Abstract
Coronary artery disease (CAD) requiring multivessel revascularization, commonly defined by involvement of the left anterior descending artery plus ≥1 major epicardial vessel, left-main disease, or elevated anatomic complexity such as higher SYNTAX scores, is traditionally managed with conventional sternotomy coronary artery bypass grafting (CABG), but its invasiveness has driven interest in minimally invasive alternatives. This systematic review compares cardiac outcomes of minimally invasive coronary revascularization versus conventional CABG in patients with multivessel or complex CAD. The review followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and searched PubMed/MEDLINE, Google Scholar, the Cochrane Library, and ScienceDirect from inception to November 2025. Minimally invasive techniques included minimally invasive direct CABG (MIDCAB), minimally invasive multivessel CABG (MICS-CABG), endoscopic or robotic-assisted CABG (TECAB/Endo-CAB), and hybrid coronary revascularization (HCR) combining minimally invasive LIMA-left anterior descending (LAD) grafting with percutaneous coronary intervention (PCI). Comparative studies versus conventional sternotomy CABG were eligible. Two reviewers independently performed study selection, data extraction, and quality assessment using ROB 2.0 for randomized controlled trials (RCTs) and ROBINS-I for observational studies. Nineteen studies were included, comprising a small number of RCTs and predominantly propensity-matched or retrospective comparative cohorts, which informed confidence in findings. Due to substantial heterogeneity in surgical approaches, patient selection, outcome definitions, and follow-up duration, results were synthesized narratively. Across the included evidence, minimally invasive coronary revascularization demonstrated cardiac outcomes comparable to conventional CABG in complex CAD patients. Early (in-hospital or 30-day) and mid-term (1-5 year) mortality remained low and similar between groups, typically ranging from 0.5-3%. Rates of myocardial infarction and stroke were likewise comparable, generally within 1-4% and 0.5-2%, respectively. Composite major adverse cardiac/cerebrovascular events (MACCE/MACE) outcomes were equivalent across approaches, most commonly 5-12%. Atrial fibrillation was less frequent in several endoscopic or highly minimally invasive cohorts, though reductions were not uniform across all techniques. Repeat revascularization ranged from 2-7%, with slightly higher rates observed in some HCR cohorts, likely reflecting PCI durability rather than failure of the surgical LIMA-LAD graft. Perioperative outcomes consistently favored minimally invasive approaches, including reduced blood loss, shorter ventilation times, and decreases of 0.5-2 days in ICU stay and 2-4 days in total hospital stay. Standardized cardiac functional measures, such as LVEF or heart failure class, were inconsistently reported and therefore not pooled. Overall, minimally invasive coronary revascularization provides major clinical outcomes comparable to conventional CABG while offering meaningful reductions in perioperative morbidity and faster recovery, supporting its selective use in appropriately chosen complex CAD patients, particularly in experienced, high-volume centers.