Abstract
Objective
Previous studies have shown the safety and effectiveness of totally endoscopic coronary artery bypass. We report our initial experience performing totally endoscopic coronary artery bypass using the da Vinci Xi platform without an EndoWrist stabilizer, combining the GelPOINT Mini, AirSeal, and Nuvo Stabilizer.
Methods
All consecutive patients undergoing totally endoscopic coronary artery bypass were included from January 2024 to December 2025 from our center. The primary end point was to evaluate sternotomy conversion rates. Secondary end points consisted of mortality and major adverse cardiac and cerebrovascular events.
Results
During the study period, 84 patients underwent totally endoscopic coronary artery bypass. The mean age and body mass index were 63.6 ± 10.5 years and 30 ± 4.6 kg/m2, respectfully. The median left ventricular ejection fraction and hemoglobin A1c were 60.0% (58.0-65.0) and 5.7% (5.3-6.3), respectively. The median Society of Thoracic Surgeons score was 0.55 (0.35-0.86). Intraoperatively, the median left internal thoracic artery left anterior descending flow was 50.0 (40.0-61.5) mL/min. Thirty-one patients (36.9%) underwent totally endoscopic coronary artery bypass as part of a hybrid revascularization strategy, including 7 cases (8.3%) of reverse hybrid revascularization. Most patients (n = 52, 61.9%) were extubated in the operating room. There were no conversions to sternotomy, but 1 patient required reoperation for bleeding. Postoperatively, there were no strokes, myocardial infarctions, or deaths. The median hospital length of stay was 2.0 (1.0-3.0) days, and 98.8% (83/84) of patients were discharged directly home. At 30-day follow-up, there were no deaths.
Conclusions
This initial totally endoscopic coronary artery bypass experience enabled the identification of key technical challenges related to coronary stabilization, visualization, and suture management. The derived surgeon-driven solutions may guide future technology development and contribute to simplifying the procedure, improving reproducibility, and facilitating broader adoption of totally endoscopic coronary artery bypass.
Key Words: CABG, cardiac surgery, robotic, TECAB
Intraoperative view of totally endoscopic anastomosis with all 4 robotic arms.
Central Message.
This early TECAB experience identified key technical barriers and generated surgeon-driven solutions that may guide future technology development toward more reproducible and scalable TECAB platforms.
Perspective.
New robotic platforms will accelerate innovation in cardiac surgery. However, progress should not be dictated by technology alone. Surgeon-driven solutions, such as the use of a fourth robotic arm for suture management and a nano-endoscopic camera as a coronary irrigation, highlight how innovation must align with the technical demands of coronary microsurgery.
Over the past decade, robotic-assisted minimally invasive direct coronary artery bypass (MIDCAB) has emerged as an effective strategy for left internal thoracic artery (LITA) to left anterior descending (LAD) artery revascularization.1 At our institution, a dedicated robotic coronary surgery program,2 led by a single surgeon (G.T.), performed more than 300 robotic MIDCAB procedures between 2021 and 2024.
As the program matured, important limitations became evident. Although robotic MIDCAB provides excellent access to the LAD, exposure of lateral wall coronary targets remains challenging through a limited thoracotomy.3 Consequently, a substantial proportion of patients requiring multivessel or multiarterial revascularization continued to undergo conventional sternotomy coronary artery bypass grafting (CABG), whereas the robotic program remained largely focused on isolated LITA-LAD revascularization.
To expand the applicability of robotic coronary surgery, our group transitioned toward totally endoscopic coronary artery bypass (TECAB). TECAB eliminates thoracotomy and enables fully endoscopic coronary anastomoses, facilitating access to lateral wall targets and supporting the use of bilateral internal thoracic arteries.
A broader adoption of TECAB has been limited by technological constraints, including the absence of a dedicated coronary stabilizer in the current generation robotic platforms.4 To address this limitation, we previously described a modified TECAB approach combining the GelPOINT Mini (Applied Medical) access platform with the Medtronic Nuvo Stabilizer (Medtronic) to enable beating heart coronary anastomosis.5 Similar efforts have been recently published,6 and other groups have adopted this technique successfully. Building on our initial approach, we progressively introduced additional technical refinements aimed at improving stabilization, visualization, and suture management during the procedure.
The present study describes the technical refinements that facilitated totally robotic, off-pump coronary anastomosis in a closed-chest environment without an EndoWrist stabilizer, with the goal of identifying surgeon-driven innovations that may guide future device development and simplify broader adoption of TECAB. Despite the long-term goal of expanding robotic coronary surgery to lateral wall targets and increasing the proportion of patients eligible for robotic CABG, the initial phase of our TECAB program was intentionally focused on anterior wall revascularization, prioritizing patients’ safety and technical refinement of the procedure before adventuring toward the lateral wall.
