Minimally invasive surgical coronary artery revascularization—how to initiate a safe and sustainable program

The recent reconfirmation of coronary artery bypass grafting (CABG) superiority over current percutaneous coronary interventions (PCIs) in various clinical scenarios resulted in renewed interest in less invasive surgical coronary artery revascularization. The continuous refinement of minimally invasive CABG (MI-CABG) techniques is paralleled by exciting advances in surgical technology that facilitate the safe and efficient harvesting of the internal thoracic artery (ITA) and the construction of multi-vessel coronary artery anastomosis under either direct vision or by using videoscopic or robotic platforms. Experienced MI-CABG centres reported excellent perioperative and long terms outcomes that are comparable to CABG by sternotomy access and contemporary comparative investigations progressively focus on the various robotic and non-robotic MI-CABG approaches in isolation, or as part of hybrid revascularization strategies that combine the well documented benefits of ITA to left anterior descending (LAD) artery anastomosis and PCI of other coronary lesions that require revascularization. Expert MI-CABG centres agree that the introduction of new MI-CABG programs should follow a systematic process that include careful infrastructure planning, team education, training, skill development and patient selection in collaboration with industry and experienced MI-CABG teams. The extensive MI-CABG learning curve is well described and require partnership with various clinical and non-clinical role-players to ensure the safe and sustainable transition from conventional CABG by sternotomy access to MI-CABG in an era of decreasing surgical volume, fewer training opportunities, increasing healthcare cost constraints and an aging population with increased risk profiles and expectations. This manuscript provides an overview of contemporary MI-CABG technology, describe the fundamental aspects of MI-CABG infrastructure planning and explain the various MI-CABG techniques with the intention of assisting upcoming centres in both developed and developing regions to establish safe and sustainable MI-CABG programs.