Robotic-assisted versus conventional coronary artery bypass grafting: a systematic review, meta-analysis, and trial sequential analysis of 39,918 patients

Robotic-assisted coronary artery bypass grafting (RA-CABG) is an evolving minimally invasive alternative to conventional CABG (C-CABG), but comparative evidence remains fragmented. We conducted a comprehensive systematic review, meta-analysis, and trial sequential analysis to compare outcomes between RA-CABG and C-CABG.

Following PRISMA 2020 guidelines, we searched PubMed, Embase, Cochrane CENTRAL, and Web of Science through January 2026. Studies comparing RA-CABG to C-CABG reporting at least one outcome of interest were eligible. Random-effects meta-analyses using DerSimonian-Laird estimators were performed. Risk of bias was assessed using ROBINS-I. Trial sequential analysis evaluated the conclusiveness of cumulative evidence.

Nine studies comprising 39,918 patients (13,638 RA-CABG; 26,280 C-CABG) were included. All included studies were observational in design, and long-term outcome data were sparse. RA-CABG was associated with significantly lower mortality (OR 0.55, 95% CI 0.43-0.69; P < 0.001; I²=0%), atrial fibrillation (OR 0.53; P < 0.001), respiratory failure (OR 0.31; P < 0.001), blood transfusion (OR 0.28; P < 0.001), hospital length of stay (MD - 1.95 days; P < 0.001), and ICU stay (MD - 22.7 h; P < 0.001). Stroke showed a non-significant trend favoring RA-CABG (OR 0.76; P = 0.071). Trial sequential analysis confirmed conclusive evidence for mortality, atrial fibrillation, respiratory failure, and blood transfusion. Results were robust across sensitivity analyses.