The robotic revolution in cardiac surgery

Abstract

Robotic-assisted cardiac surgery (RACS) is revolutionizing the landscape of cardiovascular interventions through technological precision, minimally invasive techniques, and improved clinical outcomes. Despite its rapid expansion, significant gaps remain regarding standardization, cost-efficiency, surgeon learning curves, and patient-centered outcomes. The study critically examines current innovations, evaluates comparative clinical and economic impacts, and synthesizes key trends and contradictions from 26 recent studies. The objective is to assess the clinical efficacy, scalability, and systemic implications of RACS across diverse procedures, such as mitral valve repair, coronary artery bypass grafting, and emerging robotic heart and congenital surgeries. Employing a mixed-methods approach, including qualitative analysis of patient experiences and quantitative evaluation of national databases and long-term outcomes, the review integrates systematic reviews, case studies, and meta-analyses for a comprehensive comparative synthesis. Findings highlight superior perioperative outcomes, faster recovery, and reduced complication rates in RACS compared to the conventional surgery. Robotic proficiency correlates strongly with surgical volume, institutional infrastructure, and interdisciplinary training, while economic evaluations remain mixed, indicating higher upfront costs but potential long-term savings. Notably, patient satisfaction is consistently high due to reduced invasiveness and faster rehabilitation yet concerns about accessibility and healthcare equity persist. Contradictory evidence surrounds the cost–benefit balance in low-volume centers and the influence of patient complexity on the learning curve, although emerging evidence suggests that these factors are becoming less prohibitive with experience and technological refinement. The review identifies gaps in multicenter longitudinal studies, standard training frameworks, and integration of Internet of Robotic Things (IoRT) in clinical workflows. It recommends expanding global data-sharing platforms, refining robotic surgical curricula, and enhancing AI-driven support systems for precision guidance. The implications span patient care quality, surgical education, healthcare economics, and future robotic innovations. Limitations include potential publication bias and underrepresentation of low-resource settings. Future research should focus on longitudinal, multicentric trials evaluating robotic outcomes across different demographics, procedures, and healthcare infrastructures. In conclusion, the robotic revolution in cardiac surgery promises transformative advances, yet requires coordinated global efforts to bridge disparities, optimize training, and validate its long-term value in complex cardiovascular care.

Introduction

Robotic cardiac surgery represents a pivotal advancement in the evolution of surgical practice, transforming how complex heart procedures are performed. As an innovative approach that incorporates precision robotics, enhanced visualization, and minimally invasive techniques, robotic-assisted cardiac surgery has moved from experimental curiosity to a credible and increasingly adopted clinical method. Over the past two decades, the rise of robotic interventions has reshaped expectations around surgical precision, patient recovery, and operative efficiency [1, 2].

Robotic technologies in cardiac surgery typically employ systems like the Da Vinci Surgical System, enabling surgeons to operate through small incisions with robotic arms, 3D visualization, and tremor filtration. These capabilities have expanded the scope of procedures, including mitral valve repair, coronary artery bypass grafting (CABG), and even heart transplantation, with reduced trauma, faster recovery, and enhanced outcomes [3, 4].

The global adoption of robotic surgery, however, remains uneven due to steep learning curves, infrastructural requirements, and cost considerations. Nevertheless, recent data suggest significant improvements in surgical training, patient outcomes, and cost-effectiveness with growing institutional experience and technological refinement [5, 6]. These shifts underscore the timeliness and relevance of examining the current state, challenges, and future implications of the robotic revolution in cardiac surgery.

Issues and gaps

Despite the promise of robotic cardiac surgery, several critical issues and gaps persist within the field. One of the most prominent challenges is the steep learning curve associated with robotic systems. Proficiency in robotic cardiac procedures requires extensive training and continuous experience, particularly given the technical complexity and unique skill sets required [7, 8]. Even among experienced cardiac surgeons, transitioning to robotic methods necessitates a period of adaptation, which can affect surgical outcomes during the early phase of implementation [9].

In addition to training barriers, cost remains a significant constraint. Robotic surgical systems require substantial investment, not only in the acquisition of technology but also in ongoing maintenance, disposable instrument usage, and team training. Although evidence suggests that robotic surgery can lead to reduced hospital stays and complications, the economic justification remains contentious in low- and middle-income healthcare settings [5, 10].

Moreover, access and adoption rates are disproportionately skewed toward high-income countries and specialized centers, leaving a global disparity in the availability of robotic cardiac care. Several countries are only beginning to integrate robotic platforms into routine cardiac procedures, and often, these efforts are confined to elite academic hospitals [4, 11].

Patient-related outcomes have also been a topic of ongoing analysis. Although robotic cardiac procedures often report better cosmetic outcomes, reduced pain, and quicker recovery, patient satisfaction and psychological perceptions still need deeper exploration. Studies highlight that while many patients value the minimally invasive nature of robotic surgery, anxiety regarding the novelty and perceived risks of automation persists [12].

Furthermore, technical complications specific to robotic systems, such as limited tactile feedback, system latency, or malfunction risks, present additional challenges, particularly in complex or emergency scenarios [13]. There is a need for standardized protocols, better system design, and enhanced safety mechanisms to mitigate these risks.

Finally, many clinical trials and meta-analyses still lack long-term follow-up data, limiting our understanding of outcomes such as graft patency, valve durability, or reintervention rates in robotic surgery. The limited scope of existing randomized-controlled trials and their inconsistent reporting standards also impede conclusive comparisons with the conventional surgical techniques [2, 14].

Scope and objectives

The research endeavors to provide a comprehensive and critical overview of the robotic revolution in cardiac surgery by addressing both the clinical evolution and the broader implications of robotic technology within the domain. It aims to explore the multifaceted dimensions of robotic cardiac surgery, from technical innovations and clinical outcomes to training, patient experience, and economic viability.

The first objective of the review is to examine the progression of robotic cardiac procedures, including landmark innovations, such as robotic-assisted mitral valve repair, coronary revascularization, and even heart transplantation. These developments mark a significant shift in how complex cardiac operations are approached [1, 3].

