Robotic versus non-robotic endoscopic invasive mitral valve repair: a narrative review of current evidence and evolving practice.

BACKGROUND AND

OBJECTIVE

Mitral valve repair is the gold standard for degenerative disease, with access evolving from sternotomy to minimally invasive thoracoscopic and robotic techniques. Both are safe, widely used, and reproducible. This narrative review compares robotic and non-robotic approaches regarding outcomes and efficiency.

METHODS

A literature search was conducted using PubMed, Embase, Cochrane Library, and Scopus, including studies published January 1990-January 2025. The Boolean search strategy included: "mitral valve" AND "robotic" AND "endoscopic" OR "thoracoscopic" OR "minimally invasive". The search was limited to English-language articles. Eligible studies were peer-reviewed and directly compared robotic versus non-robotic endoscopic mitral valve repair in adults (≥18 years) with mitral regurgitation. Abstracts, conference proceedings, reviews, meta-analyses, pediatric studies, case reports <10 patients, and non-comparative studies were excluded.

KEY CONTENT AND FINDINGS: A total of 9 studies were included. Patient age ranged 46-69 years, mostly male. Body mass index (BMI) was similar across groups. Mitral valve repair was performed in all cases. Operative times were longer in the robotic group: cardiopulmonary bypass (CPB) ranged 85 [interquartile range (IQR), 73-105] to 275 [standard deviation (SD) ±56] minute, and cross-clamp 57 (IQR, 48-67) to 152 (SD ±38) minute. Intensive care units (ICU) stay varied, with Albano et al. reporting 41 (IQR, 20-45) vs. 45 (IQR, 43-73) h and Rufa et al. 20.5 (IQR, 20-40) vs. 22 (IQR, 20-27.5) h for robotic vs. endoscopic cohorts. Ventilation was shorter with robotics: 3 (IQR, 0-6) vs. 6 (IQR, 4-10) h. Neurologic events were uncommon in both groups (1-3.2% robotic vs. 1.3-4.8% endoscopic). Atrial fibrillation (AF) incidence ranged 17.6-50%, generally higher in endoscopic groups. In-hospital mortality was consistently <1%. Median hospital stay was shorter in robotic groups: 8-10 vs. 9-11 days in endoscopic ones.

CONCLUSIONS

Minimally invasive mitral valve repair is safe and reproducible, with no survival difference between robotic and non-robotic approaches. Robotic cases showed longer bypass and cross-clamp times but shorter hospital stays. Transfusion needs were inconsistent, neurologic complications were rare and slightly fewer with robotics, and both methods showed excellent mid-term durability. Further studies are necessary to confirm these data.