & 59.0
& &\tabularnewline
\textbf{Sex} & \textbf{N} & \textbf{N} & \textbf{N} & \textbf{N} &
\textbf{N} & \textbf{\%} & \textbf{\%} & \textbf{N} & \textbf{N} &
\textbf{N} & \textbf{\%} & \textbf{\%} & \selectlanguage{greek}\textbf{χ2**}\selectlanguage{english} &\tabularnewline
Males & 23 & 23 & 23 & 23 & 23 & 57.5 & 57.5 & 25 & 25 & 25 & 62.5 &
62.5 & &\tabularnewline
Females & 17 & 17 & 17 & 17 & 17 & 42.5 & 42.5 & 15 & 15 & 15 & 37.5 &
37.5 & \textbf{0.208} & \textbf{0.648}\tabularnewline
\textbf{BMI} & & & & & & & & & & & & & &\tabularnewline
Mean\selectlanguage{ngerman}± S.D. & 27.2 & 27.2 & 27.2 & \selectlanguage{ngerman}± & \selectlanguage{ngerman}± & \selectlanguage{ngerman}± & 1.7 & 27.3 & 27.3 & \selectlanguage{ngerman}± & \selectlanguage{ngerman}±
& 2.1 & &\tabularnewline
Range & 24.0 & 24.0 & 24.0 & - & - & - & 30.0 & 24.0 & 24.0 & - & - &
31.0 & \textbf{-0.230} & \textbf{0.819}\tabularnewline
\textbf{Hypertension} & 33 & 33 & 33 & 33 & 33 & 82.5 & 82.5 & 35 & 35 &
35 & 87.5 & 87.5 & \textbf{0.392} & \textbf{0.531}\tabularnewline
\textbf{Diabetes Mellitus} & 15 & 15 & 15 & 15 & 15 & 37.5 & 37.5 & 17 &
17 & 17 & 42.5 & 42.5 & \textbf{0.208} & \textbf{0.648}\tabularnewline
\textbf{Dyslipidemia} & 31 & 31 & 31 & 31 & 31 & 77.5 & 77.5 & 33 & 33 &
33 & 82.5 & 82.5 & \textbf{0.313} & \textbf{0.576}\tabularnewline
\selectlanguage{greek}\emph{*t: Independent Samples t-test **χ2: Chi-square test}\selectlanguage{english} & \selectlanguage{greek}\emph{*t:
Independent Samples t-test **χ2: Chi-square test}\selectlanguage{english} & \selectlanguage{greek}\emph{*t:
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\bottomrule
\end{longtable}

The median pre-operative creatinine in group I and group II were 1.2 and
1.1 (P= 0.299), respectively, which is not statistically significant
(Table 2). None of the patients in both groups had cerebrovascular
disease, peripheral vascular disease, prior Myocardial Infarction (MI),
congestive heart failure, liver disease, chronic lung disease, prior
cardiac surgery or PCI, preoperative aspirin administration,
preoperative clopidogrel administration, or preoperative
dual-antiplatelets administration.

\textbf{Table (2)}\selectlanguage{english}
\begin{longtable}[]{@{}lllllllllllllll@{}}
\toprule
\textbf{Characteristic} & \textbf{Group I (n=40)} & \textbf{Group I
(n=40)} & \textbf{Group I (n=40)} & \textbf{Group I (n=40)} &
\textbf{Group II (n=40)} & \textbf{Group II (n=40)} & \textbf{Group II
(n=40)} & \textbf{Group II (n=40)} & \textbf{Group II (n=40)} &
\textbf{Group II (n=40)} & \textbf{Sig.} & \textbf{Sig.} & \textbf{P} &
\textbf{P}\tabularnewline
\midrule
\endhead
\textbf{Pre-operative creatinine} & & & & & & & & & & & & & \textbf{t*}
& \textbf{t*}\tabularnewline
Median & 1.2 & 1.2 & 1.2 & 1.2 & 1.1 & 1.1 & 1.1 & 1.1 & 1.1 & 1.1 &
\textbf{1.046} & \textbf{1.046} & \textbf{0.299} &
\textbf{0.299}\tabularnewline
IQR & 1.0 & - & - & 1.3 & 1.3 & 1.0 & 1.0 & - & - & 1.2 & 1.2 & &
&\tabularnewline
\emph{*t: Independent Samples t-test} & \emph{*t: Independent Samples
t-test} & \emph{*t: Independent Samples t-test} & \emph{*t: Independent
Samples t-test} & \emph{*t: Independent Samples t-test} & \emph{*t:
Independent Samples t-test} & \emph{*t: Independent Samples t-test} &
\emph{*t: Independent Samples t-test} & \emph{*t: Independent Samples
t-test} & \emph{*t: Independent Samples t-test} & \emph{*t: Independent
Samples t-test} & \emph{*t: Independent Samples t-test} & \emph{*t:
Independent Samples t-test} & \emph{*t: Independent Samples t-test} &
\emph{*t: Independent Samples t-test}\tabularnewline
\bottomrule
\end{longtable}

The median left ventricular ejection fraction (EF) was 56\% (IQR,
54-60\%) in Group I and 55\% (IQR, 52-60\%) in Group II (P=0.579). 9
patients (22.5\%) in Group I had atrial fibrillation (AF) versus 11
(27.5\%) in Group II (P=0.606). Median pulmonary artery pressure (PAP)
was 25 in both groups (P=0.330). There was no statistically significant
difference between both groups regarding EF, AF, and median PAP (Table
3). No left ventricular dilatation or right ventricular dysfunction were
noted in both groups preoperatively.

\textbf{Table (3)}\selectlanguage{english}
\begin{longtable}[]{@{}llllllllllllll@{}}
\toprule
\textbf{Characteristic} & \textbf{Group I (n=40)} & \textbf{Group I
(n=40)} & \textbf{Group I (n=40)} & \textbf{Group I (n=40)} &
\textbf{Group II (n=40)} & \textbf{Group II (n=40)} & \textbf{Group II
(n=40)} & \textbf{Group II (n=40)} & \textbf{Group II (n=40)} &
\textbf{Group II (n=40)} & \textbf{Sig.} & \textbf{P} &
\textbf{P}\tabularnewline
\midrule
\endhead
\textbf{Ejection fraction \%} & & & & & & & & & & & \textbf{t*} &
&\tabularnewline
Median & 56.0 & 56.0 & 56.0 & 56.0 & 56.0 & 55.5 & 55.5 & 55.5 & 55.5 &
55.5 & \textbf{0.557} & \textbf{0.557} & \textbf{0.579}\tabularnewline
IQR & 54.0 & - & - & 60.0 & 60.0 & 52.0 & 52.0 & - & - & 60.0 & &
&\tabularnewline
\textbf{Atrial fibrillation} & & & & & & & & & & & \selectlanguage{greek}\textbf{χ2**}\selectlanguage{english} &
\selectlanguage{greek}\textbf{χ2**}\selectlanguage{english} &\tabularnewline
N - \% & 9 & 9 & 9 & 22.5 & 22.5 & 11 & 11 & 11 & 11 & 27.5 &
\textbf{0.267} & \textbf{0.267} & \textbf{0.606}\tabularnewline
\textbf{Median PAP} & & & & & & & & & & & \textbf{t*} & &\tabularnewline
Median & 25.0 & 25.0 & 25.0 & 25.0 & 25.0 & 25.0 & 25.0 & 25.0 & 25.0 &
25.0 & & &\tabularnewline
IQR & 23.0 & - & - & 30.0 & 30.0 & 22.0 & 22.0 & - & - & 30.0 &
\textbf{0.909} & \textbf{0.909} & \textbf{0.330}\tabularnewline
\selectlanguage{greek}\emph{*t: Independent Samples t-test **χ2: Chi-square test}\selectlanguage{english} & \selectlanguage{greek}\emph{*t:
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\bottomrule
\end{longtable}