Second, the research seeks to assess the clinical outcomes associated with robotic cardiac surgery compared to conventional open or minimally invasive techniques. Key metrics, such as morbidity, mortality, operative time, length of hospital stay, and patient satisfaction, will be analyzed using recent national and international data [5, 15, 16].

Third, the study aims to understand the learning curve and training dynamics for surgeons transitioning into robotic cardiac practices. By synthesizing findings from high-volume centers and multicenter experiences, the review will highlight best practices in surgical training and program development [7, 17, 18].

A fourth objective is to explore the integration of digital technologies and automation in robotic cardiac platforms. The role of Internet of Robotic Things (IoRT), machine learning, and intraoperative analytics will be investigated as part of the emerging landscape of smart surgery [6, 19].

Finally, the review intends to propose a forward-looking perspective, offering policy and research recommendations to improve accessibility, cost-effectiveness, and patient-centered outcomes in robotic cardiac care. These objectives are structured to provide a holistic understanding of the potential and challenges associated with the robotic transformation of cardiac surgery.

Novelty and contributions

The review distinguishes itself by integrating recent and cutting-edge contributions that capture the current trajectory of robotic cardiac surgery globally. One novel contribution is the inclusion of first-time innovations, such as robotic-assisted cardiac-liver transplantation [20] and beating-heart totally endoscopic coronary bypass (TECAB) with decade-long follow-up results [21]. These clinical milestones highlight the expanding capabilities of robotics in increasingly complex cardiac procedures.

Another novel aspect lies in exploring how institutional volume correlates with surgical outcomes. A large-scale cohort study by Zhuli et al. [6] demonstrated improved outcomes in centers with higher robotic surgery volumes, reinforcing the importance of centralized expertise and experience. The connection between volume and outcome also contributes to understanding the scalability and reproducibility of robotic programs.

Furthermore, the review integrates the latest findings on the role of patient complexity and how it does not necessarily compromise surgical learning curves or outcomes during early experiences with robotic cardiac procedures [18]. The insight challenges previous assumptions that only low-risk patients benefit from robotic interventions and supports broader patient eligibility.

Importantly, the research also adds a patient-centered dimension to the discourse. By including qualitative insights into the patient experience [12], the review expands the narrative beyond clinical efficacy and technical proficiency to incorporate emotional, psychological, and experiential factors, which are crucial for holistic healthcare delivery.

Technological innovations beyond the operating room are also addressed. Nagrale et al. [19] introduced the concept of the Internet of Robotic Things (IoRT) in cardiac surgery, illustrating how connected devices and real-time data processing can optimize procedural planning, execution, and follow-up care. The integration of robotic and digital technologies represents a frontier of intelligent and autonomous surgical ecosystems.

The review further contributes to economic debates by integrating recent analyses of the cost-effectiveness of robotic cardiac surgery. Sonarkar et al. [10] emphasized that despite higher initial costs, robotic surgery could offer long-term financial benefits through shorter recovery times and reduced postoperative complications. The contribution is particularly relevant for policymakers and healthcare planners in resource-limited settings.

Finally, by synthesizing data from international registries such as The Society of Thoracic Surgeons [15] and longitudinal outcomes from multicenter studies [11], the review provides a globally relevant and data-rich account of robotic cardiac surgery. It captures both breadth and depth, offering a rare synthesis that bridges technological advances, clinical outcomes, institutional strategies, and patient perspectives.

Methods

Eligibility criteria

To ensure the robustness and relevance of the present systematic review, rigorous eligibility criteria were defined prior to the initiation of the review process. Only peer-reviewed journal articles published between 2020 and 2025 were considered, as the period marks a substantial growth in research and clinical application of robotic cardiac surgery. Articles were included if they focused specifically on robotic-assisted cardiac surgery, incorporating aspects, such as surgical outcomes, learning curves, cost-efficiency, patient experience, or technological advancement. Studies involving robotic interventions in related cardiac procedures (e.g., mitral valve repair, coronary artery bypass grafting, and aortic valve replacement) were also eligible, provided that they featured robotic technology as the core component. Furthermore, both quantitative and qualitative studies were included to provide a comprehensive and multidimensional understanding of the topic. Exclusion criteria involved studies that merely mentioned robotic surgery without detailing outcomes, techniques, or implications, as well as conference abstracts, editorials, or articles lacking methodological transparency. The selected body of literature had to demonstrate either clinical application, systematic data analysis, or insight into the educational, economic, or technological ramifications of robotic cardiac procedures.

One critical consideration in establishing eligibility was ensuring representation across global surgical practices. For example, the longitudinal, international study conducted by Wei et al. [11] on robotic aortic valve replacement and Watanabe et al. [4] on Japan's universal healthcare integration of robotic mitral valve repair was prioritized due to their multi-institutional and cross-cultural data contributions. Similarly, Lee et al. [16] provided a systematic review of congenital robotic cardiac surgery worldwide, thereby justifying the global lens used in selecting eligible research. These examples highlight the importance of incorporating diverse clinical environments and patient demographics into the analysis.

Review selection

The review selection process involved multiple stages of screening and evaluation. Initially, a comprehensive literature search was performed using databases, including PubMed, Scopus, Web of Science, and ScienceDirect, using keywords, such as “robotic cardiac surgery,” “robot-assisted heart surgery,” “TECAB,” “robotic mitral valve,” and “robotic aortic valve replacement.” The search retrieved over 130 titles. Titles and abstracts were screened independently by two reviewers for relevance and compliance with the predefined eligibility criteria. Any disagreements were resolved through discussion or adjudication by a third reviewer.

