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Introduction Robot-assisted coronary artery bypass grafting (CABG) ( figure 1) is not widely practised in the UK but potentially carries significant advantages over PCI, sternotomy CABG and minimally invasive direct CABG (MIDCAB). Performed through a 4cm left minithoracotomy with no rib spreading and hence less access trauma, it is associated with less pain and faster recovery than both conventional MIDCAB and sternotomy, avoids sternal morbidity, and facilitates the use of the left internal mammary artery (LIMA) to revascularize the LAD. NHS England is encouraging the greater adoption of robot-assisted surgery, and we are likely to see this happen for cardiac surgery in the coming years.Method Between April 2019 and September 2020, robot-assisted MIDCAB (LIMA-LAD) was performed in 52 patients by a single surgeon. We examined the pre-operative and operative characteristics as well as post-operative outcomes and five-year survival.Results The median age was 64 years (IQR, 54 to 71), 5 (9.6%) were female and 11 (21.2%) were non-elective presentations. Left ventricular (LV) function was moderate (EF 30-50%) in 5 (9.6%) and good (EF>50%) in 47 (10.4%). Median euroscore II was 0.79 (IQR 0.59, 0.99). Four patients (7.7%) required conversion to sternotomy and these all occurred in the first half of the cohort reflecting the learning curve. There was no mortality and no strokes. The median critical care LOS was 23 hours (IQR = 20 to 28hrs),1 (1.9%) patient was readmitted to critical care, the median post-operative hospital stay was 3.5 days (IQR = 3 to 5 days), and 1 (1.0%) patient required a reoperation for bleeding. There was no in-hospital mortality, and the survival at 1 year was 100% and 98% at 5 years (one death from non-cardiac cause). All patients were free from angina and no further coronary intervention was needed.Conclusion Robot-assisted MIDCAB is a safe and durable less invasive alternative to either sternotomy or conventional MIDCAB, with short hospital stays and excellent long term outcomes.Abstract 437 Figure 1