Materials and Methods
Study Design
This study represents a retrospective analysis of all patients undergoing TECAB between February 2024 and December 2025. Eligibility criteria for robotic CABG at our center have been previously described.2 All patients were evaluated by a multidisciplinary heart team for consensus recommendation. TECAB was offered to patients considered suitable for minimally invasive CABG based on coronary anatomy and clinical characteristics.
Patients with atrial fibrillation and elevated risk of thromboembolic events (high CHA2DS2-VASc score) underwent concomitant robotic left atrial appendage occlusion, as previously described.7,8
The primary end point evaluated sternotomy conversion rates, whereas secondary end points consisted of mortality, stroke, repeat revascularization, and myocardial infarction. The protocol received approval from the Institutional Review Board of Main Line Health Hospitals (IRB 45CFR164.512, November 11, 2020). Because of the retrospective deidentified study design, the requirement for informed consent was waived.
Data collection followed the standardized nomenclature and variable definitions of the Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database. The dataset underlying the analysis is available on reasonable request, subject to institutional approval. The study was designed, analyzed, and reported in line with the Strengthening the Reporting of Observational Studies in Epidemiology guidelines.
Patient Population
A total of 84 consecutive patients underwent TECAB during the study period. Baseline patient characteristics are summarized in Table 1. Four additional patients, initially planned to undergo TECAB, were intraoperatively converted to MIDCAB.
Table 1.
Baseline patient characteristics
| Characteristic | N = 84 |
|---|---|
| Age, y, mean (SD) | 63.6 (10.5) |
| Male sex | 65 (77.4%) |
| BMI, kg/m2, mean (SD) | 30.0 (4.6) |
| Urgent cases | 24 (28.6%) |
| STS PROM, median (IQR) | 0.55 (0.35-0.86) |
| Creatinine, mg/dL, median (IQR) | 0.9 (0.8-1.0) |
| Dialysis | 0 (0.0%) |
| Tobacco use | |
| Active smoker | 8 (9.5%) |
| Former smoker | 27 (32.1%) |
| Never smoker | 49 (58.3%) |
| COPD | 11 (13.1%) |
| Diabetes | 27 (32.1%) |
| HbA1C, %, median (IQR) | 5.7 (5.3-6.3) |
| Hypertension | 76 (90.5%) |
| Cerebrovascular accident | 6 (7.1%) |
| Peripheral vascular disease | 9 (10.7%) |
| Prior AMI | 22 (26.2%) |
| Previous PCI | 20 (23.8%) |
| Previous CABG | 0 (0.0%) |
| Previous valve surgery | 0 (0.0%) |
| Atrial fibrillation | |
| Paroxysmal | 5 (6.0%) |
| Persistent | 1 (1.2%) |
| Pacemaker | 0 (0.0%) |
| Diseased coronaries | |
| 1 | 29 (34.5%) |
| 2 | 29 (34.5%) |
| 3 | 26 (31.0%) |
| Preoperative EF, %, median (IQR) | 60.0 (58.0-65.0) |
BMI, Body mass index; STS PROM, Society of Thoracic Surgeons Predicted Risk of Mortality; IQR, interquartile range; COPD, chronic obstructive pulmonary disease; HbA1C, hemoglobin A1C; AMI, acute myocardial infarction; PCI, percutaneous coronary intervention; CABG, coronary artery bypass grafting; EF, ejection fraction.
Surgical Technique
All procedures were performed using the da Vinci Xi platform (Video 1). Robotic ports were positioned in the second, fourth, and sixth intercostal spaces between the midclavicular and anterior axillary lines to optimize access to the LAD. Before LITA harvesting, the pericardium was opened anterior and posterior to the left phrenic nerve to facilitate exposure of the coronary targets and promote drainage of pericardial fluid into the left pleural cavity.
The LITA was harvested in a skeletonized fashion. During harvesting, the bedside team prepared the stabilization platform consisting of a Nuvo stabilizer introduced through a GelPOINT Mini together with a NanoScope camera (Arthrex) and 2 pediatric irrigation catheters to provide continuous saline flushing of the coronary target (Figure 1).
Figure 1.
Coronary stabilization platform using the GelPOINT Mini with a NanoScope camera.
