**5. Patient selection**

Each patient should be individually assessed by a multidisciplinary team of cardiac surgeons and cardiologists to determine the best approach regarding myocardial revascularization. Clinical status, associated comorbidities, and anatomical features should be considered when determining the appropriate strategy for myocardial revascularization.

Robotic-assisted CABG is more frequently used to treat total occlusion or ostial stenosis of the left anterior descending (LAD) artery, and occasionally to treat proximal LAD stenosis which is unsuitable for percutaneous intervention. Roboticassisted CABG is also feasible in the treatment of multivessel disease, though rarely performed, in which both ITAs and a second graft can be used individually or with sequential anastomosis techniques [2].

Minimally invasive CABG may also be integrated with a hybrid approach, i.e., achieving simultaneous or delayed complete revascularization with both CABG (usually for the left coronary system) and percutaneous coronary interventions (PCI) (usually for the right coronary system), providing patients with the advantages of each technique in the least invasive manner possible [32].

Robotic-assisted MIDCAB is one of the most commonly performed roboticassisted CABG procedures around the globe [33]. This is often conducted off-pump and consists of the endoscopic harvesting of the LITA with robotic instrumentation followed by direct anastomosis of the left anterior descending (LAD) artery through a left anterior mini-thoracotomy. Robotic MIDCAB may be preferred in patients with isolated disease of the LAD, or within the framework of hybrid coronary revascularization (HCR) strategy to treat patients with multivessel coronary stenosis along with PCI to all diseased non-LAD vessels [34]. Although robotic MIDCAB is not optimal for hemodynamically unstable patients, patients with limited pulmonary reserve or patients with significantly impaired left ventricular systolic function, favorable outcomes have been previously reported [35].

Although patient selection for robotic-assisted CABG was initially limited to non-redo patients with isolated single-vessel or double-vessel disease rather than multi-vessel disease and those with preserved ventricular function, inclusion criteria has since then broadened to include also redo patients, provided one internal thoracic artery (ITA) is still adequate for grafting. Studies have demonstrated that the procedure was viable in patients with a history of previous open CABG [36], MIDCAB [33], and TECAB [37].

In current practice, many patients with a confirmed indication for surgical myocardial revascularization can be deemed as candidates for robotic-assisted CABG. Potential contraindications include acute myocardial ischemia, serious multi-organ dysfunction, severe pulmonary dysfunction, restricted workspace inside the thoracic cavity (e.g., in severe pectus excavatum), thoracic adhesions, and obesity (BMI > 35 kg/m2) [38]. Relative contraindications to TECAB are serious left pleural fibrosis in patients with a history of chronic lung disease or lung surgery. Management with an off-pump approach may not be always feasible in patients with severely impaired lung function and peripheral cardiopulmonary bypass (CPB) support to enhance gas exchange may be considered in these cases. Emergent procedures and patients with advanced left ventricular systolic dysfunction potentially requiring advanced postoperative myocardial support are currently ruled out [32].
