Advancing robotic aortic valve replacement beyond isolated therapy: a platform for multivalve therapy

The application of robotic cardiac surgery has long been considered the pinnacle of surgical care for an isolated procedure. This has been for good reason, as the quality and reproducibility of isolated procedures like mitral valve (MV) repair and robotic-assisted, minimally invasive, direct coronary artery bypass have grown steadily across the globe with shrinking learning curves. Once a robotic team's learning curve has crested, however, additional opportunities may be explored that may include concomitant procedures. Following the core surgical principles of safety and procedural homogeneity with open operations, robotic cardiac surgery may be extended in a stepwise fashion to multi-valve operations, concomitant maze procedures, aortic root enlargement, septal myectomy, and even valve and coronary bypass operations, all via the same transaxillary working incision. We will review the development and operative techniques of concomitant procedures that may be utilized in conjunction with robotic aortic valve replacement (RAVR).