Postoperative Outcomes of Minimally Invasive Versus Conventional Off-Pump Coronary Artery Bypass Within an ERACS Protocol: A Matched Analysis

Background/Objectives: Minimally invasive coronary artery bypass grafting (MICS-CABG) offers reduced access trauma compared with conventional off-pump coronary artery bypass (OPCAB) but requires more demanding surgical and anesthetic conditions, including single-lung ventilation. Enhanced Recovery After Cardiac Surgery (ERACS) pathways—particularly those incorporating early extubation in a post-anesthesia care unit (PACU) and routine ICU bypass—may harmonize postoperative recovery across different surgical approaches. This study evaluated whether a standardized early-extubation ERACS protocol could achieve comparable short-term recovery outcomes between MICS-CABG and OPCAB. Methods: This single-center retrospective study included all adult patients who underwent off-pump MICS-CABG via mini-thoracotomy or OPCAB via sternotomy between January 2020 and December 2024 within an ERACS pathway. Propensity score matching (1:1) was applied using key demographic and clinical variables. Primary outcomes were hospital length of stay (LOS), ventilation time, and unplanned ICU transfer. Secondary outcomes included postoperative complications, transfusion requirements, pain scores, and in-hospital mortality. Results: Of 144 MICS-CABG patients, 131 met inclusion criteria and 116 were propensity-matched to 116 OPCAB patients. Operative duration was longer in MICS-CABG (238.9 ± 65 vs. 175.0 ± 48 min; p < 0.001). However, ventilation time (112.2 ± 56.9 vs. 116.9 ± 64.7 min; p = 0.59), hospital LOS (8.7 ± 4.0 vs. 8.6 ± 4.1 days; p = 0.78), and unplanned ICU transfer (0.9% vs. 2.6%; p = 0.37) were comparable. Postoperative complications, transfusion rates, pain scores, and in-hospital mortality also did not differ significantly. Conclusions: Within a structured ERACS pathway incorporating early extubation and ICU bypass, MICS-CABG and OPCAB achieved similar short-term recovery outcomes despite differences in operative complexity. These findings suggest that ERACS can provide a consistent postoperative recovery framework across both revascularization strategies.