Objective: Robotic-assisted minimally invasive direct coronary artery bypass (RA-MIDCAB) is a proven alternative to conventional off-pump sternotomy for revascularizing the left anterior descending artery (LAD) in low-risk patients. However, its role in higher-risk candidates remains poorly established. This study compares RA-MIDCAB with off-pump CABG (OPCAB) in intermediate/high-risk patients with moderately reduced left ventricular ejection fraction (LVEF). Methods: We retrospectively analyzed all consecutive high/intermediate-risk patients with depressed LVEF who underwent left internal mammary artery to LAD RA-MIDCAB or OPCAB at our center between January 2021 and August 2025. The primary outcome, assessed at discharge and follow-up, was a composite of all-cause mortality, stroke, and repeat revascularization. Secondary outcomes included ICU stay, red blood cells (RBC) transfusion volume, oro-tracheal intubation time, and acute kidney injury. Kaplan–Meier curves estimated the cumulative freedom from the primary outcome. Restricted mean survival time (RMST) at 1 year was calculated, with non-inferiority confirmed if the lower bound of the 95% CI exceeded − 8 days. A generalized linear model adjusted for confounders. Results: Seventy-two patients were included: 20 RA-MIDCAB and 52 OPCAB. EuroSCORE was 3.8 ± 1.9 and 3.5 ± 2.4 in RA-MIDCAB and OPCAB, respectively (p = 0.384), while mean LVEF was 40 ± 13 and 45 ± 9, respectively (p = 0.454). Other variables were comparable; however, RA-MIDCAB patients had higher rates of prior myocardial infarction (MI) (45% vs. 11.5%; p = 0.003) and PCI (40% vs. 13.4%; p = 0.022). Procedural time was longer for RA-MIDCAB (196 ± 66 vs. 182 ± 66 min; p = 0.048). Thirty-day mortality was comparable (0% RA-MIDCAB, 3.8% OPCAB; p = 0.374), while ICU stay and intubation time were shorter in the RA-MIDCAB group. Fewer RA-MIDCAB patients required >5 RBC units. At one year, freedom from the primary outcome was 95% vs. 83.6% (p = 0.2), with RMST favoring RA-MIDCAB by 34.6 days (p = 0.0067), meeting the non-inferiority threshold. Results remained consistent after adjustment. Conclusions: RA-MIDCAB is noninferior to OPCAB in intermediate- to high-risk patients with moderately depressed LVEF, offering a valuable alternative to conventional surgical revascularization. These findings need further confirm through the analysis of larger datasets and longer follow-up.

Management of the left subclavian artery (LSA) during aortic arch surgery is complex due to its deep anatomical location and potential pathological alterations, posing risks such as stroke, spinal cord injury, and recurrent laryngeal nerve damage. Revascularization of the LSA is critical in various clinical scenarios to maintain adequate perfusion to the vertebral arteries, spinal cord, and upper limb, especially in patients with anatomical variations, prior bypass surgeries, or increased risk of ischemia. Coverage of the LSA during thoracic endovascular repair (TEVAR) without revascularization significantly increases stroke and spinal cord ischemia rates. We provided a narrative review, evaluating contemporary open and endovascular options for the treatment of the aortic arch, and consequently of the LSA. Frozen elephant trunk (FET), endovascular strategies (branched and fenestrated TEVAR), but also emerging hybrid devices, are all valuable treatments with respective strengths and limitations to be understood to obtain the best patient-prosthesis match. Individualized treatment selection based on pathology, urgency, and patient factors is essential to optimize outcomes. This evolving paradigm integrates open and endovascular techniques to enhance patient care in complex aortic arch disease.