Studies such as that by Hadaya et al. [5], which conducted a national analysis comparing robotic-assisted and conventional mitral valve repair, were included for their robust data sets and methodological clarity. Similarly, Iribarne et al. [15] provided insights into national cardiac surgery trends from the Society of Thoracic Surgeons database, thus meeting the review’s criteria for large-scale, data-rich studies. Special attention was given to articles that contributed uniquely to the body of evidence. For instance, Faraz et al. [3] documented the first robotic-assisted heart transplant, offering pioneering insight into procedural expansion. Meanwhile, the qualitative study by Pazar et al. [12] offered patient-centered insights that would otherwise be absent in a purely clinical evaluation. These selections ensured that the review not only examined the efficacy of robotic technologies but also considered their broader implications on patient care and healthcare delivery systems.

The PRISMA flowchart (Fig. 1) outlines the systematic selection process undertaken to identify and include relevant studies for the review on the robotic revolution in cardiac surgery. Initially, 103 records were identified through database searches, with an additional 5 records sourced from other references, yielding a total of 108 studies. After removing duplicates, 59 unique records remained for screening. Of these, 30 were excluded based on title and abstract evaluation, resulting in 29 full-text articles assessed for eligibility. Following a thorough evaluation, 3 articles were excluded for not meeting the inclusion criteria such as lack of focus on cardiac robotics or insufficient data leaving 26 studies that were ultimately included in both the qualitative and quantitative syntheses. The rigorous selection ensures that the review is grounded in high-quality, relevant, and up-to-date evidence.

Fig. 1.

Study selection process for robotic revolution in cardiac surgery

Data extraction

Following the selection process, a standardized data extraction form was developed and employed to systematically collect relevant information from each of the 26 recent studies. The extracted data included publication details (author, year, and journal), study type (quantitative, qualitative, or mixed-methods), study design (prospective, retrospective, review, or experimental), sample size, surgical procedure type (e.g., mitral valve repair, TECAB, and aortic valve replacement), patient demographics, outcome measures (mortality, complications, recovery time, cost, and learning curve), and key findings. Additionally, any mention of technological innovations, training protocols, or patient-reported outcomes was noted.

Quantitative data were primarily drawn from clinical outcomes studies, such as those by Hadaya et al. [5] and Zhuli et al. [6], which provided statistical comparisons between robotic-assisted and conventional surgeries, focusing on mortality, procedural times, length of hospital stay, and complication rates. Notably, Zhuli et al. [6] analyzed over 10,000 robotic surgeries, establishing correlations between hospital volume and clinical outcomes, thus adding granularity and statistical power to the review. The meta-analysis by Hwang et al. [2] further contributed comprehensive statistical summaries over 2 decades of robotic coronary artery bypass grafting outcomes.

In contrast, qualitative data were extracted from studies like Pazar et al. [12], which employed interviews to understand patient experiences and emotional outcomes post-robotic surgery. Meanwhile, Sutter et al. [22] and Chang et al. [7] offered pedagogical insights and longitudinal assessments of surgical learning curves, contributing a professional development perspective. The incorporation of diverse study types and data points allowed for an integrative analysis that captures both clinical efficacy and experiential dimensions of robotic cardiac surgery.

The extraction process was verified through double entry by two independent reviewers to minimize errors. Discrepancies were resolved through consensus or third-party consultation, ensuring data integrity and reproducibility. Studies like that of Kitahara et al. [17], detailing outcomes from 550 robotic mitral valve surgeries, provided high-volume institutional data, while Sonarkar et al. [10] offered economic analysis, adding depth to the cost-effectiveness dimension of the review.

Table 1 presents robotic cardiac surgery has advanced significantly across multiple domains, including surgical innovation, patient outcomes, and procedural techniques. Groundbreaking applications such as robotic-assisted heart and combined cardiac-liver transplants demonstrate the field’s rapid evolution [3, 20]. Surgeons are increasingly leveraging robotic systems for complex procedures like totally endoscopic mitral valve repair and TECAB, aided by innovations in minimally invasive extracorporeal circulation [17, 23]. However, gaps remain in long-term outcome tracking and standardized training frameworks, especially in congenital and pediatric cardiac surgery [8, 16]. Studies show the learning curve is steep and varies depending on institutional experience and surgeon mobility, influencing efficiency and outcomes [7, 9, 18].

Table 1.

Gap analysis and real case comparisons in robotic cardiac surgery

Key area	Current evidence/advancement	Gaps or challenges identified	Real case or study insight	Citation(s)
1. Surgical innovations	Robotic-assisted transplantation, TECAB, and endoscopic mitral valve surgery are becoming mainstream	Limited long-term outcome studies across diverse procedures	First robotic-assisted heart transplant sets a precedent	Addissouky [20], Faraz et al. [3], Kitahara et al. [17]
2. Learning curve & proficiency	Structured learning curve analysis and transfer of expertise models improving surgeon skill acquisition	Variability in proficiency timelines between surgeons and institutions	Moving from one center to another affects operative times	Chang et al. [7], Khairallah et al. [9], Halkos et al. [8]
3. Clinical outcomes	Robotic-assisted surgeries show lower complication rates and shorter hospital stays	Concerns about safety during early stage adoption and need for standardization	Robotic vs conventional mitral valve repair showed better clinical and cost outcomes	Hadaya et al. [5], Rosati et al. [18]; Wei et al. [11]
4. Cost-effectiveness & economics	Robotic surgery is more expensive initially but may be cost-effective over time due to reduced complications	High upfront cost limits adoption in lower resource settings	AIP conference data discusses robotic surgery economics	Sonarkar et al. [10],Watanabe et al. [4]
5. Patient perspective	Patients report quicker recovery, less pain, and higher satisfaction	Emotional and psychological readiness of patients underexplored	Qualitative interviews highlight positive patient experiences	Pazar et al. [12]
6. National trends & adoption	Increasing robotic surgery cases globally, backed by national databases	Uneven adoption across countries due to policy and infrastructure limitations	STS database and Japan's national healthcare-supported adoption	Iribarnc et al. [15]; Watanabe et al. [4]
7. Procedure-specific outcomes	High success in robotic coronary artery bypass and aortic valve replacement	Lack of comparative data across centers with different surgical volumes	Over I0,000 cases analyzed showing better outcomes at high-volume centers	Zhuli et al. [6], Nisivaco et al. [21], Wei et al. [11]
8. Robotics in congenital and complex cases	Robotic tools increasingly used in congenital cardiac procedures	Lack of standardized pediatric robotic cardiac surgery guidelines	Worldwide review shows variability in congenital robotic practices	Lee et al. [16]
9. Technology integration (loT, Al)	Robotics integrating with Internet of Things (loRT) and advanced visualization tools	Ethical, cybersecurity, and training gaps in adopting high-tech surgical systems	Proposed IoRT frameworks to assist remote surgeries and analytics	Nagrale et al. [19], Tasoudis et al. [13]
10. Procedural techniques comparison	Endoaortic balloon occlusion seen as viable for robotic surgery	More RCTs needed comparing procedural techniques in robotic vs open surgeries	Meta-analysis compares clamp vs balloon in minimally invasive surgery	Naito and Takagi [14]
11. Standardization of training	Protocols developed for training (e.g., "How I teach robotic CABG")	No global consensus on robotic training curriculum	Teaching protocols help propagate robotic CABG	Sutter et al. [22]
12. Role of extracorporeal circulation	Emergence of minimally invasive extracorporeal circulation (MiECC) in robotic procedures	Limited data on outcomes in complex cases	Study on MiECC during totally endoscopic surgery supports feasibility	Condello et al. [23]

