Cardiovascular

Robot-Assisted Minimally Invasive Direct Coronary Artery Bypass Graft in High-Risk Patients with Reduced Left Ventricular Function: Comparison with Conventional Off-Pump Coronary Artery Bypass Graft Surgery.

Besola L, Folcarelli I, et al. • Medicina (Kaunas, Lithuania) • 2026

PubMed 42654416 DOI 10.3390/medicina62081519

TL;DR

RA-MIDCAB is noninferior to OPCAB in intermediate- to high-risk patients with moderately depressed LVEF, offering a valuable alternative to conventional surgical revascularization.

Key Findings

Results

RA-MIDCAB demonstrated non-inferiority to OPCAB based on restricted mean survival time analysis at one year.

RMST favored RA-MIDCAB by 34.6 days (p = 0.0067)
Non-inferiority threshold was confirmed as the lower bound of the 95% CI exceeded -8 days
Results remained consistent after adjustment with a generalized linear model
Freedom from the primary composite outcome (all-cause mortality, stroke, repeat revascularization) at one year was 95% for RA-MIDCAB vs. 83.6% for OPCAB (p = 0.2)

Results

Thirty-day mortality was comparable between RA-MIDCAB and OPCAB groups.

30-day mortality was 0% in the RA-MIDCAB group and 3.8% in the OPCAB group (p = 0.374)
72 total patients were included: 20 RA-MIDCAB and 52 OPCAB
EuroSCORE was 3.8 ± 1.9 for RA-MIDCAB and 3.5 ± 2.4 for OPCAB (p = 0.384)
Mean LVEF was 40 ± 13 for RA-MIDCAB and 45 ± 9 for OPCAB (p = 0.454)

Results

ICU stay and oro-tracheal intubation time were shorter in the RA-MIDCAB group compared to OPCAB.

Both ICU stay and intubation time were reported as shorter in the RA-MIDCAB group
These were secondary outcomes assessed in the study
The study period was January 2021 to August 2025 at a single center

Results

Fewer RA-MIDCAB patients required large volumes of red blood cell transfusions compared to OPCAB patients.

Fewer RA-MIDCAB patients required more than 5 RBC units
RBC transfusion volume was a prespecified secondary outcome
This difference was observed despite RA-MIDCAB patients having higher baseline rates of prior myocardial infarction (45% vs. 11.5%; p = 0.003) and prior PCI (40% vs. 13.4%; p = 0.022)

Results

RA-MIDCAB had a longer procedural time than OPCAB.

Procedural time was 196 ± 66 minutes for RA-MIDCAB vs. 182 ± 66 minutes for OPCAB (p = 0.048)
This was a statistically significant difference
Despite longer operative time, RA-MIDCAB was associated with shorter ICU stay and intubation time

Results

RA-MIDCAB patients had significantly higher rates of prior myocardial infarction and prior percutaneous coronary intervention compared to OPCAB patients at baseline.

Prior MI rate was 45% in RA-MIDCAB vs. 11.5% in OPCAB (p = 0.003)
Prior PCI rate was 40% in RA-MIDCAB vs. 13.4% in OPCAB (p = 0.022)
Other baseline variables were described as comparable between groups
A generalized linear model was used to adjust for these confounders in outcome analysis

Methods

The study population consisted of intermediate/high-risk patients with moderately reduced left ventricular ejection fraction undergoing LAD revascularization.

All patients had depressed LVEF; mean LVEF was 40 ± 13 in RA-MIDCAB and 45 ± 9 in OPCAB
This represents a higher-risk population than typically studied for RA-MIDCAB
All procedures involved left internal mammary artery to LAD bypass
The study was retrospective and analyzed consecutive patients at a single center
Kaplan-Meier curves were used to estimate cumulative freedom from the primary composite outcome

What This Means

This research compared two surgical approaches for treating blocked heart arteries in higher-risk patients whose hearts were not pumping as strongly as normal. The study looked at robot-assisted minimally invasive bypass surgery (RA-MIDCAB), performed through small incisions in the chest wall, versus conventional off-pump bypass surgery (OPCAB), performed through a full chest-opening incision (sternotomy), in 72 patients treated at a single hospital between 2021 and 2025. All patients had reduced heart pumping function and were considered intermediate to high surgical risk. The study found that the robot-assisted minimally invasive approach was at least as good as the conventional open approach — a finding described as 'non-inferiority.' Patients who had the robotic procedure spent less time on a breathing machine and in the intensive care unit, and fewer needed large blood transfusions. Survival and freedom from major complications (death, stroke, or need for repeat heart procedures) were similar between the two groups at one year. Notably, the robotic surgery group actually included patients with more prior heart attacks and prior heart procedures, meaning they were arguably at even higher baseline risk, yet still fared comparably or better on several measures. This research suggests that robot-assisted minimally invasive bypass surgery may be a viable option for patients previously considered too high-risk for this less invasive approach, potentially offering faster recovery with comparable safety. However, the authors caution that the study involved relatively small numbers of patients at a single center and that larger studies with longer follow-up are needed to confirm these findings before broader conclusions can be drawn.

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Citation

Besola L, Folcarelli I, Giorgi F, Mazzola M, Ruggiero D, Colli A. (2026). Robot-Assisted Minimally Invasive Direct Coronary Artery Bypass Graft in High-Risk Patients with Reduced Left Ventricular Function: Comparison with Conventional Off-Pump Coronary Artery Bypass Graft Surgery.. Medicina (Kaunas, Lithuania). https://doi.org/10.3390/medicina62081519

Key Findings

What This Means

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