Advancing coronary artery revascularization by robotics and automated connector technology

Coronary artery bypass grafting (CABG) has remained the most durable treatment for advanced coronary artery disease for more than six decades. Its long-term success is largely attributable to the use of the left internal mammary artery (LIMA) to bypass the left anterior descending artery (LAD), which provides superior patency and survival benefits compared with other revascularization strategies. Despite its proven effectiveness, conventional CABG is associated with substantial surgical trauma due to sternotomy and the frequent use of cardiopulmonary bypass. In an era increasingly focused on patient-centered care, sustainability, and healthcare efficiency, these limitations have prompted renewed interest in less invasive alternatives that preserve surgical durability. This thesis explores how robotic-assisted, minimally invasive, and hybrid coronary revascularization strategies can bridge the gap between durability and invasiveness. Rather than framing coronary revascularization as a binary choice between percutaneous coronary intervention (PCI) and CABG, the work adopts an integrated perspective in which surgical and percutaneous techniques are combined in a patient-tailored manner. The central hypothesis is that hybrid and robotic-assisted approaches can retain the biological advantages of surgical grafting while reducing surgical trauma, procedural variability, and system-level burden. Part I evaluates clinical outcomes of minimally invasive direct coronary artery bypass grafting (MIDCAB), robotic-assisted MIDCAB (RA-MIDCAB), and hybrid coronary revascularization (HCR). A meta-analysis comparing MIDCAB with PCI for isolated proximal LAD disease confirms the durability of the LIMA–LAD graft and suggests a potential long-term survival advantage of surgical revascularization. Nationwide registry analyses from the Netherlands demonstrate that HCR achieves mid-term outcomes comparable to conventional CABG and off-pump CABG (OPCAB) in selected patients, while offering advantages in recovery and perioperative morbidity. These findings support a shift toward more nuanced patient selection rather than procedural replacement. Part II examines the economic and environmental implications of robotic-assisted coronary surgery. Cost analyses indicate that although robotic platforms require substantial upfront investment, these costs may be offset by reduced hospital stays and faster recovery. Environmental assessments highlight meaningful differences in resource use and waste generation between revascularization strategies, emphasizing that sustainability considerations become relevant when clinical outcomes are comparable. Part III places robotic coronary surgery within a broader European context, identifying structural barriers to adoption, including training requirements, regulatory heterogeneity, and the absence of enabling technologies. Part IV addresses this limitation through the development and preclinical evaluation of the Octocon, a novel automated coronary connector designed to overcome the hemodynamic and biological shortcomings of earlier devices. Ex vivo testing demonstrates feasible, reproducible anastomoses within a fully endoscopic robotic setting, supporting its potential role as an enabling technology for totally endoscopic coronary artery bypass (TECAB). In conclusion, this thesis demonstrates that coronary revascularization is evolving toward a more integrated, patient-centered, and sustainable paradigm. By combining clinical evidence, system-level evaluation, and technological innovation, it provides a framework for preserving the strengths of surgical revascularization while adapting it to the demands of modern healthcare.