Robotic procedures are associated with reduced complications, shorter hospital stays, and higher patient satisfaction, as supported by both national databases and multicenter analyses [5, 11, 15]. However, cost remains a major barrier, with robotic systems requiring high initial investment, although longer-term cost-effectiveness has been demonstrated [4, 10]. High-volume centers tend to yield better clinical outcomes, reinforcing the importance of procedural consistency and surgeon proficiency [6, 21]. Technology integration, including the Internet of Robotic Things (IoRT), presents promising avenues for future innovation but raises concerns around cybersecurity and standardization [13, 19]. Despite the evident patient-centered benefits [12] and teaching frameworks being developed [22], the field still requires broader policy support and more randomized trials to bridge current gaps and ensure equitable, global access.

Data synthesis

Data synthesis was carried out through both narrative and thematic integration due to the heterogeneity of study designs and outcome measures across the included articles. The synthesis began with categorizing the studies into key thematic areas: clinical outcomes and safety, surgical learning curves, technological advancements, patient experience, and economic impact. The thematic clustering allowed the reviewers to discern patterns, identify gaps, and generate comprehensive conclusions regarding the current landscape of robotic cardiac surgery.

In terms of clinical outcomes, studies consistently reported comparable or superior results for robotic-assisted surgeries when compared to traditional methods. For instance, Hadaya et al. [5] demonstrated that robotic mitral valve repair was associated with reduced hospital stays and lower complication rates. Nisivaco et al. [21], through a decade-long follow-up of robotic TECAB procedures, reported durable outcomes with low reoperation rates. Similarly, Wei et al. [11] revealed promising long-term outcomes in robotic aortic valve replacements across multiple centers.

The theme of surgical learning curves and skill acquisition was evident in multiple studies. Chang et al. [7] and Khairallah et al. [9] explored how surgeons' proficiency evolved with case volume and inter-institutional mobility, respectively. Halkos et al. [8] emphasized the importance of structured training in robotic techniques, which has profound implications for surgical curriculum development. Importantly, Rosati et al. [18] found that patient complexity did not significantly hinder the surgeon’s learning curve, thereby supporting early adoption even in complex cases.

Technological advancements in robotic surgery were prominently discussed across the included studies. Addissouky [20] and Nagrale et al. [19] explored the integration of organ preservation technologies and Internet of Robotic Things (IoRT), respectively, highlighting the trajectory toward fully integrated, AI-supported surgical ecosystems. Tasoudis et al. [13] reviewed robotic applications for intracardiac and endovascular procedures, pointing to a future where these technologies may encompass an even broader range of interventions.

Patient experience emerged as a meaningful theme in the review. According to Pazar et al. [12], patients undergoing robotic-assisted surgery reported a sense of increased safety, quicker recovery, and overall satisfaction. These insights were particularly valuable in substantiating the psychosocial benefits of robotic surgery, often overlooked in quantitative outcome studies.

Finally, cost-effectiveness and healthcare economics were addressed in the studies by Sonarkar et al. [10] and Hadaya et al. [5]. While initial investments in robotic systems are high, these studies highlighted potential long-term savings through reduced postoperative care, shorter hospitalization, and fewer complications. Importantly, Watanabe et al. [4] discussed how Japan’s national healthcare system managed to scale robotic mitral valve repair within a publicly funded model, offering a case study in economic scalability.

Synthesizing these varied perspectives has revealed a robust body of evidence supporting the clinical, educational, and economic merits of robotic cardiac surgery. However, the synthesis also uncovered areas requiring further inquiry, particularly around equitable access, long-term device reliability, and standardization of training protocols. These insights inform the subsequent discussion and guide recommendations for future research and policy development.

Results and findings

Advancing precision

The advent of robotic-assisted cardiac surgery has transformed the landscape of cardiothoracic procedures by enhancing precision, reducing invasiveness, and offering faster recovery times. Over the past two decades, robotic technology has evolved from isolated trials to structured programs that now contribute significantly to surgical outcomes globally. Central to the shift is the successful integration of robotics into procedures, such as mitral valve repair, coronary artery bypass grafting (CABG), and even complex multi-organ transplants [3, 20]. Studies collectively suggest that robotic techniques have demonstrated non-inferior, and in some cases superior, clinical outcomes compared to conventional open-heart surgery, particularly when implemented in high-volume centers [6, 11].

