The first robot-assisted cardiovascular operation in a human patient was described in May 1998, performed by Dr. Didier Loulmet at Hôpital Broussais in Paris, where a coronary revascularization was carried out. Later that same month, Dr. Alain Carpentier performed the first robot-assisted mitral repair at the same institution. Robot-assisted cardiac surgery has continued to evolve ever since, driven by the goal of reducing surgical trauma. Today, the robotic approach stands among the most advanced surgical options for correcting degenerative mitral regurgitation (MR), representing a benchmark of excellence at leading institutions, where superior visualization and dexterity translate into shorter hospital stays and fewer postoperative complications relative to conventional sternotomy. Despite these clinical advantages, worldwide adoption remains limited, constrained by a steep learning curve and by the considerable financial, logistical, and institutional hurdles involved in launching a program from the ground up.
The article under review evaluates outcomes from the first 100 consecutive cases of a robot-assisted mitral valve program built from scratch. Its significance lies in showing that the early obstacles associated with robotic techniques can be overcome safely: through progressive standardization of the operative technique, a 99% mitral repair success rate and remarkably low morbidity were achieved from the program’s earliest stages, even when patients with complex mitral pathology were included.
This retrospective observational study examines a cohort of 100 consecutive patients who underwent robot-assisted mitral valve surgery, performed by a single surgeon at a single institution between March 2022 and February 2025. Particular emphasis was placed on describing repair success rate, the incidence of intraoperative complications, overall survival, and freedom from recurrent moderate or severe MR. Aortic occlusion and cardiopulmonary bypass (CPB) times were additionally analyzed by quartile to track progression along the learning curve.
The median age of the operated patients was 63.6 years, with a median Society of Thoracic Surgeons Predicted Risk of Mortality (STS-PROM) score of 0.55% (range, 0.1%-9.2%). Posterior leaflet prolapse accounted for the MR in 67% of patients. The repair success rate was high at 99% (91 of 92 attempts), with no 30-day mortality and no strokes reported. Only four patients (4%) required conversion to sternotomy (two for bleeding, two for new-onset aortic insufficiency), and notably, none occurred among the final 40 cases of the series.
To assess technical progression, CPB and myocardial ischemia times were compared across quartiles. Myocardial ischemia time fell significantly, from 148 minutes in the first quartile to 106 minutes in the last, while total CPB time showed no comparable reduction. Over a median follow-up of 8 months, two patients required robotic reintervention for recurrent MR, and one patient died from hemorrhagic complications while carrying a mechanical valve prosthesis. At medium-term follow-up, echocardiography confirmed that every patient who underwent mitral repair maintained mild or lesser MR.
Based on these findings, the authors conclude that robot-assisted mitral surgery is capable of delivering favorable results even during a program’s earliest phase, achieving high repair rates and low morbidity even among patients presenting the conventional relative contraindications to the robotic approach, such as prior cardiac surgery, complex valve pathology, and severe chest-wall deformity.
COMMENTARY:
Robot-assisted mitral surgery has traveled a long road since its earliest experimental stages and initial technical descriptions. In recent years, very high-volume reference centers have shown that this platform is not only safe but capable of extraordinary outcomes, achieving repair rates above 97%-99% depending on the series, with anecdotal mortality reported in large cohorts, most notably the landmark series of 1000 patients published by Gillinov and colleagues in 2018 (JTCVS). Even so, the pronounced learning curve has remained this technique’s Achilles’ heel, a concern that Toubat and colleagues address directly in the present study by demonstrating that the startup phase of a program can be conducted safely under a structured approach, reaching repair success rates comparable to those of larger published series. Nevertheless, the true barrier to expanding this technique worldwide continues to be the substantial logistical, financial, and technical challenge of building a program from nothing.
This study offers a current snapshot of an early institutional learning curve. Among its most noteworthy features is the broadening of surgical indications toward more complex patients, including Barlow disease, anterior prolapse, and reoperative cases, once the first 50 cases had been completed, all without compromising outcomes: the repair rate held at 99%, and sternotomy conversions disappeared entirely in the series’ final stretch. Another compelling aspect is what the evolution of operative times reveals. While total CPB time remained essentially unchanged, myocardial ischemia time dropped sharply and significantly, from 148 to 106 minutes between the first and last quartiles. Given that the team was simultaneously taking on anatomically more demanding cases, this improvement in cross-clamp efficiency points to genuine mastery of the technique.
Still, the study leaves several questions open. A median clinical follow-up of only 8 months calls for caution, and it remains to be confirmed whether repairs performed during this initial learning phase will prove as durable over time as those achieved through conventional open surgery. It is likewise unclear whether this rapid and successful progression toward complex cases would translate directly to Spanish centers, where the absence of centralized referral and mitral surgical volumes differ considerably from the American model. The broader reproducibility of these results also remains constrained by the current technological monopoly and by the scarcity of platforms equipped with instruments purpose-built for cardiovascular surgery. Looking ahead, next-generation systems such as the recently introduced Da Vinci 5® bring innovations like haptic feedback. Whether this restored tactile sensation will meaningfully shorten learning curves in clinical practice, thereby helping new centers adopt robotic programs without compromising patient safety, remains to be demonstrated. Other surgical specialties have already shown that robotic platforms can standardize highly complex operations; cardiovascular surgery’s turn has now arrived. The real value of this platform may lie less in refining the skills of surgeons already expert in minimally invasive techniques, and more in offering a safe, direct pathway for sternotomy-trained surgeons to embrace minimally invasive surgery through a far gentler learning curve. The challenge today is no longer technological but attitudinal: we must decide whether to accept the effort this transition demands in order to give our patients something better, or to retreat behind the argument that “there is no reason to change what already works.”
In conclusion, this work shows that launching a well-structured robotic mitral valve repair program is both feasible and capable of results closely comparable to those of high-volume centers. It further indicates that tackling complex anatomy need not compromise patient safety or meaningfully prolong myocardial ischemia time. In this sense, the robotic approach is establishing itself as an accessible tool rather than a technological curiosity confined to a handful of hyperspecialized centers.
REFERENCE:
Toubat O, Pitoulis F, Szeto J, Catalano M, Shin M, Iyengar A, et al. Outcomes following the first 100 cases of a new robotic mitral valve program. JTCVS Open. 2026;101813. doi: 10.1016/j.xjon.2026.101813.
