As alternatives to conventional coronary artery bypass grafting (CABG), robot-assisted CABG (R-CABG) and percutaneous coronary intervention (PCI) offer less invasive treatments for coronary artery disease (CAD). However, data comparing outcomes of R-CABG versus PCI are limited.
Methods:
Databases were systematically searched for studies comparing R-CABG versus PCI. Random-effects models were used to calculate pooled odds ratios (ORs) with 95% confidence intervals (CIs), both overall and stratified by left main or multivessel (LM+MV) or isolated left anterior descending artery (LAD) disease. Kaplan–Meier curves were digitally extracted to reconstruct individual participant data (IPD), from which hazard ratios (HRs) were estimated for survival analyses.
Results:
Six retrospective studies, including 1,896 patients (R-CABG: 894, 47.1%), were analyzed. The mean age was 63.8 ± 11.3 years, and 78.7% were male patients. Follow-up ranged from 2 to 8 years. Overall, R-CABG was associated with a lower odds of target vessel revascularization (TVR; OR = 0.50, 95% CI: 0.27 to 0.93, P = 0.03) and myocardial infarction (MI; OR = 0.44, 95% CI: 0.26 to 0.76, P < 0.01), with no significant difference in all-cause mortality. Among patients with LM+MV disease, R-CABG reduced TVR and MI. In LAD lesions, R-CABG significantly lowered the likelihood of MI (OR = 0.18, 95% CI: 0.04 to 0.71) as well as major adverse cardiovascular events (MACE; OR = 0.51, 95% CI: 0.28 to 0.93). Time-to-event analysis from reconstructed IPD demonstrated significantly improved freedom from reintervention (HR = 0.31, 95% CI: 0.16 to 0.60) and MACE (HR = 0.24, 95% CI: 0.15 to 0.60) with R-CABG, whereas no significant difference was found for all-cause mortality.
Conclusions:
R-CABG was associated with less TVR and MI compared with PCI in CAD patients, with no difference in all-cause mortality.
StarkBJohnsonC and
RothGA.Global prevalence of coronary artery disease: an update from the global burden of disease study. J Am Coll Cardiol2024; 83 (13 suppl): 2320.
2.
DavidsonLJClevelandJCWeltFG, et al. A practical approach to left main coronary artery disease: JACC state-of-the-art review. J Am Coll Cardiol2022; 80: 2119–2134.
3.
DąbrowskiEJKożuchM and
DobrzyckiS.Left main coronary artery disease-current management and future perspectives. J Clin Med2022; 11: 5745.
4.
DokollariASicouriSPrendergrastG, et al. Robotic-assisted versus traditional full-sternotomy coronary artery bypass grafting procedures: a propensity-matched analysis of hospital costs. Am J Cardiol2024; 213: 12–19.
5.
BonattiJWallnerSCrailsheimI, et al. Minimally invasive and robotic coronary artery bypass grafting—a 25-year review. J Thorac Dis2021; 13: 1923–1944.
6.
YokoyamaYKunoTMalikA, et al. Outcomes of robotic coronary artery bypass versus nonrobotic coronary artery bypass. J Card Surg2021; 36: 3187–3192.
7.
MuaddiHEl HafidMChoiWJ, et al. Clinical outcomes of robotic surgery compared to conventional surgical approaches (laparoscopic or open): a systematic overview of reviews. Ann Surg2021; 273: 467–473.
HwangBRenJWangK, et al. Systematic review and meta-analysis of two decades of reported outcomes for robotic coronary artery bypass grafting. Ann Cardiothorac Surg2024; 13: 31125–31325.
10.
AluthmanUBafageehSWAshourMA, et al. A robotic-assisted hybrid coronary revascularization program: establishment and early experience in the Middle East. J Card Surg2022; 37: 4783–4789.
11.
HamiltonGWYeohJDinhD, et al. Trends and real-world safety of patients undergoing percutaneous coronary intervention for symptomatic stable ischaemic heart disease in Australia. Heart Lung Circ2022; 31: 1619–1629.
12.
NinomiyaRYoshizawaMKoedaY, et al. Safety and feasibility of retrograde INOUE-BALLOON for balloon aortic valvuloplasty without rapid ventricular pacing during transcatheter aortic valve replacement. Cardiovasc Interv Ther2022; 37: 372–380.
13.
ChoiKHBrunoFChoYK, et al. Comparison of outcomes between 1- and 2-stent techniques for Medina Classification 0.0.1 coronary bifurcation lesions. JACC Cardiovasc Interv2023; 16: 2083–2093.