After LITA division, a 12-mm AirSeal working port was inserted in the second intercostal space at the parasternal line. A 1.2-cm left subxiphoid incision was created and progressively dilated before insertion of a 15-mm trocar with an XS Alexis retractor. An additional 8-mm trocar was placed on the right side of the subxiphoid region and connected to the fourth robotic arm. Equipped with micro-forceps and controlled by a second surgeon at a secondary console, this arm was used for tissue retraction and suture management during the anastomosis.
The Nuvo stabilizer mounted on the GelPOINT Mini was advanced through the subxiphoid access and sealed onto the Alexis retractor to maintain a stable CO2 environment. After docking, the stabilizer was positioned over the target vessel and secured to a table-mounted support system. An Estech retractor was used during the first 12 cases and subsequently replaced by the multiSTATION platform (LSI), which provided improved rigidity and stability.
All coronary anastomoses were performed off-pump on the beating heart using a running 7-0 Pronova polypropylene suture with routine use of an intracoronary shunt.
Hybrid Procedure
Hybrid coronary revascularization strategies were used when appropriate, following multidisciplinary heart team evaluation.
As per our institutional protocol, all patients received aspirin throughout the preoperative and postoperative period. Clopidogrel was initiated at 8:00 pm on the day of surgery and continued for 1 year after the procedure.
In reverse hybrid strategies, surgical revascularization was generally deferred for at least 30 days after the acute coronary event requiring percutaneous coronary intervention to non-LAD targets, allowing stabilization of the clinical condition and appropriate timing of dual antiplatelet therapy management.
Patients receiving dual antiplatelet therapy underwent platelet function testing (P2Y12 assay) 5 days before surgery. On the basis of the results, clopidogrel was discontinued 5 days before surgery when P2Y12 values were less than 100 or 3 days prior when values were less than 150. In cases with higher platelet reactivity, clopidogrel was continued up to the time of surgery.
Statistical Analysis
Categorical variables were presented as frequencies and percentages. The Kolmogorov–Smirnov test was applied to assess the distribution of continuous variables. Normally distributed data were expressed as mean and SD, whereas skewed variables were reported as median with interquartile range. Statistical analyses were conducted using R software (version 4.4.3; R Foundation for Statistical Computing) through the RStudio environment.
Results
Operative Outcomes
The mean operating room time was 4.7 ± 1.0 hours. The LITA was used in all patients, with a median LITA–LAD flow of 50 mL/min (40-61.5). Hybrid and reverse hybrid coronary revascularization was performed in 36.9% and 8.3% of patients, respectively. In this initial series, primarily aimed at refining the TECAB technique in the absence of a dedicated robotic stabilizer, multiarterial grafting was performed in 4 patients (4.8%). Revascularization beyond the anterior wall was progressively undertaken toward the end of this early experience. No intraoperative transfusions were required. Intraoperative outcomes are summarized in Table 2.
Table 2.
Intraoperative outcomes
| Outcome | N = 84 |
|---|---|
| Time in OR, h, mean (SD) | 4.7 (1.0) |
| Cryonerve use | 84 (100%) |
| Left atrial appendage occlusion | 7 (8.3%) |
| Conversion to sternotomy | 0 (0.0%) |
| Intraoperative transfusions | 0 (0.0%) |
| LITA-LAD flow, mL/min, median (IQR) | 50.0 (40.0-61.5) |
| Distal anastomosis | |
| 1 | 80 (95.2%) |
| 2 | 4 (4.8%) |
| Target coronary | |
| LAD | 84 (100%) |
| Diagonal | 1 (1.2%) |
| OM | 2 (2.4%) |
| Grafts | |
| LITA | 84 (100%) |
| RITA | 2 (2.4%) |
| BITA | 2 (2.4%) |
| Multiarterial | 4 (4.8%) |
| Total arterial | 2 (2.4%) |
| Sequential grafting | 2 (2.4%) |
| Hybrid revascularization | 31 (36.9%) |
| Reverse hybrid | 7 (8.3%) |
OR, Operating room; LITA, left internal thoracic artery; LAD, left anterior descending; IQR, interquartile range; OM, obtuse marginal; RITA, right internal thoracic artery; BITA, bilateral internal thoracic artery.
Postoperative Outcomes
Sixty-two percent of patients were extubated in the operating room, and median ventilation time was 3.5 hours. There were no perioperative strokes, operative mortality, or postoperative dialysis. Median hospital length of stay was 2 days, with 75% of patients discharged on postoperative day 1 or 2.
