Danny Ramzy

Robot-assisted surgery has emerged as a transformative advancement in modern operative care, enabling enhanced visualization, dexterity, and precision. Although adoption has been rapid across multiple surgical specialties, integration into cardiac surgery has evolved more gradually due to the technical complexity of procedures and the requirement for consistently excellent outcomes. Robotic mitral valve repair represents the most mature application of robotic cardiac surgery, demonstrating excellent perioperative outcomes and long-term durability. Emerging robotic platforms are expanding the competitive landscape, while innovations in telerobotics and teleproctoring are poised to improve access and scalability. Robotic cardiac surgery is transitioning toward broader integration. Continued technological innovation, cost reduction, and global dissemination of expertise will define the next phase of its evolution.

Background: A minimally invasive surgical technique for aortic valve replacement using a custom surgical retractor specifically designed for transcervical approach to cardiothoracic surgery has previously been described. We hypothesized that the adjunct and integration of robotic technology may improve surgical dexterity and render the transcervical approach advantageous over lateral approaches for robotic aortic valve replacement (AVR). We therefore sought to evaluate its feasibility. This is a preclinical cadaveric feasibility study; no human outcomes are reported. Clinical validation will be addressed in future trials. Methods: A dry lab was firstly set up in the robotic operating room (OR) to explore the concept, with chest phantom incorporating synthetic aortic root mounted atop the surgical table. The minimally invasive surgery was then repeated on five fresh frozen cadavers using an identical setup. The specially designed transcervical retractor system was mounted on the table for exposure. A da Vinci Xi robot was docked from the side and arms allocated for instrumentation or camerascope. Key steps of AVR were performed by console and bedside surgeons working in harmony. Objective procedural metrics were prospectively recorded for each cadaver, including pericardial opening time, aortotomy creation, leaflet excision, prosthesis delivery, inspection and deployment, and aortotomy closure. All times were measured from video timestamps by two independent observers. Results: Quantitative findings are summarised. A transient loss of visualisation occurred once when adipose tissue obscured the 30° scope; switching to a 0° lens resolved the issue. No difficulty was encountered passing the prosthesis through the uniportal access; however, in two cadavers mild resistance required momentary elevation of the sternum via the retractor ratchet. The cadaver provided a realistic representation of transcervical anatomy, surgical approach for detailing instrumentation and OR setup, similar to live surgery. Key steps of the aortic valve replacement procedure were successfully executed by console surgeon and bedside assistant working in harmony and integrating the use of the robot with the specially designed transcervical retractor system. Conclusions: Advanced Videoscopic Aortic surgery, Transcervical Approach, Robot assisted (AVATAR) AVR looks feasible. Key steps were easily performed with the robot when used in cooperation with the robot enabling retraction system.

Background/Objectives: Minimally invasive techniques for mitral valve repair have evolved over the past thirty years and include mini-thoracotomies and the robotic platform. This study provides a historical perspective on minimally invasive mitral valve approaches and evaluates long-term outcomes of a large series of robotic mitral valve repairs. Methods: A single-institution, prospectively maintained registry was used to evaluate robotic mitral valve repairs performed by four surgeons from 2005 to 2023. There were 1412 robotic mitral valve repairs performed during this time and stratified by the first 120 and subsequent patients. We evaluated operative outcomes and freedom from more than 2+ mitral regurgitation at five years as well as ten-year survival. Results: Of the 1412 robotic mitral valve repairs performed, 93.6% (n = 1322) were for degenerative disease. Compared to the first 120 patients, the subsequent patients had a significant reduction in cross-clamp time (112 (IQR = 103–130) versus 75 (IQR = 65–88) min) and cardiopulmonary bypass time (153.5 (IQR = 134.5–177.5) versus 116 (IQR = 103–136) min), and all with p < 0.01. The majority of patients had posterior leaflet prolapse (65.6%, n = 926). The repair rate was 98.1%, n = 1385. Survival at ten-year follow-up for the patients included in the first 120 procedures was 91.5% (95% confidence interval (CI) = 86.4–96.6%) versus 92.8% (95% CI = 91.7–93.9%) for the patients who were in the latter group, p = 0.58. Freedom from >2+ mitral regurgitation at 5 years was 97.0% (95% CI = 95.3–98.7%) for the patients in the first 120 procedures and 92.7% (95% CI = 91.5–93.9%), p = 0.22, for those in the latter group. Conclusions: The robotic platform offers an excellent durable repair for mitral regurgitation in our experience of over 1400 patients. The robotic platform for mitral valve repair offers a teachable and safe approach to mitral valve disease for patients.

The application of robot-assisted thoracoscopy to cardiac surgery affords an opportunity to leverage the exceptional intraoperative exposure, visualization, and dexterity of the robotic platform. Here, we report the case of a 72-year-old woman who presented to our institution for evaluation of a left ventricular mass that was identified following workup for an embolic event. We present an intraoperative video that provides technical details of the robot-assisted resection of the lesion, which was found to be a left ventricular papillary fibroelastoma arising from the mitral chordal apparatus. This case highlights the advantages provided by the robotic platform, which permitted complete, minimally invasive surgical excision of the lesion while minimizing the burden of surgical trauma.