Minimally invasive approaches to coronary artery bypass grafting: techniques, current evidence, and future directions

Conventional coronary artery bypass grafting (CABG) is most commonly performed via median sternotomy, an approach that can be associated with postoperative pain, sternal wound complications, and prolonged recovery. Over the past two decades, multiple minimally invasive coronary surgery strategies have been developed, offering sternotomy-sparing alternatives that may reduce surgical trauma and accelerate recovery in appropriately selected patients. This review summarizes contemporary minimally invasive strategies, focusing on their procedural steps, patient selection, clinical outcomes, and evolving role in contemporary coronary revascularization.

Contemporary techniques include minimally invasive direct coronary artery bypass (MIDCAB), endoscopic/robotic-assisted coronary artery bypass, totally endoscopic coronary artery bypass (TECAB), and hybrid coronary revascularization (HCR), which combines CABG with percutaneous coronary intervention (PCI). Available evidence, largely from observational series and experienced centers, supports favorable graft patency and recovery profiles; however, comparative long-term data remain limited for multivessel and robotic approaches. Owing to their inherent technical complexity, steep learning curves, and high costs of robotic platforms, widespread adoption of MI-CABG has remained limited.

MI-CABG offers an important sternotomy-sparing option for selected patients with coronary artery disease. Wider adoption will depend on careful patient selection, structured training, multidisciplinary Heart Team decision-making, and stronger comparative evidence defining which patients benefit most.