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Background and Aims Minimally invasive cardiac surgery (MICS) is increasingly performed to reduce surgical trauma and enhance recovery, yet optimal strategies for postoperative pain control and patient-centered outcomes remain unclear. We hypothesized that intrathecal morphine (ITM), when added to a multimodal analgesic protocol, improves quality of recovery (QoR) following robotically-assisted minimally invasive direct coronary artery bypass (RAMIDCAB) surgery.Methods In this multicentre, double-blind, randomized, placebo-controlled trial, approved by the ethical committee (EudraCT 2022–003684-14), patients undergoing RAMIDCAB were randomized 1:1 to receive either ITM (5 µg/kg) with intravenous (IV) saline, or intrathecal saline with IV morphine (0.1 mg/kg) (control). All patients followed a standardized Enhanced Recovery Program (ERP). The primary endpoint was QoR-40 score at 24 hours post-extubation. Secondary endpoints included pain scores, opioid consumption, rescue analgesia, and adverse events.Results Sixty-four patients were randomized. Compared to control, ITM did not result in a minimally clinically important improvement in the QoR-40 score at 24 or 48 hours (figure 1). However, ITM provided significantly better postoperative analgesia in the early postoperative period (figure 2). Cumulative opioid consumption over 24 hours was significantly lower in the ITM group (–11.9 mg morphine equivalents, p = 0.0004) (figure 3) and fewer patients required rescue analgesia (ARR –22.2%, p = 0.02). There were no statistically significant differences in adverse events between groups.Conclusions Although ITM did not improve overall QoR-40 scores, it significantly enhanced early postoperative analgesia and reduced opioid requirements. These findings support the integration of ITM into ERP protocols for MICS.Abstract OP06 Figure 1Quality of recovery-40 scores at 24 and 48 hoursAbstract OP06 Figure 2Postoperative resting and dynamic pain scoresAbstract OP06 Figure 3Cumulative opioid consumption over 24 hours