Robotic mitral repair: maintaining quality at all levels of complexity

Over the last two decades, robotic mitral valve surgery has evolved from application of standard repair techniques for focal degenerative disease to a broad range of repair techniques navigating nearly all mitral pathologies at different complexity levels, the latter only performed in highly experienced robotic programs. The basic setup and steps of the operation have been standardized and many groups have reported reproducibility, excellent long-term durability and exceedingly rare mortality rates comparable to sternotomy. This has created a surge of interest in robotic cardiac surgery by patients, referring physicians and cardiac surgeons, all seeking the least invasive approach to mitral valve repair. In response, a growing number of major institutions have initiated robotic programs. This article discusses the gaps in practice before the widespread shift to a robotic approach as a standard treatment of mitral valve disease. In addition, we describe our techniques to approach complex mitral pathologies that transcend current, limited patient selection criteria.