At a median follow-up of 7.7 months, there were no deaths, strokes, or myocardial infarctions. One patient undergoing LITA-LAD required repeat revascularization via drug-eluting balloon due to severe LITA and LAD vasospasm after cocaine use. Postoperative outcomes are summarized in Table 3.
Table 3.
Postoperative outcomes
| Outcome | N = 84 |
|---|---|
| Extubated in the OR | 52 (61.9%) |
| Ventilated h, median (IQR) | 3.5 (2.6, 4.3) |
| Ventilation >24 h | 0 (0.0%) |
| Postop stroke | 0 (0.0%) |
| Postoperative transfusions | 1 (1.2%) |
| Bleeding requiring reexploration | 1 (1.2%) |
| Creatinine, mg/dL, median (IQR) | 1.0 (0.8-1.1) |
| Acute kidney injury | 1 (1.2%) |
| Postoperative dialysis | 0 (0.0%) |
| New atrial fibrillation | 4 (4.8%) |
| Arrhythmia requiring pacemaker | 0 (0.0%) |
| Length of hospital stay, d, median (IQR) | 2.0 (1.0-3.0) |
| Discharged POD 1 or 2 | 63 (75%) |
| Patients discharged home | 83 (98.8%) |
| 30-d mortality | 0 (0.0%) |
| 30-d CV rehospitalization | 6 (7.1%) |
| Median follow-up, mo, mean (range) | 7.7 (0.4-24.4) |
| Follow-up mortality | 0 (0.0%) |
| Follow-up repeat revascularization | 1 (1.2%) |
| Follow-up stroke | 0 (0.0%) |
| Follow-up MI | 0 (0.0%) |
OR, Operating room; IQR, interquartile range; POD, postoperative day; CV, ardiovascular; follow-up; MI, myocardial infarction.
Reexploration for Bleeding
One patient required surgical reexploration for postoperative bleeding approximately 5 hours after surgery while mobilizing and remaining hemodynamically stable. The reexploration was performed entirely robotically. The source of bleeding was a malpositioned clip on a collateral branch of the LITA. The patient recovered uneventfully after the revision.
Conversion to Robotic Minimally Invasive Direct Coronary Bypass
Besides the 84 patients, 4 additional patients required intraoperative conversion from an initially planned TECAB to MIDCAB. Of note, no conversions to median sternotomy were necessary. All conversions occurred within the first 25 cases. The indications for conversion included inadequate stabilization of the distal coronary target in 2 patients, excessive bleeding resulting in poor visualization of the coronary target in 1 patient, and absence of graft flow on transit-time flow measurement after completion of the anastomosis in 1 patient. In all 4 cases, the procedure was successfully completed using robotic MIDCAB, and all patients experienced favorable postoperative outcomes, as summarized in Table E1, Table E2, Table E3.
Coronary Anastomosis
A total of 88 distal coronary anastomoses were performed in 84 patients. The majority of cases involved a single LITA–LAD anastomosis (95.2%), whereas 4 patients underwent 2 distal anastomoses during the same procedure. In selected cases, additional targets included the diagonal branch and obtuse marginal artery. All coronary anastomoses were performed on the beating heart without cardiopulmonary bypass. During the initial phase of the program, mean anastomotic time was approximately 31 to 33 minutes. In the most recent cases, coronary anastomoses were routinely completed in 17 to 22 minutes (Figure 2).
Figure 2.
Learning curve of robotic coronary anastomosis during TECAB. Anastomotic time across 84 consecutive TECAB procedures demonstrates a progressive reduction with increasing experience. Suture rupture events are marked with X symbols. TECAB, Totally endoscopic coronary artery bypass.
Six cases were complicated by intraoperative suture breakage, resulting in prolonged anastomotic times (38-44 minutes). These events occurred throughout the series, including later cases, and represented the principal technical factor associated with extended anastomotic time.
Discussion
Evolution of the Robotic Coronary Program
This study describes the evolution of a mature robotic coronary surgery program from robotic MIDCAB to TECAB and the technical refinements that emerged during the first 84 procedures. Our objective was to identify the procedural challenges encountered during adoption of TECAB on the da Vinci Xi platform and the solutions developed to overcome them.
The transition to TECAB was motivated by the desire to expand the applicability of robotic coronary surgery beyond isolated LITA-LAD revascularization. Although robotic MIDCAB proved highly effective for anterior wall revascularization, the thoracotomy required to perform the coronary anastomosis remained a limitation, particularly in patients with multivessel disease. Despite a mature robotic coronary program, approximately 60% of our CABG volume continued to be performed through median sternotomy because of the technical challenges associated with accessing non-LAD coronary targets through a limited thoracotomy.