The most treated coronary arteries were the right coronary in 24
patients (60\%) of Group I versus 20 patients (50\%) of Group II
(P=0.369), and the left circumflex in 16 patients (40\%) of Group I
versus 20 patients (50\%) of Group II (P=0.369). None of the patients in
both groups had left anterior descending or ramus intermedius artery
lesions. Regarding the mitral valve lesions, mitral stenosis was found
in 24 patients (60\%) of Group I versus 16 patients (40\%) of Group II
(P=0.074), mitral regurgitation in 8 patients (20\%) of Group I versus 4
patients (10\%) of Group II (P=0.210), and mixed mitral lesions
(stenosis + regurgitation) in 8 patients (20\%) of Group I versus 20
patients (50\%) of Group II (P=0.005). There was a statistically
significant association between groups regarding mixed mitral valve
lesions only. However, the association was not statistically significant
regarding left circumflex artery lesions, right coronary artery lesions,
mitral valve stenosis, and mitral valve regurgitation. The median time
interval between PCI and mitral valve surgery in Group I was 93 days
(IQR, 91-95) (Table 4).

\textbf{Table (4)}\selectlanguage{english}
\begin{longtable}[]{@{}llllllllllll@{}}
\toprule
\begin{minipage}[b]{0.08\columnwidth}\raggedright\strut
\textbf{Characteristic}\strut
\end{minipage} & \begin{minipage}[b]{0.08\columnwidth}\raggedright\strut
\textbf{Characteristic}\strut
\end{minipage} & \begin{minipage}[b]{0.08\columnwidth}\raggedright\strut
\textbf{Group I (n=40)} \textbf{N \%}\strut
\end{minipage} & \begin{minipage}[b]{0.08\columnwidth}\raggedright\strut
\textbf{Group I (n=40)} \textbf{N \%}\strut
\end{minipage} & \begin{minipage}[b]{0.08\columnwidth}\raggedright\strut
\textbf{Group I (n=40)} \textbf{N \%}\strut
\end{minipage} & \begin{minipage}[b]{0.08\columnwidth}\raggedright\strut
\textbf{Group I (n=40)} \textbf{N \%}\strut
\end{minipage} & \begin{minipage}[b]{0.08\columnwidth}\raggedright\strut
\textbf{Group II (n=40)} \textbf{N \%}\strut
\end{minipage} & \begin{minipage}[b]{0.08\columnwidth}\raggedright\strut
\textbf{Group II (n=40)} \textbf{N \%}\strut
\end{minipage} & \begin{minipage}[b]{0.08\columnwidth}\raggedright\strut
\textbf{Group II (n=40)} \textbf{N \%}\strut
\end{minipage} & \begin{minipage}[b]{0.08\columnwidth}\raggedright\strut
\textbf{Group II (n=40)} \textbf{N \%}\strut
\end{minipage} & \begin{minipage}[b]{0.08\columnwidth}\raggedright\strut
\selectlanguage{greek}\textbf{χ2*}\selectlanguage{english}\strut
\end{minipage} & \begin{minipage}[b]{0.08\columnwidth}\raggedright\strut
\textbf{P}\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\textbf{Coronary artery lesions}\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\textbf{Left circumflex artery lesions}\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
16\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
16\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
40.0\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
40.0\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
20\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
20\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
50.0\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
50.0\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\textbf{0.808}\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\textbf{0.369}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\textbf{Right coronary artery lesion}\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
24\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
24\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
60.0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
60.0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
20\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
20\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
50.0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
50.0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\textbf{0.808}\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\textbf{0.369}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\textbf{Left anterior descending lesions}\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
0.0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
0.0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
0.0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
0.0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\textbf{-}\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\textbf{-}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\textbf{Ramus intermedius lesions}\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
0.0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
0.0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
0.0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
0.0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
0.0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
0.0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\textbf{-}\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\textbf{-}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\textbf{Mitral valve lesions}\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\textbf{Mitral valve stenosis}\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
24\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
24\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
60.0\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
60.0\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
16\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
16\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
40.0\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
40.0\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\textbf{3.200}\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\textbf{0.074}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\textbf{Mitral valve regurgitation}\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
8\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
8\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
20.0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
20.0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
4\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
4\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
10.0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
10.0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\textbf{1.569}\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\textbf{0.210}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\textbf{Mixed mitral valve lesions}\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
8\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
8\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
20.0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
20.0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
20\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
20\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
50.0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
50.0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\textbf{7.912}\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\textbf{0.005**}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\textbf{Time of PCI to valve surgery (days)}\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\textbf{Time of PCI to valve surgery (days)}\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
Median\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
93.0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
93.0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
93.0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
93.0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
-\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
-\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
-\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
-\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\textbf{-}\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\textbf{-}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
IQR\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
91.0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
-\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
-\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
95.0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
-\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
-\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\selectlanguage{greek}\emph{*χ2: Chi-square test **: statistically significant}\selectlanguage{english}\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\selectlanguage{greek}\emph{*χ2: Chi-square test **: statistically significant}\selectlanguage{english}\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\selectlanguage{greek}\emph{*χ2: Chi-square test **: statistically significant}\selectlanguage{english}\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\selectlanguage{greek}\emph{*χ2: Chi-square test **: statistically significant}\selectlanguage{english}\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\selectlanguage{greek}\emph{*χ2: Chi-square test **: statistically significant}\selectlanguage{english}\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\selectlanguage{greek}\emph{*χ2: Chi-square test **: statistically significant}\selectlanguage{english}\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\selectlanguage{greek}\emph{*χ2: Chi-square test **: statistically significant}\selectlanguage{english}\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\selectlanguage{greek}\emph{*χ2: Chi-square test **: statistically significant}\selectlanguage{english}\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\selectlanguage{greek}\emph{*χ2: Chi-square test **: statistically significant}\selectlanguage{english}\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\selectlanguage{greek}\emph{*χ2: Chi-square test **: statistically significant}\selectlanguage{english}\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\selectlanguage{greek}\emph{*χ2: Chi-square test **: statistically significant}\selectlanguage{english}\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

The median aortic cross-clamp and cardiopulmonary bypass times were 44
(IQR, 39-48) and 62 minutes (IQR, 59-68) for Group I, versus 60.5 (IQR,
55-65) and 82 minutes (IQR, 75-88) for Group II (P=0.001), this
difference between groups is statistically significant. 8 patients
(20\%) in Group I needed inotropic support versus 12 patients (30\%) in
Group II (P= 0.302), which is not statistically significant. No patients
in both groups did need any mechanical support in the form of
intra-aortic balloon pump (IABP). None of the patients in both groups
had intraoperative ECG changes in the form of ischemia or arrhythmias
(Table 5). The AF patients preoperatively in both groups went through
several changes in the rhythm and rate intraoperatively before returning
to baseline AF again.

