[Minimally invasive coronary surgery: new developments in myocardial revascularization]

Minimally invasive coronary revascularization has gained increasing interest as it represents a significant approach to reducing well-known complications of conventional sternotomy, such as bleeding, need for transfusions, postoperative atrial fibrillation, wound infections, and prolonged hospital stay. These potential benefits, described in numerous retrospective and observational studies, appear to be associated with faster functional recovery and improved quality of life, although prospective evidence remains limited at present. The harvesting of the internal mammary artery, initially performed under direct vision through a mini-thoracotomy, has been progressively refined through the introduction of thoracoscopy and, in highly specialized centers, with robotic assistance. The choice of the incision site and extent is now tailored to the patient's anatomy and the objectives of revascularization, resulting in an increasingly personalized approach. Among available techniques, the minimally invasive direct coronary artery bypass - in which the left internal mammary artery is anastomosed to the left anterior descending artery - represents a consolidated and effective option for isolated left anterior descending coronary artery lesions. Minimally invasive coronary surgery extends these possibilities to multivessel revascularization, performed with or without cardiopulmonary bypass, allowing accurate anastomoses even on lateral and inferior wall vessels. The totally endoscopic coronary artery bypass represents a further evolution, based on completely endoscopic access, whose clinical use remains limited to a few highly specialized centers, sometimes with robotic support, particularly during conduit harvesting. Overall, minimally invasive coronary surgery represents an evolving field, supported by a growing number of publications and clinical experiences in Europe, North America, and also in Italy, where centers such as the Santa Maria Hospital in Bari perform a significant proportion of minimally invasive revascularizations. According to the available literature, this approach is associated with reduced perioperative complications, shorter hospital stays, and faster return to daily activities, with greater patient acceptance. Thoracoscopy and robotics are promising innovations that may further enhance outcomes, while mini-invasiveness remains the cornerstone of an increasingly central evolution in coronary surgery.