Clinical outcomes

Robotic-assisted cardiac surgeries are associated with improved short-term outcomes, including lower postoperative pain, reduced bleeding, shorter ICU stays, and faster return to daily activities [1, 5]. In a large national cohort, Hadaya et al. [5] found that patients undergoing robotic mitral valve repair had fewer complications and reduced hospital costs compared to those undergoing conventional sternotomy-based approaches. Similar findings are echoed in the 10-year single-institution follow-up study by Nisivaco et al. [21], which demonstrated excellent survival and low reintervention rates after robotic totally endoscopic coronary bypass (TECAB).

However, these benefits are often conditional on patient selection and institutional experience. Iribarne et al. [15], through the Society of Thoracic Surgeons database, reported a variability in outcomes when robotic techniques were applied across centers with differing caseloads and team proficiency. This reflects the broader pattern identified by Zhuli et al. [6], where hospital volume correlated positively with surgical outcomes, indicating a steep but surmountable learning curve.

The learning curve

The adoption of robotic surgery demands a distinct skillset, and several studies emphasize the learning curve as both a barrier and an eventual benefit. Chang et al. [7] analyzed a decade’s worth of a surgeon’s performance, revealing that robotic proficiency typically stabilizes after 50–75 cases. Similarly, Khairallah et al. [9] illustrated how operative times and complication rates decreased significantly when surgeons transitioned from less experienced to high-volume centers, demonstrating the transferability of skills once core proficiency is achieved.

Kitahara et al. [17], in their report of 550 robotic mitral valve surgeries, confirmed that procedure times, patient outcomes, and intraoperative metrics all improved with programmatic maturity. Their findings challenge the misconception that robotic surgery remains inherently time-intensive and costly, particularly once institutional expertise is established.

Nonetheless, patient complexity does not appear to negatively influence early robotic experience. Rosati et al. [18] found that even during the initial phase of robotic program implementation, patient outcomes remained stable across a broad spectrum of case difficulties, underscoring the robustness of the robotic platform when supported by proper protocols and training.

Technological integration and innovations

The expansion of robotic surgery has been buoyed by synergistic technological innovations, including the integration of the Internet of Robotic Things (IoRT) and improved extracorporeal circulation systems. Nagrale et al. [19] argue that IoRT enables real-time data sharing between surgeons, machines, and clinical databases, enhancing intraoperative decision-making and patient-specific customization. Condello et al. [23] reported that minimally invasive extracorporeal circulation (MiECC) complements robotic platforms by minimizing cardiopulmonary bypass complications, particularly in totally endoscopic procedures.

In terms of instrumentation, the development of more flexible robotic arms and high-definition 3D cameras has improved visualization and dexterity within confined cardiac spaces. Tasoudis et al. [13] highlighted these advancements as critical to enabling robotic access for intracardiac and endovascular procedures, including complex valve replacements and atrial septal defect closures.

Quantitative vs. qualitative outcomes

Quantitative metrics, such as operative time, blood loss, reoperation rates, and length of hospital stay, have shown consistent improvement with robotic-assisted surgery, particularly in centers with robust programs [11, 21]. However, qualitative insights add nuance to the understanding of patient experience.

Pazar et al. [12], in a qualitative analysis of patient narratives, found that individuals undergoing robotic-assisted procedures reported reduced psychological stress, higher satisfaction with cosmetic outcomes, and improved quality of recovery. Patients emphasized the perceived technological advancement of their care as a positive emotional influence, suggesting that the benefits of robotic surgery may extend beyond clinical endpoints into psychosocial domains.

Case studies and real-world applications

The global adoption of robotic cardiac surgery is increasingly substantiated by real-world case studies and institutional experiences that demonstrate its feasibility, scalability, and clinical benefits. Faraz et al. [3] reported a groundbreaking achievement with the world’s first robotic-assisted heart transplant, illustrating the technology’s capacity to support even the most intricate cardiac procedures. The milestone reflects a broader trend toward expanding the boundaries of what is possible with robotic intervention in cardiac care.

In Japan, Watanabe et al. [4] documented the national implementation of robot-assisted mitral valve repair under universal health coverage. Their findings emphasize that with standardized protocols and system-wide support, robotic cardiac surgery programs can be scaled successfully and equitably. The experience not only validates the technical aspects of robotic cardiac surgery but also its feasibility within public healthcare infrastructures.

Robotic applications have also started to gain traction in congenital and pediatric cardiac surgery. Lee et al. [16] conducted a comprehensive review of global cases involving robotic congenital cardiac procedures. Although still early in development, the initial outcomes show promise for expanding robotic surgery into pediatric populations domains traditionally considered too delicate for robotic instrumentation. In the field of remote surgery, SS Innovations International [24] marked a historic moment by performing the world’s first robotic cardiac telesurgeries using the SSI Mantra 3 system. Technological advancement demonstrates the potential for overcoming geographical barriers to specialized care, opening doors to surgical access in remote or underserved regions.

High-volume centers continue to showcase successful integration of robotic platforms. Kitahara et al. [17] detailed over 550 robotic mitral valve procedures within a single program, highlighting consistency in patient safety and outcomes. Zhuli et al. [6] further emphasized that increased procedural volume correlates with improved outcomes, supporting the centralization of robotic expertise. Complementing these clinical applications are innovations in support technologies. For example, extracorporeal circulation enhancements for minimally invasive procedures have advanced surgical safety and control [23], while Addissouky [20] explored organ preservation techniques in hybrid robotic transplant surgeries.

Finally, optimizing surgeon performance remains key. Studies show that the learning curve can be efficiently transferred across institutions with appropriate mentoring and data feedback systems [7, 9]. Training strategies [8] and AI-guided navigation tools [19] are also enhancing safety and precision. Patient-reported outcomes support these findings, with high satisfaction levels noted in robotic cardiac care experiences [12]. Collectively, these case studies underscore the readiness of robotic cardiac surgery for broader, global application.