\textbf{Table (5)}\selectlanguage{english}
\begin{longtable}[]{@{}lllllllllllllll@{}}
\toprule
\textbf{Characteristic} & \textbf{Group I (n=40)} & \textbf{Group I
(n=40)} & \textbf{Group I (n=40)} & \textbf{Group I (n=40)} &
\textbf{Group I (n=40)} & \textbf{Group II (n=40)} & \textbf{Group II
(n=40)} & \textbf{Group II (n=40)} & \textbf{Group II (n=40)} &
\textbf{Group II (n=40)} & \textbf{Group II (n=40)} & \textbf{Group II
(n=40)} & \textbf{Sig.} & \textbf{P}\tabularnewline
\midrule
\endhead
\textbf{Aortic cross-clamp time (min)} & & & & & & & & & & & & &
\textbf{t*} &\tabularnewline
Median & 44.0 & 44.0 & 44.0 & 44.0 & 44.0 & 44.0 & 60.5 & 60.5 & 60.5 &
60.5 & 60.5 & 60.5 & \textbf{-10.433} & \textbf{0.001**}\tabularnewline
IQR & 39.0 & - & - & 48.0 & 48.0 & 48.0 & 55.0 & 55.0 & - & - & - & 65.0
& &\tabularnewline
\textbf{Cardiopulmonary bypass time (min)} & & & & & & & & & & & & &
&\tabularnewline
Median & 62.0 & 62.0 & 62.0 & 62.0 & 62.0 & 62.0 & 82.0 & 82.0 & 82.0 &
82.0 & 82.0 & 82.0 & \textbf{-9.752} & \textbf{0.001**}\tabularnewline
IQR & 59.0 & - & - & 68.0 & 68.0 & 68.0 & 75.0 & 75.0 & - & - & - & 88.0
& &\tabularnewline
\textbf{Operative need for inotropic support} & \textbf{N} & \textbf{N}
& \textbf{N} & \textbf{N} & \textbf{\%} & \textbf{N} & \textbf{N} &
\textbf{N} & \textbf{N} & \textbf{\%} & \textbf{\%} & \textbf{\%} &
\selectlanguage{greek}\textbf{χ2***}\selectlanguage{english} &\tabularnewline
Yes & 8 & 8 & 8 & 8 & 20.0 & 12 & 12 & 12 & 12 & 30.0 & 30.0 & 30.0 &
\textbf{1.067} & \textbf{0.302}\tabularnewline
No & 32 & 32 & 32 & 32 & 80.0 & 28 & 28 & 28 & 28 & 70.0 & 70.0 & 70.0 &
&\tabularnewline
\textbf{ECG changes in the form of ischemia or arrhythmias} & 0 & 0 & 0
& 0 & 0.0 & 0 & 0 & 0 & 0 & 0.0 & 0.0 & 0.0 & \textbf{-} &
\textbf{-}\tabularnewline
\selectlanguage{greek}\emph{**t: Independent Samples t-test **: statistically significant
***χ2: Chi-square test}\selectlanguage{english} & \selectlanguage{greek}\emph{**t: Independent Samples t-test **:
statistically significant ***χ2: Chi-square test}\selectlanguage{english} & \selectlanguage{greek}\emph{**t:
Independent Samples t-test **: statistically significant ***χ2:
Chi-square test}\selectlanguage{english} & \selectlanguage{greek}\emph{**t: Independent Samples t-test **:
statistically significant ***χ2: Chi-square test}\selectlanguage{english} & \selectlanguage{greek}\emph{**t:
Independent Samples t-test **: statistically significant ***χ2:
Chi-square test}\selectlanguage{english} & \selectlanguage{greek}\emph{**t: Independent Samples t-test **:
statistically significant ***χ2: Chi-square test}\selectlanguage{english} & \selectlanguage{greek}\emph{**t:
Independent Samples t-test **: statistically significant ***χ2:
Chi-square test}\selectlanguage{english} & \selectlanguage{greek}\emph{**t: Independent Samples t-test **:
statistically significant ***χ2: Chi-square test}\selectlanguage{english} & \selectlanguage{greek}\emph{**t:
Independent Samples t-test **: statistically significant ***χ2:
Chi-square test}\selectlanguage{english} & \selectlanguage{greek}\emph{**t: Independent Samples t-test **:
statistically significant ***χ2: Chi-square test}\selectlanguage{english} & \selectlanguage{greek}\emph{**t:
Independent Samples t-test **: statistically significant ***χ2:
Chi-square test}\selectlanguage{english} & \selectlanguage{greek}\emph{**t: Independent Samples t-test **:
statistically significant ***χ2: Chi-square test}\selectlanguage{english} & \selectlanguage{greek}\emph{**t:
Independent Samples t-test **: statistically significant ***χ2:
Chi-square test}\selectlanguage{english} & \selectlanguage{greek}\emph{**t: Independent Samples t-test **:
statistically significant ***χ2: Chi-square test}\selectlanguage{english} & \selectlanguage{greek}\emph{**t:
Independent Samples t-test **: statistically significant ***χ2:
Chi-square test}\selectlanguage{english}\tabularnewline
\bottomrule
\end{longtable}

The median intensive care unit (ICU) length of stay (hours) and hospital
length of stay (days) were 39 hours (IQR, 32-45) and 5.5 days (IQR, 5-6)
for Group I, versus 56.5 hours (IQR, 49-69) and 8.5 days (IQR, 7-13) for
Group II (P=0.001), that difference between groups is statistically
significant. The median bleeding loss (ml) postoperatively was 925 (IQR,
650-1200) in group I versus 1075 (IQR, 900-1400) in group II (P= 0.021),
which is statistically significant, with a median of 2 units of packed
red blood cells (RBCs) transfused (IQR, 1--2) in group I compared to a
median of 2 packed RBCs units transfused (IQR, 2-3) in group II (P=
0.002), which is statistically significant also. However, the rate of
re-exploration for bleeding did not differ significantly between both
groups, with 1 case only (2.5\%) in group I versus 2 cases (5\%) in
group II (P= 0.556) (Table 6), and no postoperative delayed cardiac
tamponade noted in any of the two groups.

The post-operative complications for groups I and II included 0 (0\%)
versus 3 (7.5\%) prolonged mechanical ventilation (\textgreater{}24 h)
(P= 0.077), 0 (0\%) versus 1 (2.5\%) respiratory complications (P=
0.314), 0 (0\%) versus 2 (5\%) wound infection (P= 0.152), 0 (0\%)
versus 1 (2.5\%) cerebrovascular accidents (P= 0.314), 2 (5\%) versus 1
(2.5\%) acute kidney injury (P= 0.556), respectively. There is no
statistically significant difference between both groups regarding these
previous post-operative complications. None of the patients in both
groups died within the first 30 days after surgery (Table 6).