TECAB offers several theoretical advantages. By eliminating thoracotomy and allowing coronary anastomoses to be performed entirely endoscopically, it creates a platform that can ultimately facilitate access to lateral wall targets and broader application of multiarterial coronary revascularization.9 Furthermore, TECAB enables bilateral internal thoracic artery grafting while preserving sternal integrity, thereby supporting anaortic revascularization strategies that have been associated with a reduction in neurological complications.10
Of note, our objective was not to immediately expand TECAB to complex multivessel revascularization. Instead, the initial phase of the program focused on developing a safe and reproducible platform. We deliberately concentrated on LITA-LAD revascularization while refining coronary stabilization, visualization, and suture management before progressively extending the technique to more complex coronary targets. We believe the lessons learned during this process may help other experienced robotic coronary programs shorten the learning curve and accelerate the safe adoption of TECAB.
Finally, our experience suggests that TECAB should be viewed as an advanced extension of robotic MIDCAB rather than an entry point into robotic coronary surgery. The technical foundation acquired during more than 300 robotic MIDCAB procedures was instrumental in the safe adoption of a totally endoscopic beating-heart approach and in the development of the innovations described in this study.
Clinical Impact of the Totally Endoscopic Coronary Artery Bypass Platform
The clinical outcomes observed in this early experience also highlight the potential impact of TECAB on postoperative recovery. In this series, TECAB was associated with excellent perioperative outcomes, including zero operative mortality, perioperative strokes, and sternotomy conversions. TECAB was also associated with a rapid postoperative recovery, with most patients extubated early and with 75% of patients discharged on postoperative day 1 or 2. In our prior robotic MIDCAB program, patients were discharged after a median hospitalization of 4 days, largely reflecting the impact of the minithoracotomy,2 which is in contrast to TECAB.11 These findings suggest that the benefits of TECAB extend beyond cosmetic considerations and may translate into meaningful improvements in postoperative recovery and resource use. Previous comparisons between TECAB and robotic-assisted MIDCAB have not shown significant differences.12,13 A plausible explanation for these discrepancies lies in an arrested heart TECAB, as performed in the study by Kofler and colleagues12 and in approximately 56% of the study by Pasrija and colleagues.13
Technical Evolution
Optimization of coronary stabilization
One of the earliest technical challenges encountered during this experience was reliable stabilization of the distal coronary target. During the initial phase of the program, the Medtronic Nuvo stabilizer was mounted using an Estech table-mounted support system. Although adequate in most cases, this configuration occasionally lacked the rigidity required for precise stabilization of the beating coronary target during anastomosis.
Among the first 25 cases, 4 procedures required conversion from a planned TECAB to robotic MIDCAB. Two of these conversions were directly related to inadequate stabilization of the target vessel, highlighting the critical importance of a stable operative platform for successful beating-heart TECAB. These early experiences prompted adoption of the Multistation support system (LSI), which provided improved rigidity and stability.
After this modification, stabilization of the coronary target became significantly more reproducible and no further conversions related to target stabilization occurred. We believe that coronary stabilization remains one of the most important technological requirements for broader TECAB adoption and that future device development should focus on improving the precision, ease of positioning, and rigidity of stabilization systems.
Improving visualization of the coronary target
Another important technical challenge was maintaining adequate visualization of the coronary arteriotomy during the anastomosis. Although intracoronary shunts were routinely used for distal perfusion, significant back-bleeding was sometimes encountered, particularly in chronic total occlusion (CTO) cases with well-developed collateral circulation. Initially, CTO lesions were considered ideal candidates for TECAB because of their theoretical tolerance to longer ischemic times. However, in practice, the presence of robust collateral backflow often resulted in significant bleeding from the distal vessel. In 1 early case, conversion to thoracotomy was required due to the inability to obtain adequate visualization of the coronary target despite the use of shunts and proximal and distal snares.
To improve visualization, a nano-endoscopic camera system (NanoScope) was introduced, directly inserted through the GelPOINT. This system incorporates a high-pressure saline irrigation channel that effectively functions as a robotic coronary irrigation. This modification proved particularly valuable given the high-definition magnification of the robotic optical system, which tends to amplify even small amounts of bleeding. After the adoption of this tool, we observed substantial improvements in visualization and a progressive reduction in anastomotic time, particularly in CTO cases.
