Robotic assisted minimally invasive direct coronary artery bypass surgery and hybrid coronary revascularization: Clinical outcomes and cost-analysis

Coronary artery disease (CAD) is a leading global health problem, causing over 17.9 million deaths annually, or 32% of all deaths worldwide. It is primarily caused by atherosclerotic plaque buildup in coronary arteries, which restricts blood flow to the heart muscle. If untreated, CAD can lead to myocardial infarction, heart failure, or sudden cardiac death.

The standard treatment for advanced CAD is coronary artery bypass grafting (CABG), where blood is rerouted around blocked arteries using grafts from the saphenous vein or the left internal thoracic artery (LITA). The LITA-to-left anterior descending artery (LAD) graft has excellent long-term patency, exceeding 90% at 10 years. However, CABG is invasive and requires sternotomy and cardiopulmonary bypass, which carry risks such as bleeding, infections, and stroke.

Percutaneous coronary intervention (PCI), which uses stents to reopen blocked arteries, offers a less invasive alternative with quicker recovery. Yet, PCI has limited long-term durability, particularly in patients with complex or multivessel disease, due to higher rates of restenosis and repeat procedures.

To address these challenges, robotic-assisted minimally invasive direct coronary artery bypass (RA-MIDCAB) has emerged as a promising technique. Using robotic technology, RA-MIDCAB allows for precise grafting of the LITA to the LAD without sternotomy. This approach results in fewer complications, shorter hospital stays, and faster recovery—especially for patients with isolated LAD disease.

Hybrid coronary revascularization (HCR) combines RA-MIDCAB for the LAD with PCI for non-LAD vessels, offering a comprehensive treatment for multivessel disease while avoiding full sternotomy and bypass. HCR provides the long-term benefits of LITA grafting with the reduced invasiveness of PCI.

Clinical studies show that RA-MIDCAB achieves patency rates similar to conventional CABG and that HCR leads to fewer blood transfusions, shorter hospital stays, and quicker rehabilitation. Meta-analyses support a survival benefit for the LITA-LAD graft and fewer repeat revascularizations with HCR.

Despite these advantages, RA-MIDCAB and HCR have not been widely adopted, mainly due to the technical complexity of robotic surgery, steep learning curves, and lack of strong representation in current guidelines. More large-scale, long-term studies are needed to confirm their value in routine practice.

In the Netherlands, RA-MIDCAB and HCR have been performed in specialized centers since 2015. National registry data show excellent outcomes, with a survival rate of over 97% at 19 months and low rates of target vessel revascularization. However, differences in adoption between hospitals highlight the need for standardized protocols and training.

Economic considerations are important. While RA-MIDCAB has higher initial costs due to robotic infrastructure and training, these are balanced by shorter hospital stays and fewer complications. HCR adds cost complexity through PCI, but potential savings arise from quicker recovery and earlier return to work. Tailored reimbursement models and care pathways are needed to enhance cost-effectiveness.

Wider adoption of RA-MIDCAB and HCR is hindered by surgical complexity and lack of guideline inclusion. Innovations such as smart vessel connectors may help simplify procedures like the LITA anastomosis, making them more accessible.

Future research should refine patient selection—especially for elderly or high-risk groups—and assess long-term outcomes and quality of life. Expanding the evidence base is essential to integrate these techniques into everyday care.

RA-MIDCAB and HCR represent significant progress in CAD treatment by combining the proven effectiveness of traditional surgery with the benefits of minimal invasiveness. Their thoughtful implementation could improve outcomes and align cardiac care with modern healthcare goals.