\textbf{Table (6)}\selectlanguage{english}
\begin{longtable}[]{@{}llllllllllll@{}}
\toprule
\begin{minipage}[b]{0.06\columnwidth}\raggedright\strut
\textbf{Outcome}\strut
\end{minipage} & \begin{minipage}[b]{0.06\columnwidth}\raggedright\strut
\textbf{Group I (n=40)}\strut
\end{minipage} & \begin{minipage}[b]{0.06\columnwidth}\raggedright\strut
\textbf{Group I (n=40)}\strut
\end{minipage} & \begin{minipage}[b]{0.06\columnwidth}\raggedright\strut
\textbf{Group I (n=40)}\strut
\end{minipage} & \begin{minipage}[b]{0.06\columnwidth}\raggedright\strut
\textbf{Group I (n=40)}\strut
\end{minipage} & \begin{minipage}[b]{0.06\columnwidth}\raggedright\strut
\textbf{Group I (n=40)}\strut
\end{minipage} & \begin{minipage}[b]{0.06\columnwidth}\raggedright\strut
\textbf{Group II (n=40)}\strut
\end{minipage} & \begin{minipage}[b]{0.06\columnwidth}\raggedright\strut
\textbf{Group II (n=40)}\strut
\end{minipage} & \begin{minipage}[b]{0.06\columnwidth}\raggedright\strut
\textbf{Group II (n=40)}\strut
\end{minipage} & \begin{minipage}[b]{0.06\columnwidth}\raggedright\strut
\textbf{Group II (n=40)}\strut
\end{minipage} & \begin{minipage}[b]{0.06\columnwidth}\raggedright\strut
\textbf{Sig.}\strut
\end{minipage} & \begin{minipage}[b]{0.06\columnwidth}\raggedright\strut
\textbf{P}\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\textbf{ICU length of stay (hours)}\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\textbf{U*}\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
Median\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
39.0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
39.0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
39.0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
39.0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
39.0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
56.5\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
56.5\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
56.5\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
56.5\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
IQR\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
32.0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
-\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
-\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
45.0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
45.0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
49.0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
-\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
-\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
69.0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\textbf{-8.379}\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\textbf{0.001**}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\textbf{Blood loss (ml)}\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
Median\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
925.0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
925.0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
925.0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
925.0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
925.0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
1075.0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
1075.0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
1075.0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
1075.0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\textbf{-2.316}\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\textbf{0.021**}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
IQR\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
650.0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
-\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
-\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
1200.0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
1200.0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
900.0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
-\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
-\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
1400.0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\textbf{Packed RBCs units transferred}\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
Median\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
2.0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
2.0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
2.0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
2.0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
2.0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
2.0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
2.0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
2.0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
2.0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\textbf{-3.091}\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\textbf{0.002**}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
IQR\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
1.0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
-\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
-\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
2.0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
2.0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
2.0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
-\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
-\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
3.0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\textbf{Hospital length of stay (days)}\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
Median\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
5.5\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
5.5\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
5.5\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
5.5\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
5.5\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
8.5\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
8.5\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
8.5\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
8.5\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\textbf{-6.571}\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\textbf{0.001**}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
IQR\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
5.0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
-\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
-\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
6.0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
6.0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
7.0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
-\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
-\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
13.0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\textbf{Prolonged mechanical ventilation (\textgreater{}24 h)}\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
0\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
0\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
0\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
0\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
0.0\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
3\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
3\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
7.5\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
7.5\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\selectlanguage{greek}\textbf{χ2***}\selectlanguage{english} \textbf{3.117}\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\textbf{0.077}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\textbf{Respiratory complications}\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
0.0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
1\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
1\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
2.5\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
2.5\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\textbf{1.013}\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\textbf{0.314}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\textbf{Wound infection}\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
0.0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
2\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
2\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
5.0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
5.0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\textbf{2.051}\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\textbf{0.152}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\textbf{Cerebrovascular accidents}\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
0.0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
1\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
1\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
2.5\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
2.5\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\textbf{1.013}\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\textbf{0.314}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\textbf{Re-operation for bleeding}\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
1\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
1\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
1\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
1\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
2.5\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
2\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
2\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
5.0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
5.0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\textbf{0.346}\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\textbf{0.556}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\textbf{Acute kidney injury}\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
2\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
2\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
2\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
2\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
5.0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
1\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
1\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
2.5\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
2.5\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\textbf{0.346}\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\textbf{0.556}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\textbf{30-day mortality}\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
0.0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
0.0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
0.0\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\textbf{-}\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\textbf{-}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\selectlanguage{greek}\emph{*U: Mann Whitney U test **: statistically significant ***χ2:
Chi-square test}\selectlanguage{english}\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\selectlanguage{greek}\emph{*U: Mann Whitney U test **: statistically significant ***χ2:
Chi-square test}\selectlanguage{english}\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\selectlanguage{greek}\emph{*U: Mann Whitney U test **: statistically significant ***χ2:
Chi-square test}\selectlanguage{english}\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\selectlanguage{greek}\emph{*U: Mann Whitney U test **: statistically significant ***χ2:
Chi-square test}\selectlanguage{english}\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\selectlanguage{greek}\emph{*U: Mann Whitney U test **: statistically significant ***χ2:
Chi-square test}\selectlanguage{english}\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\selectlanguage{greek}\emph{*U: Mann Whitney U test **: statistically significant ***χ2:
Chi-square test}\selectlanguage{english}\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\selectlanguage{greek}\emph{*U: Mann Whitney U test **: statistically significant ***χ2:
Chi-square test}\selectlanguage{english}\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\selectlanguage{greek}\emph{*U: Mann Whitney U test **: statistically significant ***χ2:
Chi-square test}\selectlanguage{english}\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\selectlanguage{greek}\emph{*U: Mann Whitney U test **: statistically significant ***χ2:
Chi-square test}\selectlanguage{english}\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\selectlanguage{greek}\emph{*U: Mann Whitney U test **: statistically significant ***χ2:
Chi-square test}\selectlanguage{english}\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\selectlanguage{greek}\emph{*U: Mann Whitney U test **: statistically significant ***χ2:
Chi-square test}\selectlanguage{english}\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\selectlanguage{greek}\emph{*U: Mann Whitney U test **: statistically significant ***χ2:
Chi-square test}\selectlanguage{english}\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

After one year of follow-up, none of the patients in both groups had
major cardiac events or CCU admission. Postoperative routine
trans-thoracic echo (TTE) follow-up was done upon discharge, as well as
after 3 months, 6 months, and 1 year for all patients in both groups.
Regional wall motion abnormalities were noted in 15 patients (37.5\%) of
group I versus 17 patients (42.5\%) of group II (P=0.648), who all
undergone stress ECG, of whom 9 patients (22.5\%) in group I versus 11
patients (27.5\%) in group II showed positive results (P=0.606), and
qualified for diagnostic coronary angiography, which confirmed the need
for reoperation for myocardial ischemia/infarction within the first year
of follow up post-operatively in 4 patients (10\%) of group I versus 8
patients (20\%) of group II (P=0.210). All these follow up outcomes
showed no significant difference between both groups (Table 7).