Additional robotic arm for suture management
A third important technical refinement involved the introduction of an additional robotic arm to facilitate suture management. Historically, the fourth robotic arm was occupied by the coronary stabilizer with the da Vinci Si. Future robotic systems, including the anticipated DV5 Surgical System, are expected to follow a similar configuration.
Interestingly, the absence of a dedicated robotic stabilizer on the Xi platform created an unexpected opportunity. Because stabilization was achieved through an external platform, 1 robotic arm remained available. The primary function of this arm was to follow the running suture, maintain appropriate tension, and provide dynamic retraction of surrounding tissue. When a second operator was not available, the primary surgeon could alternatively use the instrument-swapping pedal to temporarily control this arm during the anastomosis. This additional arm became one of the most important technical refinements introduced during the evolution of the program that significantly improved suture control and reduced the need for additional reinforcing stitches at the anastomotic site. To our knowledge, the use of a dedicated fourth robotic arm for suture management during TECAB has not been previously described.
Anastomotic efficiency and suture management
Throughout the series, we observed a progressive reduction in anastomotic time as these technical refinements were implemented. One important observation from our experience is that suture breakage represented one of the most significant factors prolonging anastomotic time during TECAB. This breakage often required restarting the anastomosis or placing additional sutures. In addition, we have begun exploring in the last 4 cases of this series the use of long-shafted micro knot-tying devices (Cor-Knot Micro, LSI) to facilitate secure knotting in confined endoscopic environments.14
In the future, additional technological innovations such as coronary anastomotic connectors, which have previously proven valuable in TECAB15 or interrupted suture techniques combined with automated knotting systems, may further simplify the procedure and facilitate broader adoption of TECAB.
Strength and Limitations
This study must acknowledge several limitations. Its single-center, single-surgeon design and retrospective nature inherently restrict generalizability and introduce bias from unmeasured or unrecognized confounders. The absence of a comparison arm represents another limitation. However, the study was intentionally designed as a descriptive cohort of a previously published technique without any intent to establish superiority or infer comparative effectiveness. These results derive from a high-volume robotic program with extensive prior MIDCAB experience and may not be directly generalizable to all centers.
The relatively short follow-up period also may be insufficient to capture late graft-related events or patency, durability of anastomoses, or long-term clinical outcomes. Larger, multicenter studies with prospective designs and comparator groups will be necessary to validate and expand on these findings.
Conclusions
This early TECAB experience demonstrated excellent clinical outcomes while identifying the principal technical barriers that continue to limit broader adoption of totally endoscopic coronary surgery. The surgeon-driven refinements developed during this series addressed key challenges in coronary stabilization, visualization, and suture management and contributed to improved procedural efficiency and reproducibility. More important, this experience highlighted that many of the remaining obstacles to wider TECAB adoption are technological rather than conceptual. The lessons learned from these first 84 cases may help guide future device and platform development toward solutions specifically designed for the unique demands of coronary microsurgery in a closed-chest environment. Ultimately, the future of TECAB will depend on transforming a highly technical operation into a more technological, reproducible, and scalable procedure. Continued collaboration between surgeons and industry will be essential to achieve this and make TECAB ultimately mainstream.
Conflict of Interest Statement
G.T.: advisor/consultant for Peters Surgical, Medtronic, Arthrex, AtriCure, LSI; paid honoraria from AtriCure, Medtronic, LSI and Peters Surgical. H.B.: proctor for Intuitive; consultant for Edwards, Medtronic, and Atricure; medical advisory board for Enable CV and Corcym. All other authors reported no conflicts of interest.
The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.
Footnotes
The protocol received approval from the Institutional Review Board of Main Line Health Hospitals (IRB 45CFR164.512, November 11, 2020). Because of the retrospective deidentified study design, the requirement for informed consent was waived.
Supplementary Data
TECAB procedure. Brief depiction of all the TECAB's steps. Video available at: https://www.jtcvs.org/article/S2666-2507(26)00369-X/fulltext.
Appendix E1
Table E1.