14.
HiraiKKawasakiTKishiK, et al. Determinants of one-year outcome after successful percutaneous coronary intervention for chronic total occlusion; insight from Japanese CTO-PCI Expert Registry. Am J Cardiol2024; 225: 108–117.
15.
DillenDMMOtsukiHTakahashiK, et al. Impact of bifurcation lesions on outcomes after FFR-guided PCI or CABG. Circ Cardiovasc Interv2025; 18: 14610.
16.
SabatineMSBergmarkBAMurphySA, et al. Percutaneous coronary intervention with drug-eluting stents versus coronary artery bypass grafting in left main coronary artery disease: an individual patient data meta-analysis. Lancet2021; 398: 2247–2257.
17.
KirovHFischerJCaldonazoT, et al. Coronary artery bypass grafting versus percutaneous coronary intervention in patients with chronic total occlusion. Thorac Cardiovasc Surg2025; 73: 609–617.
18.
KirovHCaldonazoTRiedelLL, et al. Comparing outcomes between coronary artery bypass grafting and percutaneous coronary intervention in octogenarians with left main or multivessel disease. Sci Rep2023; 13: 22323.
19.
HasanSUPervezANaseebMW, et al. Clinical outcomes of different revascularization approaches for patients with multi-vessel coronary artery disease: a network meta-analysis. Perfusion2024; 39: 1041–1056.
20.
ZhangSChenSYangK, et al. Minimally invasive direct coronary artery bypass versus percutaneous coronary intervention for isolated left anterior descending artery stenosis: an updated meta-analysis. Heart Surg Forum2023; 26: E114–E125.
21.
MoherDLiberatiATetzlaffJ, et al. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med2009; 6: e1000097.
22.
SterneJAHernánMAReevesBC, et al. ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. BMJ2016; 355: i4919.
23.
GuyattGHOxmanADVistGE, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ2008; 336: 924–926.
24.
HigginsJPT and
ThompsonSG. Quantifying heterogeneity in a meta-analysis. Stat Med2002; 21: 1539–1558.
25.
BalduzziSRückerG and
SchwarzerG.How to perform a meta-analysis with R: a practical tutorial. Evid Based Ment Health2019; 22: 153–160.
26.
HarrerMCuijpersPFurukawaTA, et al. Doing meta-analysis with R: a hands-on guide. New York: Chapman and Hall/CRC, 2021.
27.
BalanTA and
PutterH.A tutorial on frailty models. Stat Methods Med Res2020; 29: 3424–3454.
28.
GrambschPM and
TherneauTM.Proportional hazards tests and diagnostics based on weighted residuals. Biometrika1994; 81: 515–526.
29.
RoystonP and
ParmarMKB. Restricted mean survival time: an alternative to the hazard ratio for the design and analysis of randomized trials with a time-to-event outcome. BMC Med Res Methodol2013; 13: 152.
30.
HebboEJaberWALicitraG, et al. Percutaneous coronary intervention versus robotic coronary bypass for left anterior descending artery chronic total occlusion. J Soc Cardiovasc Angiogr Interv2024; 3: 102278.
31.
PatelNCHemliJMSeetharamK, et al. Minimally invasive coronary bypass versus percutaneous coronary intervention for isolated complex stenosis of the left anterior descending coronary artery. J Thorac Cardiovasc Surg2022; 163: 1839–1846.
32.
LiSZhangHXiaoC, et al. Robotically assisted coronary artery bypass graft surgery versus drug-eluting stents for patients with stable isolated proximal left anterior descending disease. J Card Surg2021; 36: 1864–1871.
33.
SuCSShenCHChangKH, et al. Clinical outcomes of patients with multivessel coronary artery disease treated with robot-assisted coronary artery bypass graft surgery versus one-stage percutaneous coronary intervention using drug-eluting stents. Medicine2019; 98: e17202.
34.
SuCSChenYWShenCH, et al. Clinical outcomes of left main coronary artery disease patients undergoing three different revascularization approaches. Medicine2018; 97: e9778.
35.
ForouzandehFStahlEPatelS, et al. Percutaneous coronary intervention versus robotic-assisted coronary artery bypass for left anterior descending artery chronic total occlusion. JACC Cardiovasc Interv2018; 11: 1542–1544.
36.
AhmadYHowardJPArnoldAD, et al. Mortality after drug-eluting stents vs. coronary artery bypass grafting for left main coronary artery disease: a meta-analysis of randomized controlled trials. Eur Heart J2020; 41: 3228–3235.