\textbf{Table (7)}\selectlanguage{english}
\begin{longtable}[]{@{}lllllll@{}}
\toprule
\textbf{Outcome} & \textbf{Group I (n=40)} & \textbf{Group I (n=40)} &
\textbf{Group II (n=40)} & \textbf{Group II (n=40)} & \selectlanguage{greek}\textbf{χ2}\selectlanguage{english} &
\textbf{P}\tabularnewline
\midrule
\endhead
& \textbf{N} & \textbf{\%} & \textbf{N} & \textbf{\%} & &\tabularnewline
\textbf{Major cardiac events or CCU admission} & 0 & 0.0 & 0 & 0.0 &
\textbf{-} & \textbf{-}\tabularnewline
\textbf{Echo regional wall motion abnormalities} & 15 & 37.5 & 17 & 42.5
& \textbf{0.208} & \textbf{0.648}\tabularnewline
\textbf{Positive stress ECG} & 9 & 22.5 & 11 & 27.5 & \textbf{0.267} &
\textbf{0.606}\tabularnewline
\textbf{Need for reoperation for myocardial infarction or ischemia} & 4
& 10.0 & 8 & 20.0 & \textbf{1.569} & \textbf{0.210}\tabularnewline
\selectlanguage{greek}\emph{*χ2: Chi-square test}\selectlanguage{english} & \selectlanguage{greek}\emph{*χ2: Chi-square test}\selectlanguage{english} & \selectlanguage{greek}\emph{*χ2:
Chi-square test}\selectlanguage{english} & \selectlanguage{greek}\emph{*χ2: Chi-square test}\selectlanguage{english} & \selectlanguage{greek}\emph{*χ2: Chi-square
test}\selectlanguage{english} & \selectlanguage{greek}\emph{*χ2: Chi-square test}\selectlanguage{english} & \selectlanguage{greek}\emph{*χ2: Chi-square
test}\selectlanguage{english}\tabularnewline
\bottomrule
\end{longtable}

\textbf{Discussion}

The STS adult cardiac surgery database cites the operative mortality of
isolated MV replacement at 4.7\%. When performing concomitant CABG, the
operative mortality increases to 9.8\%, with a significantly greater
occurrence of post-operative complications and major morbidity occurring
in 7.0\% to 11.6\% (1). Thus, it is hypothesized that the operative risk
of combined CABG and MV surgery may be reduced by partitioning the
operation into the two lower-risk, less invasive procedures of PCI +
MVR. The present study demonstrated a low morbidity and mortality with
staged PCI + MVR for significant single coronary artery and MV disease,
compared to combined CABG and MVR.

Given the trends toward increases in minimally invasive cardiac surgery,
the broad applicability of the hybrid approach described here may be
particularly appealing. Gammie and colleagues (2) reported that from
2004 to 2008 the percentage of mitral valve operations that were done
via a minimally invasive approach increased from 11.9\% to 20.1\%
(P\textless{}.0001). With this progression, it is most likely that a
hybrid approach will increase as well. On the other hand, the short-term
benefits of a hybrid approach are not without potential long-term
hazards.

Fortunately, in-stent restenosis, one of the major limitations of
percutaneous revascularization, has decreased with each new generation
of coronary stent (3). PCI, however, has yet to match CABG with regard
to long-term benefits (4). Multiple studies have consistently
demonstrated that for patients with multi-vessel disease and/or left
main disease, regardless of the presence of diabetes, CABG yields better
outcomes than PCI in terms of mortality, myocardial infarction and need
for repeat coronary revascularization (5). Even when comparing CABG
versus PCI for patients with proximal LAD disease, Hannan et al., showed
that CABG patients had lower rates of repeat revascularization (6). The
benefit of CABG over PCI involves the long-term effects of Internal
Mammary Artery (IMA) to LAD anastomosis, the potential ability of bypass
grafts to `treat' lesions that subsequently develop and resultant
downstream effects of cytokines on arterial disease (7). On the other
hand, PCI offers lower rates of morbidity and shorter hospital stay.

The primary purpose of a hybrid valve/PCI is to substitute PCI for
bypass grafting with saphenous vein grafts (SVGs), particularly for
lesions not in the left anterior descending (LAD) coronary artery (8).
With the current excellent performance of drug-eluting coronary stents
(DES), restenosis and thrombosis rates of DES may be less than the
estimated rate of SVG failure of 20 \% at 12 months (9). The two most
common clinical objectives of hybrid procedures are to reduce overall
operative morbidity and mortality by transforming a single, high-risk
surgery into two less risky procedures, and to facilitate minimally
invasive surgery (8).

Hybrid procedures offer a reasonable alternative to traditional surgery
for patients who meet the following basic criteria: non-LAD coronary
lesions, not amenable to internal mammary bypass grafting; PCI that is
technically feasible and likely durable from a procedural standpoint;
and ability to tolerate the required antiplatelet and anticoagulation
regimens.

Our study was a prospective comparative review, of 2 years duration, of
80 patients with combined single coronary artery (requiring
revascularization in non-LAD territory) and rheumatic MV disease,
divided into two groups; Group I consisting of 40 patients who underwent
staged PCI, and mitral valve replacement 3 months later, and Group II
consisting of 40 patients who underwent combined CABG (using saphenous
venous graft) and mitral valve replacement. Our Aim was to compare
intraoperative, postoperative, and follow-up outcomes of staged PCI
versus CABG with mitral valve replacement in patients with combined
single vessel and mitral valve disease.

Reoperative coronary bypass grafting in a patient with valvular disease
poses a particular challenge in cardiac surgery. The hybrid approach is
of particular benefit in reoperative patients who have had prior CABG
with patent grafts. The technical difficulty of accessing lateral wall
targets, safely dissecting patent bypass grafts, and obtaining exposure
often precludes safe surgery, and these risks are not reflected in
traditional scoring systems. Hybrid valve/PCI may be particularly useful
in this regard and can dramatically simplify a challenging open valve
and CABG surgery by substituting PCI for reoperative bypass grafting in
lesions amenable to PCI (9). However, we excluded redo patients from our
study, as this cohort is extremely high risk, and would have affected
the results in a different way.

Although DES have shown excellent results in clinical trials, their
effectiveness in clinical practice with more complex patients and
complex lesions (high Syntax score, totally occluded coronary vessels,
bifurcated lesions, small vessels, long lesions requiring multiple
stents, ostial stenosis, calcified vessels) remains to be seen. Patients
with diabetes, who comprise 30\% of the surgical population and 37.5\%
of Group I in our study, have higher restenosis rates with DES (10).
Late stent restenosis and thrombosis is another concern.