Cost-effectiveness and economic analysis

The cost-effectiveness of robotic cardiac surgery continues to be a subject of active evaluation and debate. A comprehensive economic analysis by Sonarkar et al. [10] highlighted that although robotic cardiac surgery involves higher initial capital investment and per-procedure costs, these are often offset by tangible clinical benefits. These include reduced postoperative complications, shorter hospital stays, and faster return to work. Importantly, the study concluded that robotic cardiac surgery becomes increasingly cost-effective when performed in high-volume centers capable of leveraging economies of scale a position reinforced by national data from Hadaya et al. [5].

However, cost-effectiveness is highly context dependent. In low-volume institutions or resource-constrained environments, the financial justification for robotic systems is less convincing unless accompanied by strong reimbursement policies or high patient demand. This underscores the need for strategic investment in centers with sufficient procedural volume to sustain such advanced technology platforms over time.

As shown in Table 2, the Da Vinci Xi system by Intuitive Surgical remains the most widely adopted robotic platform for cardiac procedures, including mitral valve repair and totally endoscopic coronary artery bypass (TECAB) [5, 21]. Nonetheless, its substantial acquisition and maintenance costs, along with the recent withdrawal of cardiac-specific support in the European Union, have prompted concern regarding long-term accessibility and sustainability [25].

Table 2.

Comparative overview of leading robotic platforms in cardiac surgery: features, applications, and cost considerations

Robotic system	Manufacturer	Key features	Applications in cardiac surgery	Cost considerations	Latest findings and reference
Da Vinci Xi	Intuitive Surgical	Multi−arm, 3D HD vision, wristed instruments	Mitral valve repair, TECAB, aortic valve replacement	High initial & maintenance costs; ~ $2 M + per unit	Widely adopted; support for cardiac tools withdrawn in EU (ISMICS, 2020)
SSI Mantra 3	SS Innovations	Modular, 3D visualization, cost- effective, India-made	First robotic cardiac telesurgeries; general cardiac procedures	Lower cost (~ 20–25% of Da Vinci)	Performed world's first robotic cardiac telesurgeries (SS Innovations, 2024)
Revo-i	Meerecompany Inc. (Korea)	Open console, reusable instruments, similar design to Da Vinci	Used in mitral valve and pancreatic surgeries (limited cardiac use)	Moderate; more affordable than Da Vinci	Early use in cardiac procedures in Asia [3]
Hinotori	Medicaroid (Japan)	3-arm system, immersive console, approved for urology and general surgery	Mitral valve repair (limited reports)	Mid-range pricing	Gained approval under Japan's universal healthcare [4]
Versius	CMR Surgical (UK)	Compact, modular, open console, reusable instruments	Not yet widespread in cardiac surgery	Moderate; ~£I.SM	Used in general surgery; cardiac applications emerging [26]
Senhance	Asensus Surgical (USA)	Eye-tracking, haptic feedback, open console	Not yet widely used in cardiac surgery	Lower capital cos (~ 50% of Da Vinci)	Focused on general and gynecologic surgery [26]

Emerging alternatives such as SSI Mantra 3 offer cost-effective solutions, particularly in developing nations. SS Innovations recently performed the world’s first robotic cardiac telesurgeries using the platform [24]. Similarly, systems like Revo-i and Hinotori are gaining popularity in Asia due to lower cost structures and alignment with local healthcare systems [3, 4]. Meanwhile, modular systems, such as Versius and Senhance, show potential for reduced operational costs, appealing to budget-conscious health systems seeking economically sustainable robotic surgery options [10, 26].

AI-assisted robotic surgery

AI-assisted robotic surgery is revolutionizing cardiac procedures by enhancing accuracy, safety, and decision-making efficiency. AI's integration into robotic systems supports real-time data interpretation, intraoperative navigation, and predictive modeling for complications, which is crucial for high-risk surgeries like coronary artery bypass grafting and totally endoscopic mitral valve procedures [19]. By analyzing patient-specific data, AI can optimize surgical pathways and tool movements, significantly reducing intraoperative errors [13].

Moreover, innovations such as the Internet of Robotic Things (IoRT) offer remote monitoring and predictive maintenance, enabling advanced capabilities like telesurgery and cross-border interventions [19, 24]. These advancements are particularly valuable for expanding cardiac care to underserved regions. In training, AI helps map personalized learning curves by tracking surgeon performance, offering feedback based on instrument trajectories and timing [7, 9]. As institutions move toward standardized global robotic surgery education, AI will be critical in developing safe, effective, and scalable surgical practices [8].

Repeat surgeries and complication rates

Monitoring repeat surgeries and complication rates is vital in assessing the long-term success of robotic cardiac procedures. While initial outcomes are promising, issues like device malfunctions, incomplete repairs, or disease progression can necessitate reintervention. Iribarne et al. [15] noted that even with reduced hospital stays and fewer early complications, reoperations still occur.

Kitahara et al. [17] reported that among 550 robotic mitral valve surgeries, a small subset required reintervention for recurrent regurgitation. Similarly, Hadaya et al. [5] emphasized how surgeon experience and learning curves influence complication rates. Watanabe et al. [4] and Zhuli et al. [6] highlighted that institutions with higher surgical volumes see fewer repeat surgeries, reinforcing the importance of centralized expertise. As robotic platforms evolve, evaluating long-term outcomes and complications remains essential for guiding clinical decisions and refining training and technologies [11, 26].

Conflicting evidence and limitations

While most studies report favorable outcomes, some inconsistencies and limitations warrant discussion. Hwang et al. [2], in their meta-analysis of 2 decades of robotic CABG, reported marginal benefits in some clinical outcomes but noted no significant improvement in long-term survival over traditional surgery. This suggests that while robotics may optimize the surgical process, it does not universally translate to better outcomes across all metrics.

Furthermore, concerns persist around selection bias, where healthier or lower-risk patients are more likely to be selected for robotic procedures. Wei et al. [11] cautioned that multicenter data often lack granular information on patient comorbidities, making it difficult to isolate the true effect of robotic intervention. Similarly, some reviews fail to account for variations in anesthetic protocols, perioperative care, and institutional standards, all of which can confound results.

