• coronary artery bypass.
• coronary surgery
• minimally invasive cardiac surgery
• RA-MIDCAB

Abstract


Background: Coronary artery disease (CAD) is the leading global cause of death and disability in Western countries. Coronary artery bypass grafting (CABG) has proven to be superior to optimal medical therapy and percutaneous revascularization in specific settings as in presence of multivessel disease (MVD), chronic total occlusion (CTO), high coronary complexity and comorbid diabetes mellitus. Whilst it provides optimal long-term outcomes, it is still affected by long recovery times due to sternotomy. More recently, the combination of off-pump CABG and PCI has been introduced. Hybrid coronary revascularization is particularly helpful for patients with MVD after culprit lesion PCI for acute myocardial infarction (AMI) and for those patients with CTO of the left descending artery (LAD). Minimally invasive surgery provides results similar to conventional surgery but with reduced invasiveness thus improving post-surgery quality of life and reducing surgical risk for frail and high-risk patients. Minimally invasive direct CABG (MIDCAB) enables surgical revascularization of one or more vessels avoiding full sternotomy. In particular, robotic assisted MIDCAB (RA-MIDCAB) consists in using a robotic platform to harvest the LIMA followed by LIMA off-pump anastomosis to the LAD through a mini thoracotomy. This strategy combines the effectiveness of LIMA to LAD bypass, that offers better long-term survival and lower repeat target vessel revascularization, and the advantages of off-pump surgery with no sternotomy.
RA-MIDCAB has emerged as an optimal strategy not only for hybrid revascularization but also or for multiarterial revascularization. This strategy is equally safe as traditional surgical strategy and reduces surgical risk including mortality and bleeding. Results comparable to surgery were observed also in patients with left ventricular dysfunction.
Aim of this study is to assess the early results of RA-MIDCAB in high-risk patients with low ejection fraction and to compare to conventional off-pump CABG.

Methods: This retrospective observational study includes all consecutive patients who underwent RA-MIDCAB at the University Hospital of Pisa, between January 2021 and August 2025. This cohort of patients was compared to patients who underwent to off-pump LIMA to LAD revascularization via median sternotomy during the same period. Patients included in the robotic group could have undergone isolated LIMA to LAD revascularization or hybrid (surgery flowed by PCI) or inverse hybrid revascularization (PCI followed by surgery). Patients who underwent hybrid strategy usually underwent completion of the revascularization during the same hospitalization. Differently, those who underwent inverse hybrid technique received PCI for an acute coronary syndrome and, depending on the severity of residual coronary lesions and clinical features, could have completed revascularization either during the same hospitalization or after 30 days during a new access. Baseline, intraoperative, and postoperative parameters were assessed. Transthoracic echocardiography (TTE) was performed preoperatively, at discharge, and at during follow-up. Data from discharge and the latest follow-up visits were analyzed. The primary outcome, evaluated at discharge and at follow-up was a composite of death, stroke and repeat revascularization. Number of transfused red blood cells units, surgical revision for bleeding, surgical wound infection and improvement of left ventricular function were also evaluated.
An inverse probability weighting analysis was performed to allow comparison between RA-MIDCAB and conventional surgery groups.