The most recent data from STS (Society of Thoracic Surgeons) demonstrate
that in those undergoing isolated MV surgery, the rate of MV repair was
57.4\%, and MV replacement was 42.6\% (1). In the cases where MV
pathology and etiology were documented, 56.6\% were identified as having
mitral regurgitation due to annular or degenerative disease, without
stenosis, of which repair was performed in 75.0\% of patients. In the
present study, regarding the mitral valve lesions, mitral stenosis was
found in most of the patients; 24 patients (60\%) of Group I versus 16
patients (40\%) of Group II (P=0.074), mixed mitral lesions (stenosis +
regurgitation) come in the second place with 8 patients (20\%) of Group
I versus 20 patients (50\%) of Group II (P=0.005) (statistically
significant association between groups regarding mixed mitral valve
lesions only), and mitral regurgitation in the minority of study groups
with 8 patients (20\%) of Group I versus 4 patients (10\%) of Group II
(P=0.210). This means that mitral repair could have been feasible in a
minority of patients with pure mitral regurgitation, as the reparability
of other pathologies varies markedly. That encouraged us to exclude
mitral repair and standardize mitral replacement as the uniform approach
for mitral valve surgery in this study.

Although one needs to be cautious when making direct comparison with
other studies, reductions in the parameters of morbidity were noted when
compared with data from the most recent STS adult cardiac surgery
database outcomes. In patients undergoing CABG plus MV replacement, the
most common complication is new-onset atrial fibrillation, which occurs
in 44.2\%, and increases peri-operative morbidity and hospital length of
stay (11). This figure is higher than the 16.1\% noted in present cohort
of PCI + MIMVS (Minimally Invasive Mitral Valve Surgery) and is
consistent with prior studies suggesting a reduced incidence of
post-operative atrial fibrillation when utilizing a minimally invasive
approach for valve surgery (12). In our study, we compared staged PCI +
conventional MVR (Group I) to combined CABG + MVR (Group II). We noticed
no ECG changes in the form of arrhythmias in both groups, the AF
patients preoperatively in both groups went through several changes in
the rhythm and rate intraoperatively before returning to baseline AF
again. This may be due to the less morbid group of patients in our
study, with good EF, low median PAP, relatively good clinical status,
and nearly no comorbidities.

The staged strategy ensures optimal myocardial protection during the
mitral correction. It is our belief that myocardial protection is
greatly enhanced with hybrid procedures. By achieving 100\% completeness
of revascularization before cross-clamping in all of our valve-PCI
patients, cardioplegia administration to all regions of the heart was
possible. In contrast, if surgeons are reluctant to attempt
revascularization on high-risk or technically difficult to reach
lesions, cardioprotection may be compromised, leading to low cardiac
output postoperatively, and worsened outcomes. The reduction in
cross-clamp time for a hybrid procedure also provides significant
myocardial protective benefit, as the heart is faced with a lower
overall ischemic time, and potentially less dysfunction upon
reperfusion.

By performing PCI to treat the coronary artery disease, one obviates the
necessity of performing concomitant CABG at the time of surgery,
significantly reducing the complexity of the surgery and shortening the
operative times, which was noted in our study when compared with
conventional combined CABG and MVR. In our study, the median aortic
cross-clamp and cardiopulmonary bypass times were 44 (IQR, 39-48) and 62
minutes (IQR, 59-68) for Group I, versus 60.5 (IQR, 55-65) and 82
minutes (IQR, 75-88) for Group II (P=0.001), that difference between
groups is statistically significant.

The less traumatic nature of isolated MVR and reduced operative times in
Group I likely conferred lower bleeding and transfusion requirements,
the median bleeding loss (ml) postoperatively was 925 (IQR, 650-1200) in
group I versus 1075 (IQR, 900-1400) in group II (P= 0.021), which is
statistically significant, with a median of 2 units of packed red blood
cells (RBCs) transfused (IQR, 1--2) in group I compared to a median of 2
packed RBCs units transfused (IQR, 2-3) in group II (P= 0.002), which is
statistically significant also. However, the rate of re-exploration for
bleeding did not differ significantly between both groups, with 1 case
only (2.5\%) in group I versus 2 cases (5\%) in group II (P= 0.556). All
reoperation for bleeding cases were related to sternal wire placement,
and no postoperative delayed cardiac tamponade was noted in any of the
two groups.

Although, our study was not powered to detect a statistically
significant difference, shorter operative times and less blood product
use during cardiac surgery are associated with fewer infections, and a
lower morbidity and mortality (13, 14). However, composite
post-operative complications (prolonged mechanical ventilation
(\textgreater{}24 h), respiratory complications, wound infection,
cerebrovascular accidents, re-operation for bleeding, acute kidney
injury, and 30-day mortality) occurred less frequently in group I than
in group II.

With the goal being to optimize stent patency while minimizing the risks
of bleeding, there is concern regarding the risk of bleeding if the
surgery is performed after the PCI and the possibility of stent
thrombosis with protamine reversal. Of particular concern is the risk of
bleeding with dual antiplatelet therapy, largely based on known higher
rates of bleeding after CABG in patients receiving clopidogrel (15). In
the current study, median time of PCI to mitral valve surgery was 93
days, the patients had their antiplatelet agents stopped 5 days before
surgery and resumed their antiplatelet regimen within 24 to 48 hours
after surgery.

In the previously mentioned study by Byrne and colleagues (16), because
of the use of dual antiplatelet therapy, a high incidence of bleeding
occurred, with 22 (85\%) of the 26 patients requiring blood
transfusions. In an attempt to reduce the incidence of bleeding,
Brinster and colleagues (17) performed the PCI the day of, or evening
before, the scheduled minimally invasive aortic valve replacement in 18
patients. There were no reoperations for bleeding, and only 8 (44\%)
patients required blood transfusions.

Santana O, et al. compared the outcomes of patients taking clopidogrel
with those who were not taking clopidogrel. In the intraoperative
period, there were no differences in the requirement of blood products,
whereas in the postoperative period, there was a significantly higher
number of patients taking clopidogrel who required blood products
compared with those not taking clopidogrel. Out of concern for the
possible development of stent thrombosis, they prefer the continuation
of antiplatelet therapy at the time of valve operation (18).

In the study of Mihos CG, et al. (19), even though there was a higher
use of pre-operative clopidogrel in those undergoing PCI+MIMVS, there
were fewer intraoperative transfusions required, when compared with
CABG+MVS. The lower need for blood products in the PCI+MIVS group is
most likely due to the fact that, by its less traumatic nature,
minimally invasive valve surgery is associated with less blood loss.
Also, by virtue of the fact that there was no need to place bypass
grafts, the operative times were much shorter in this group, thereby
having less bleeding (20). Importantly, there were no cases of acute
stent thrombosis peri-operatively. In their previous work, they
evaluated 222 patients who had PCI+MIMVS, 183 of which were on
clopidogrel and were compared with 38 who were not (18). In the
intra-operative period, there were no differences in the requirement of
blood products between the two groups. Post-operatively, there was a
higher proportion of patients on clopidogrel requiring blood products
compared with those who did not take it (50.5\% versus 26.3\%, P=0.005);
however, there was no significant difference in the need for
re-operation for bleeding. Because clopidogrel use perioperatively
appears to be safe (21), their clinical practice has been to continue
anti-platelet therapy at the time of valve surgery to minimize the risk
of acute stent thrombosis.