Gaps and future research directions

Despite substantial advancements in robotic cardiac surgery, multiple research gaps continue to limit its widespread adoption and long-term integration into clinical practice. One of the most critical gaps is the lack of long-term comparative outcome data, particularly for newer procedures such as robotic aortic valve replacements. Current literature seldom extends beyond 10–15 years of follow-up, making it difficult to assess durability and life expectancy improvements associated with robotic interventions [11]. The limitation underscores the need for longitudinal studies that evaluate not only survival rates but also quality of life, reoperation risks, and prosthesis performance over extended periods.

Additionally, pediatric and congenital robotic cardiac procedures remain significantly underreported. While robotic techniques have shown promise in adult populations, their application in pediatric surgery lacks comprehensive safety profiles and efficacy assessments. Vulnerable populations such as infants and children require meticulous evaluation due to their unique anatomical and physiological characteristics [16]. Future research should prioritize prospective trials that examine outcomes, procedural feasibility, and long-term impacts in these younger cohorts.

A further challenge lies in the inconsistent standardization of training and certification for robotic cardiac surgeons across institutions and countries. Currently, there is no universally accepted curriculum or credentialing process, which creates disparities in surgeon competency and patient outcomes [8]. International consensus on training protocols, simulation requirements, and clinical proctoring is essential to ensure safe and effective robotic cardiac care globally.

Moreover, the integration of artificial intelligence (AI) in robotic cardiac surgery presents a promising yet underexplored frontier. Nagrale et al. [19] proposed AI-assisted frameworks for preoperative planning, intraoperative guidance, and real-time risk assessment. However, empirical evidence supporting these applications remains scarce, highlighting a critical area for experimental and clinical validation.

In terms of technology-specific concerns, the risk of technical failures and intraoperative malfunctions, though rare cannot be overlooked. Marchegiani et al. [26] reported isolated cases of robotic malfunctions in general surgery, emphasizing the need for rigorous quality control, system redundancies, and emergency protocols. These concerns are magnified in cardiac surgery due to the high-risk nature of the procedures. ISMICS (2020) voiced apprehensions regarding limited industry support and the withdrawal of critical instruments, which could undermine safety and innovation. While recent breakthroughs such as SS Innovations’ telesurgeries offer optimism, detailed safety data are still lacking [24]. Therefore, future research must focus on robust technological validation, failure-mode analysis, and the development of global safety registries to support broader adoption.

Discussion and conclusion

The emergence of robotic-assisted cardiac surgery has significantly transformed the landscape of cardiovascular interventions, enhancing precision, minimizing invasiveness, and improving patient outcomes. One of the most prominent findings from the review is the consistent demonstration of improved perioperative metrics in robotic cardiac surgery compared to traditional approaches. Hadaya et al. [5] revealed that robotic-assisted mitral valve repairs were associated with lower postoperative complications, reduced hospital stays, and overall cost-effectiveness, a finding supported by Sonarkar et al. [10], who conducted an in-depth economic evaluation showing favorable healthcare economics for robotic procedures.

Outcomes from high-volume centers, as noted by Zhuli et al. [6], show significantly better clinical results, suggesting a strong correlation between institutional experience and patient outcomes. Likewise, Rosati et al. [18] emphasized that patient complexity did not adversely affect early clinical outcomes, even during the initial learning curve phase, implying robust procedural adaptability. The implementation of robotic-assisted techniques in coronary artery bypass grafting (CABG) has shown remarkable progress over 2 decades. According to Hwang et al. [2], robotic CABG outcomes have reached equivalence and, in some cases, superiority to conventional approaches in terms of mortality, morbidity, and graft patency.

Several studies underscore the importance of experience and training. Chang et al. [7] and Halkos et al. [8] emphasized the learning curve inherent in robotic cardiac surgery, with performance metrics improving significantly after a defined number of cases. Khairallah et al. [9] further added that operative times improved even when surgeons transitioned between hospitals, provided that they had prior robotic experience.

Robotic cardiac surgery has also expanded into complex procedures such as robotic heart transplants and combined organ transplants. Faraz et al. [3] documented the first robotic-assisted heart transplant, representing a major leap in feasibility and safety. Similarly, Addissouky [20] highlighted innovations in robotic-assisted cardiac-liver transplantations, aided by advanced organ preservation technologies.

Patient experiences reflect the transformation. Pazar et al. [12] reported high levels of satisfaction among patients who underwent robotic-assisted cardiac surgeries, citing less pain, faster recovery, and improved cosmetic outcomes. Furthermore, the incorporation of novel technologies like the Internet of Robotic Things (IoRT) is facilitating real-time monitoring and precision-guided interventions, as observed by Nagrale et al. [19].

Robotic approaches are no longer limited to adult populations. Lee et al. [16] explored global practices in robotic congenital cardiac surgery, illustrating growing confidence in applying robotic systems in pediatric and congenital anomalies with favorable outcomes. Additionally, robotic applications are expanding into intracardiac and endovascular procedures, a development highlighted by Tasoudis et al. [13], further diversifying the clinical scope.

Recommendations

Based on the collective evidence, several recommendations emerge for the broader adoption and optimization of robotic cardiac surgery. First, there should be a structured curriculum for training and credentialing surgeons, as advocated by Sutter et al. [22]. Standardizing surgical training programs and establishing robotic fellowships could expedite proficiency while ensuring patient safety.

Second, hospitals should invest in establishing comprehensive robotic cardiac programs with dedicated multidisciplinary teams. Kitahara et al. [17] reported successful outcomes from a high-volume institution that performed over 500 robotic mitral valve surgeries, attributing their success to integrated team dynamics, standardized protocols, and continuous outcome monitoring.

Third, patient selection criteria need to be clearly defined and dynamically updated to reflect the growing body of evidence supporting robotic feasibility in high-risk or complex cases. This is particularly relevant for the elderly or those with multiple comorbidities, as demonstrated by Wei et al. [11] in their multicenter study on robotic aortic valve replacements.