Baseline patient characteristics of minimally invasive direct coronary bypass conversions
| Characteristic | MIDCAB 1 | MIDCAB 2 | MIDCAB 3 | MIDCAB 4 |
|---|---|---|---|---|
| Age, y | 68 | 70 | 64 | 73 |
| Sex | Male | Male | Male | Female |
| BMI, kg/m2 | 27.1 | 28.9 | 23.5 | 33.7 |
| Urgency | Elective | Elective | Elective | Elective |
| STS PROM | 0.46 | 0.95 | 0.40 | 0.99 |
| Creatinine, mg/dL | 1.2 | 1.1 | 1.1 | 1.1 |
| Dialysis | No | No | No | No |
| History of smoke | Never | Never | Former | Former |
| COPD | No | No | No | No |
| Diabetes | Yes | Yes | No | Yes |
| HbA1C, % | 7.1 | 5.9 | 5.7 | 6.7 |
| Hypertension | Yes | Yes | Yes | Yes |
| Cerebrovascular accident | No | Yes | No | No |
| Peripheral vascular disease | No | No | No | No |
| Prior AMI | Yes | No | No | No |
| Previous PCI | No | Yes | No | No |
| Previous CABG | No | No | No | No |
| Previous valve surgery | No | No | No | No |
| Atrial fibrillation | No | No | Yes | No |
| Pacemaker | No | No | No | No |
| CAD vessels | 2 | 3 | 2 | 2 |
| Preoperative EF, % | 60 | 60 | 60 | 63 |
MIDCAB, Minimally invasive direct coronary bypass; BMI, body mass index; STS PROM, Society of Thoracic Surgeons Predicted Risk of Mortality; COPD, chronic obstructive pulmonary disease; HbA1C, hemoglobin A1C; AMI, acute myocardial infarction; PCI, percutaneous coronary intervention; CABG, coronary artery bypass grafting; CAD, coronary artery disease; EF, ejection fraction.
Table E2.
Intraoperative outcomes of minimally invasive direct coronary bypass conversions
| Outcome | MIDCAB 1 | MIDCAB 2 | MIDCAB 3 | MIDCAB 4 |
|---|---|---|---|---|
| Time in OR, h | 4.4 | 4.8 | 3.8 | 5.1 |
| Cryonerve use | Yes | Yes | Yes | Yes |
| Left atrial appendage occlusion | No | No | No | No |
| Conversion to sternotomy | No | No | No | No |
| Intraoperative transfusions | No | No | No | No |
| LITA-LAD flow, mL/min | 50 | 35 | 51 | 43 |
| Distal anastomosis number | 1 | 1 | 1 | 1 |
| Target coronary | LAD | LAD | LAD | LAD |
| Grafts | LITA | LITA | LITA | LITA |
| Multiarterial | No | No | No | No |
| Total arterial | No | No | No | No |
| Sequential grafting | No | No | No | No |
| Hybrid revascularization | Yes | Yes | Yes | Yes |
| Reverse hybrid | No | Yes | No | No |
MIDCAB, Minimally invasive direct coronary bypass; OR, operating room; LITA, left internal thoracic artery; LAD, left anterior descending.
Table E3.
Postoperative outcomes of minimally invasive direct coronary bypass conversions
| Outcome | MIDCAB 1 | MIDCAB 2 | MIDCAB 3 | MIDCAB 4 |
|---|---|---|---|---|
| Extubated in the OR | Yes | No | No | No |
| Ventilated h | 0 | 4.33 | 5.12 | 3.86 |
| Ventilation >24 h | No | No | No | No |
| Postoperative stroke | No | No | No | No |
| Postoperative transfusions | No | No | No | No |
| Bleeding requiring reexploration | No | No | No | No |
| Creatinine, mg/dL | 1.3 | 1.4 | 1.1 | 1.5 |
| Acute kidney injury | No | No | No | No |
| Postoperative dialysis | No | No | No | No |
| New atrial fibrillation | No | No | No | No |
| Arrhythmia requiring pacemaker | No | No | No | No |
| Length of hospital stay, d | 4 | 3 | 4 | 6 |
| Patients discharged home | Yes | Yes | Yes | Yes |
| 30-d mortality | No | No | No | No |
| 30-d CV rehospitalization | No | No | No | No |
| Follow-up, mo | 7 | 7 | 6 | 6 |
| Follow-up mortality | No | No | No | No |
| Follow-up repeat revascularization | No | No | No | No |
| Follow-up stroke | No | No | No | No |
| Follow-up MI | No | No | No | No |
MIDCAB, Minimally invasive direct coronary bypass; OR, operating room; CV, cardiovascular; MI, myocardial infarction.