Ideally, these patients would be best managed by either a longer staging
duration so that the clopidogrel can be stopped (three to six months
with drug-eluting stents), or by a very short staging duration (under 6
h), so that clopidogrel's actions are just beginning to take effect once
the surgery has been completed. Our study differs from the previously
mentioned studies in that we had a significant variation on the use of
antiplatelet agents, our Group I patients had their antiplatelet agents
stopped 5 days before surgery. The median time of PCI to mitral valve
surgery in our study was 93 days, so we feel it is safe to withhold the
antiplatelet therapy.

In these hybrid procedures, the optimal timing of the valve operation
once PCI has been performed is not known. At our institution, the time
delay between PCI and the valve operation is mainly driven by a desire
to reduce the incidence of acute kidney injury counterbalanced with the
urgency of the operation. It has been noted that the closer the 2
procedures are in time, the higher the incidence of acute kidney injury.
Data from 4,440 patients undergoing coronary angiography and cardiac
operation on the same day demonstrated this approach to be an
independent predictor for the development of acute kidney injury (22).
Another study evaluated the incidence of acute kidney injury in patients
who had cardiac catheterization and cardiac operations during the same
admission and compared it with a group of patients who had cardiac
catheterization followed by operation at a later admission (23). The
incidence of acute kidney injury in the patients who had same-admission
cardiac catheterization and operations was 50.2\% compared with 33.7\%
in those who had operations at a later date (p = 0.009). To reduce the
incidence of acute kidney injury, several institutes prefer to wait at
least 3 weeks after PCI to perform valve operations (22, 23).

We decided to wait 3 months after PCI to perform MVR, to avoid renal
failure, and to be able to stop the antiplatelet therapy safely. We have
got 2 patients (5\%) in group I versus 1 (2.5\%) in group II of acute
kidney injury (P= 0.556), in the form of elevated creatinine levels,
which resolved medically, without the need for dialysis. This difference
was not statistically significant. We attribute this to the period of 3
months between PCI \& MVR, which provide us with the protection window
against acute kidney injury.

Santana O, et al (24) compared 65 patients who had a hybrid approach
with 52 matched control patients who underwent conventional bypass
grafting and valve operation. The results demonstrated a significant
reduction in composite complications and hospital lengths of stay in the
hybrid group when compared with conventional group. This is similar to
the results per our study which showed fewer composite complications in
Group I, as well as statistically significant lower median intensive
care unit (ICU) length of stay (hours) and hospital length of stay
(days); 39 hours (IQR, 32-45) and 5.5 days (IQR, 5-6), versus 56.5 hours
(IQR, 49-69) and 8.5 days (IQR, 7-13) for Group II (P=0.001),
respectively.

The postoperative complications were comparable with no statistically
significant difference for groups I and II, with less prolonged
mechanical ventilation (\textgreater{}24 h) 0 (0\%) versus 3 (7.5\%),
and less respiratory complications 0 (0\%) versus 1 (2.5\%) for group I.
This may be due to less aggressive and less time consuming is the
isolated MVR than the combined CABG + MVR, which paves the way for
faster extubation with less respiratory complications. The 3 patients of
Group II eventually got extubated, one of them got chest infection which
has been resolved using appropriate antibiotics. However, both
approaches did include a sternotomy.

By virtue of avoiding a sternotomy, minimally invasive surgery results
in less thoracic surgical trauma and alterations in pulmonary physiology
and biomechanics, which contributes to an enhanced post-operative
recovery and faster extubation, with a reported significantly lower
incidence of prolonged mechanical ventilation occurring in 18.3\% of the
PCI + MIMVS cohort, and 29\% in CABG plus MV replacement, leading to
shorter intensive care unit length of stay with the PCI + MIMVS
approach, when compared with sternotomy. We don't see this significant
difference in our study, because both groups were approached through a
median sternotomy, with low incidence of prolonged mechanical
ventilation, most probably due to exclusion of any lung disease or other
comorbidities from our study groups.

Our present study showed slightly less wound infection in group I; 0
(0\%) versus 2 (5\%), most probably due to less operative time, ICU \&
hospital stay, blood transfusion requirements, \& other postoperative
complications which usually encourage infection. However, this
difference is not significant, probably due to the similar approach used
in both groups; sternotomy, and similar baseline characteristics between
both groups.

The cerebrovascular accidents encountered in our study was one stroke
patient in group II without any residual deficit. No other cases were
reported in both groups, probably due to relatively good baseline
characteristics of the patients included in our study, with good carotid
duplex preoperatively, and exclusion of old patients above 60 years old
with any central or peripheral vascular disease.

Several groups have investigated hybrid approaches of PCI combined with
valve operations. In 2014, Santana et al., published the results of over
200 patients who underwent PCI for coronary revascularization followed
by a minimally invasive valve procedure. They found a mortality rate of
3.6\% and an all-cause mortality rate of 12\% at 4.5 years. They also
demonstrated a decreased complication rate and length of stay for the
hybrid group compared to those undergoing conventional sternotomy (24).

In 2015, George et al. described a series of 26 patients who underwent a
single-stage hybrid procedure involving PCI of a non-LAD vessel followed
by a valve operation (21). Recalculating the STS risk after the PCI was
performed, they found a 35\% risk reduction in the re-operative group
and a 17\% risk reduction in the non-reoperative group. In addition,
they had no in-hospital mortalities and very few complications. No
coronary-stent thromboses were noted during a follow-up period of two
years.

Specific to mitral valve, Umakanthan et al. described the Vanderbilt
experience with 32 consecutive patients who underwent a hybrid
procedure, including PCI and mitral valve surgery. Of these procedures,
28 (89 \%) were performed as a single-stage procedure in a hybrid
operating room (25). The observed in-hospital mortality rate was 3 \%
(1/32) and survival at one and two years was 96 \% and 89~\%,
respectively. The series was expanded to 39 patients and reported by
Solenkova et al., noting a predicted mortality for conventional CABG/
mitral of 14.1 \% versus an observed in-hospital mortality of only
2.6~\% (1/39). (26)

This is different from our study which showed no operative/30-day
mortality in both groups. This may be attributed to the baseline
characteristics of our group of elective patients who are low risk
patients with few or no comorbidities.