Fourth, policymakers and healthcare administrators should consider incentivizing the adoption of robotic systems through subsidies or insurance support. Watanabe et al. [4] illustrated that universal health coverage facilitated the successful launch of robotic mitral valve repair programs in Japan, suggesting a model that could be replicated globally.

Finally, continued investment in data-driven technologies such as the STS Adult Cardiac Surgery Database [15] can enable large-scale benchmarking, improve procedural transparency, and guide future clinical practice guidelines.

Implications of the review

The review has profound implications for clinical practice, health systems, and medical education. Clinically, robotic-assisted surgery offers a paradigm shift in how cardiac procedures are performed. With reduced trauma, fewer complications, and faster recovery, patients benefit from improved quality of life post-surgery. The shift is especially critical in an aging global population with an increasing cardiovascular disease burden.

For healthcare systems, robotic surgery presents an opportunity to improve resource utilization. Though initial costs are high, long-term savings from reduced hospital stays and complications offer a compelling economic case. Sonarkar et al. [10] demonstrated that robotic approaches, when scaled, become cost-effective due to fewer reinterventions and enhanced operational efficiency.

From an educational perspective, the growing demand for robotic proficiency necessitates a reevaluation of surgical curricula. The steep learning curve, noted by Chang et al. [7] and Khairallah et al. [9], reinforces the need for dedicated simulation labs and mentorship-based training models. Integrating real-time feedback and performance analytics, as suggested by Fida et al. [1], can further enhance skill acquisition and retention.

In the broader context of digital health, the convergence of robotics, artificial intelligence, and real-time monitoring systems [19] opens new frontiers in remote surgery, telemonitoring, and augmented diagnostics. These innovations could decentralize access to cardiac surgery, particularly in underserved regions or during complex emergencies.

Limitations

Despite its promising trajectory, robotic cardiac surgery faces notable limitations. High upfront costs remain a substantial barrier to entry for low- and middle-income countries, as highlighted in the economic analyses by Sonarkar et al. [10]. Furthermore, the availability of specialized equipment and the need for a dedicated operating room setup can limit scalability.

Another key limitation is the steep learning curve associated with robotic systems. As shown by Halkos et al. [8], it takes significant time and case volume for surgeons to reach proficiency, which may discourage adoption among established practitioners accustomed to traditional techniques. Moreover, the lack of standardized training pathways across countries and institutions creates inconsistency in surgical outcomes and experiences.

Patient access also remains uneven. Urban, high-income centers are more likely to offer robotic surgery, while rural or resource-limited hospitals often lack the infrastructure or expertise. This creates disparities in care, which were not fully addressed in several of the reviewed studies.

The evidence base is still evolving, with a predominance of retrospective and observational studies. Randomized-controlled trials (RCTs) comparing robotic and conventional surgery are limited, which constrains the ability to draw definitive conclusions about long-term survival, quality of life, or cost-effectiveness.

Future research

Future research should focus on generating high-quality evidence through multicenter RCTs comparing robotic-assisted and conventional cardiac surgeries across different populations and comorbidity profiles. Areas, such as long-term graft patency, neurocognitive outcomes, and psychological well-being post-robotic surgery, remain underexplored and warrant detailed investigation.

There is also a pressing need for real-world implementation studies to assess how robotic cardiac programs function across various healthcare settings, including rural and underfunded hospitals. These studies should evaluate barriers to adoption, maintenance challenges, and ways to integrate robotic systems into existing infrastructures.

Technological advancements will also benefit from research into the integration of artificial intelligence (AI) for intraoperative decision-making, automated suturing, and predictive analytics. Nagrale et al. [19] discussed the Internet of Robotic Things, which holds the potential to optimize procedural workflows through machine learning and remote monitoring.

Additionally, the development of next-generation robotic systems lighter, more affordable, and with enhanced haptic feedback could revolutionize accessibility. Comparative effectiveness research on different robotic platforms, such as the da Vinci vs. newer systems, would provide vital data for procurement decisions.

Finally, patient-centered research, such as that conducted by Pazar et al. [12], should be expanded to understand the psychosocial impact of robotic surgery, including anxiety, satisfaction, and long-term rehabilitation outcomes.

Conclusion

The robotic revolution in cardiac surgery signifies a transformative era in cardiovascular care. From mitral valve repairs and coronary artery bypasses to pioneering robotic heart transplants, the integration of robotics into cardiac procedures has brought about remarkable clinical, economic, and experiential benefits. The collective evidence from the reviewed literature underscores enhanced patient outcomes, reduced complications, and promising economic sustainability especially when robotic programs are implemented at scale in high-volume centers.

Despite these advancements, challenges remain in terms of cost, training, and access equity. The steep learning curve, infrastructural requirements, and regional disparities in service availability must be addressed through strategic investment, standardized training programs, and supportive healthcare policies. Encouragingly, initiatives such as Japan’s government-supported robotic programs [4] and comprehensive institutional efforts [17] offer replicable models for global adoption.

Moving forward, the future of robotic cardiac surgery lies in interdisciplinary collaboration. By uniting cardiac surgeons, engineers, data scientists, and policymakers, the field can continue to evolve toward safer, more precise, and universally accessible heart care. With the ongoing integration of AI, IoRT, and telemedicine, the horizon of robotic cardiac surgery extends well beyond the operating room into a new era of personalized, technology-driven healthcare.

Author’s contributions

Jack Ng Kok Wah, the sole author and the corresponding author, has made substantial contributions to the conception, study, and writing of the review article. Jack Ng Kok Wah reviewed, edited, and approved the final manuscript, ensuring that it met academic standards and provided a balanced, evidence-based discussion. Jack Ng Kok Wah confirms that the article represents original work and bears full accountability for the content presented in the publication.

Funding

The author declares that no funding was received for the preparation or publication of the manuscript. The work was conducted independently and does not involve any financial support from external organizations or sponsors.

Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Availability of data and materials

No datasets were generated or analyzed during the current study.