37.
GalloMBlitzerDLaforgiaPL, et al. Percutaneous coronary intervention versus coronary artery bypass graft for left main coronary artery disease: a meta-analysis. J Thorac Cardiovasc Surg2022; 163: 94–105.
38.
HashimotoMWehmanB and
BalkhyHH.Robotic totally endoscopic coronary artery bypass: tips and tricks for using an anastomotic device. J Thorac Cardiovasc Surg2020; 159: e57–e60.
39.
BalkhyHHNisivacoSMHashimotoM, et al. Robotic total endoscopic coronary bypass in 570 patients: impact of anastomotic technique in two eras. Ann Thorac Surg2022; 114: 476–482.
40.
DavierwalaPMVerevkinABergienL, et al. Twenty-year outcomes of minimally invasive direct coronary artery bypass surgery: the Leipzig experience. J Thorac Cardiovasc Surg2023; 165: 115–127.
41.
NisivacoSKitaharaHBhasinR, et al. A decade of robotic beating-heart totally endoscopic coronary bypass (TECAB) at a single institution: outcomes with 10-year follow-up. J Thorac Cardiovasc Surg2025; 169: 1753–1760.
42.
DavidsonLJClevelandJCWeltFG, et al. A practical approach to left main coronary artery disease: JACC state-of-the-art review. J Am Coll Cardiol2022; 80: 2119–2134.
43.
CampeauLCorbaraFCrochetD, et al. Left main coronary artery stenosis: the influence of aortocoronary bypass surgery on survival. Circulation1978; 57: 1111–1115.
44.
LawtonJSTamis-HollandJEBangaloreS, et al. 2021 ACC/AHA/SCAI guideline for coronary artery revascularization: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation2022; 145: E18–E114.
45.
BittlJAHeYJacobsAK, et al. Bayesian methods affirm the use of percutaneous coronary intervention to improve survival in patients with unprotected left main coronary artery disease. Circulation2013; 127: 2177–2185.
46.
ChenSLXuBHanYL, et al. Comparison of double kissing crush versus Culotte stenting for unprotected distal left main bifurcation lesions: results from a multicenter, randomized, prospective DKCRUSH-III study. J Am Coll Cardiol2013; 61: 1482–1488.
47.
Álvarez-ContrerasLFlores-UmanzorECepas-GuillenP, et al. Clinical impact of medical therapy versus revascularization in patients with chronic coronary total occlusions. J Invasive Cardiol2021; 33: E2–E8.
48.
KimBSYangJHJangWJ, et al. Clinical outcomes of multiple chronic total occlusions in coronary arteries according to three therapeutic strategies: bypass surgery, percutaneous intervention and medication. Int J Cardiol2015; 197: 2–7.
49.
KawashimaHTakahashiKOnoM, et al. Mortality 10 years after percutaneous or surgical revascularization in patients with total coronary artery occlusions. J Am Coll Cardiol2021; 77: 529–540.
50.
O’BrienJMDautovR and
SapontisJ.Chronic total occlusions: a state-of-the-art review. Heart Lung Circ2024; 33: 764–772.
51.
ParkTKLeeSHChoiKH, et al. Late survival benefit of percutaneous coronary intervention compared with medical therapy in patients with coronary chronic total occlusion: a 10-year follow-up study. J Am Heart Assoc2021; 10: e019022.
52.
WangCLiuSKamronbekR, et al. Percutaneous coronary intervention versus coronary artery bypass grafting for chronic total occlusion of coronary arteries: a systematic review and meta-analysis. J Interv Cardiol 2023; 2023: 9928347.
53.
ShoaibAMohamedMCurzenN, et al. Clinical outcomes of percutaneous coronary intervention for chronic total occlusion in prior coronary artery bypass grafting patients. Catheter Cardiovasc Interv2022; 99: 74–84.
54.
HalkosMELibermanHADevireddyC, et al. Early clinical and angiographic outcomes after robotic-assisted coronary artery bypass surgery. J Thorac Cardiovasc Surg2014; 147: 179–185.
55.
KoflerMStastnyLReinstadlerSJ, et al. Robotic versus conventional coronary artery bypass grafting: direct comparison of long-term clinical outcome. Innovations2017; 12: 239–246.
56.
GeorgeJCVargheseV and
MadderRD.Robot-assisted cardiovascular interventions. J Soc Cardiovasc Angiogr Interv2025; 4 (3 part b): 102568.
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