References
- 1.Van Puyvelde J., Baudo M., Torregrossa G., Oosterlinck W. The role of robotic coronary artery bypass grafting in the current practice of surgical myocardial revascularization. Ann Cardiothorac Surg. 2024;13(5):439–441. doi: 10.21037/acs-2023-rcabg-0198. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Dokollari A., Sicouri S., Erten O., et al. Long-term clinical outcomes of robotic-assisted surgical coronary artery revascularisation. EuroIntervention. 2024;20(1):45–55. doi: 10.4244/EIJ-D-23-00373. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Baudo M., Torregrossa G. Robotic coronary artery bypass grafting: current status and future perspectives. Vessel Plus. 2025;9(13) doi: 10.20517/2574-1209.2025.69. [DOI] [Google Scholar]
- 4.Torregrossa G., Amabile A., Nisivaco S., Algoet M., Oosterlinck W., Balkhy H.H. The stradivari violin of robotic heart surgery: the robotic EndoWrist stabilizer. Innovations (Phila) 2024;19(6):612–615. doi: 10.1177/15569845241279259. [DOI] [PubMed] [Google Scholar]
- 5.Torregrossa G., Yakobitis A., Murray C., Baudo M. Total endoscopic coronary artery bypass on a DaVinci Xi platform without an EndoWrist stabilizer combining the technology of GelPOINT mini, AirSeal, and Octopus Nuvo. Ann Cardiothorac Surg. 2024;13(5):461–463. doi: 10.21037/acs-2024-rcabg-0112. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Murtaza G., Cheema N.H., Enz J., Balkhy H.H. Robotic totally endoscopic beating heart off-pump coronary bypass: improvising coronary artery stabilization without the EndoWrist stabilizer. Innovations (Phila) 2025;20(3):316–317. doi: 10.1177/15569845251339158. [DOI] [PubMed] [Google Scholar]
- 7.Baudo M., Yamashita Y., Yakobitis A., Foley D., Murray C., Torregrossa G. Robotic left atrial appendage occlusion: insights from real-world practice. Int J Med Robot. 2026;22(2) doi: 10.1002/rcs.70146. [DOI] [PubMed] [Google Scholar]
- 8.Baudo M., Yakobitis A., Murray C., Torregrossa G. Robotic-assisted left atrial appendage occlusion. Multimed Man Cardiothorac Surg. 2024;2024 doi: 10.1510/mmcts.2024.065. [DOI] [PubMed] [Google Scholar]
- 9.Nisivaco S., Kitahara H., Bhasin R., Patel B., Coleman C., Balkhy H.H. A decade of robotic beating-heart totally endoscopic coronary bypass (TECAB) at a single institution: outcomes with 10-year follow-up. J Thorac Cardiovasc Surg. 2025;169(6):1753–1760.e3. doi: 10.1016/j.jtcvs.2024.07.060. [DOI] [PubMed] [Google Scholar]
- 10.Baudo M., Torregrossa G., Puskas J.D. The 10 commandments for proximal anastomosis during CABG: techniques and technologies for vein and arterial grafts. Innovations (Phila) 2024;19(5):464–470. doi: 10.1177/15569845241279249. [DOI] [PubMed] [Google Scholar]
- 11.Hoogma D.F., Oosterlinck W., Rex S. Small incisions still require great anesthesia: anesthesiology techniques to enhance recovery in robotic coronary bypass grafting. Ann Cardiothorac Surg. 2024;13(5):409–416. doi: 10.21037/acs-2024-rcabg-0048. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Kofler M., Schachner T., Reinstadler S.J., et al. Comparative analysis of perioperative and mid-term results of TECAB and MIDCAB for revascularization of anterior wall. Innovations (Phila) 2017;12(3):207–213. doi: 10.1097/IMI.0000000000000378. [DOI] [PubMed] [Google Scholar]
- 13.Pasrija C., Kon Z.N., Ghoreishi M., et al. Cost and outcome of minimally invasive techniques for coronary surgery using robotic technology. Innovations (Phila) 2018;13(4):282–286. doi: 10.1097/IMI.0000000000000537. [DOI] [PubMed] [Google Scholar]
- 14.Torregrossa G., Baudo M., Yakobitis A., Murray C., Cavanaugh S.M., Purrman K.C. Evaluating the feasibility of a novel micro Titanium fastener to facilitate robot-assisted coronary artery bypass grafting. Innovations (Phila) 2024;19(4):439–442. doi: 10.1177/15569845241266596. [DOI] [PubMed] [Google Scholar]
- 15.Balkhy H.H., Nisivaco S.M., Hashimoto M., Torregrossa G., Grady K. Robotic total endoscopic coronary bypass in 570 patients: impact of anastomotic technique in two eras. Ann Thorac Surg. 2022;114(2):476–482. doi: 10.1016/j.athoracsur.2021.10.049. [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
TECAB procedure. Brief depiction of all the TECAB's steps. Video available at: https://www.jtcvs.org/article/S2666-2507(26)00369-X/fulltext.