As demonstrated by 5-year outcomes from the Synergy Between Percutaneous
Coronary Intervention With TAXUS and Cardiac Surgery (SYNTAX) trial
(27), a strong argument can now be made for PCI in patients with left
main or multivessel disease with low SYNTAX scores (less than 23).
However, the SYNTAX trial also clearly demonstrates a survival benefit
of CABG for patients with a higher burden of disease, as reflected by a
high SYNTAX score (greater than 33), and in specific patient subsets,
such as patients with diabetes mellitus (28). The benefit of CABG is
primarily attributable to left IMA grafting to the LAD, and the patency
of IMA grafting consistently exceeds 95\% at 10 years, setting the gold
standard with which other revascularization strategies should be
compared. Yet, significant limitations of both PCI and CABG persist.
Whereas PCI is burdened by the need for repeat target lesion
interventions, saphenous vein graft failure for non-LAD targets in CABG
can reach 30\% at 1 year, and at 10 to 15 years, only 50\% to 60\% of
the SVGs have been reported to be patent (29). Conversely, the early
restenosis and thrombosis rate of the drug-eluting stents (DES) in
non-LAD vessels is lower than that reported for SVG failure (30).

This is to a great extent in line with the results per our study.
Postoperative routine trans-thoracic echo (TTE) follow-up was done upon
discharge, as well as after 3 months, 6 months, and 1 year for all
patients in both groups. Follow-up was completed after one year.
Regional wall motion abnormalities were noted in 15 patients (37.5\%) of
group I versus 17 patients (42.5\%) of group II (P=0.648), who all
undergone stress ECG, of whom 9 patients (22.5\%) in group I versus 11
patients (27.5\%) in group II showed positive results (P=0.606), and
qualified for diagnostic coronary angiography, which confirmed the need
for reoperation for myocardial ischemia/infarction within the first year
of follow up post-operatively in 4 patients (10\%) of group I versus 8
patients (20\%) of group II (P=0.210). However, all these follow up
outcomes showed no significant difference between both groups within the
first year of follow up. None of the patients in both groups had major
cardiac events or CCU admission. We attribute this to the nature of our
patients in both groups, who have single non-LAD vessel disease
supplying limited heart territories with good functional reserve. Long
term data are needed for more informative conclusion.

As more hybrid PCI/valve procedures are being performed, many questions
remain unanswered, including the optimal order for the procedures, their
timing, the management of dual antiplatelet therapy, and the optimal
costs and logistics of the procedures (8).

\textbf{Limitations}

The primary limitation of the present study is the associated potential
for treatment selection bias. The patients who underwent PCI were
selected on the basis of favorable coronary anatomy for this procedure,
which is an important selection bias. Also, all patients had
single-vessel coronary artery disease with normal left ventricular
ejection fractions, and few or no comorbidities. High risk patients were
excluded from this study.

The follow-up of the patients was limited to 1 year, and thus no
statement may be made regarding long-term differences in outcomes, as
might be expected when comparing PCI and CABG.

\textbf{Conclusions}

In conclusion, a staged approach of PCI followed by MVR is an
alternative to the conventional combined CABG and MVR, can be performed
safely in some patients with single coronary artery and MV disease, and
is associated with good short and follow-up outcomes. As per our study,
it was associated with: (I) significantly less operative time, (II)
significantly faster post-operative recovery, as evidenced by a shorter
intensive care unit and hospital lengths of stay, (III) significantly
less bleeding \& blood transfusions, with no significant difference
regarding re-exploration for bleeding, (IV) comparable morbidity,
mortality, and early follow-up outcomes. Although our valve-PCI cohort
primarily underwent surgery through conventional sternotomy, we expect
to see even greater clinical benefits with regard to lower transfusion,
pain, and length of stay when undergoing minimally invasive, robotic, or
small incision valvular surgery.

Nevertheless, important questions remain, including the optimal timing
of the individual procedures, and the optimal antiplatelet therapy after
PCI. With ongoing advances in stent technology, procedural techniques,
and anticoagulation strategies, as well as the accumulation of long-term
outcomes data, hybrid approaches to concomitant coronary artery and
mitral valve disease will likely become increasingly common. Tailoring
the approach to individual patient pathology and comorbidities is
feasible and offers potentially better treatment paradigms.

\textbf{List of abbreviations}

\textbf{PCI} : Percutaneous Coronary Intervention

\textbf{CABG} : Coronary Artery Bypass Graft

\textbf{MVR} : Mitral Valve Replacement

\textbf{LAD} : Left Anterior Descending artery

\textbf{IABP} : Intra-Aortic Balloon Pump

\textbf{ECG} : Electrocardiogram

\textbf{ICU} : Intensive Care Unit

\textbf{CCU} : Cardiac Care Unit

\textbf{NHI} : National Heart Institute

\textbf{EF} : Ejection Fraction

\textbf{COPD} : Chronic Obstructive Pulmonary Disease

\textbf{INR} : International Normalized Ratio

\textbf{TTE} : Trans-Thoracic Echo

\textbf{BMI} : Body Mass Index

\textbf{MI} : Myocardial Infarction

\textbf{AF} : Atrial Fibrillation

\textbf{PAP} : Pulmonary Artery Pressure

\textbf{IMA} : Internal Mammary Artery

\textbf{SVG} : Saphenous Vein Grafts

\textbf{DES} : Drug-Eluting Stent

\textbf{STS} : Society of Thoracic Surgeons

\textbf{MIMVS} : Minimally Invasive Mitral Valve Surgery

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\textbf{Table Legends}

Table (1): Baseline characteristics of the study patients.

Table (2): Baseline characteristics of the study patients ``continued''.

Table (3): Baseline characteristics of the study patients ``continued''.

Table (4): Baseline characteristics of the study patients ``continued''.

Table (5): Operative characteristics of the study patients.

Table (6): Postoperative outcomes of the study patients.

Table (7): Follow-up outcomes within first year of the study patients.

\textbf{Declarations}

\textbf{Ethics Approval and Consent to Participate}

The study was conducted according to the Helsinki Declaration and
approved by the Research Ethics Committee of the Faculty of Medicine of
Ain Shams University. Informed written consent was obtained from all
participants.

\textbf{Consent for Publication}

This manuscript has been reviewed and approved by all the co-authors and
has not been submitted to any other journals for consideration for
publication.

\textbf{Availability of Data and Material}

The data sets generated and/or analyzed during the current study are
available from the corresponding author upon reasonable request.

\textbf{Competing Interests}

No competing interests exist.

\textbf{Funding}

The authors received no financial support for the research, authorship
and/or publication of this article.

\textbf{Authors' Information}

\textbf{Affiliations:}

Department of Cardiac Surgery, National Heart Institute, Giza, Egypt

Taher Mohamed Eid Abdelmoneim

Department of Cardiothoracic Surgery, Ain Shams University, Cairo, Egypt

Walaa Ahmed Saber

Department of Cardiothoracic Surgery, Ain Shams University, Cairo, Egypt

Osama Abbas Abdelhamid

Department of Cardiothoracic Surgery, Ain Shams University, Cairo, Egypt

Moustafa Gamal ELBarbary

\textbf{Contributions:}

Taher Mohamed Eid Abdelmoneim contributed to data collection,
conception, design, analysis, interpretation and writing of the work.
Walaa Ahmed Saber, Osama Abbas Abdelhamid, and Moustafa Gamal ELBarbary
contributed to revising the manuscript. All authors have read and
approved the manuscript.

\textbf{Corresponding author:}

Correspondence to Taher Mohamed Eid Abdelmoneim.

\textbf{Acknowledgements}

None.

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