Robotic endoscopic cardiac surgery in the reoperative patient: Is it feasible?

Objective: Robotic cardiac surgery is increasingly adopted in the United States but remains a relative contraindication in reoperative settings for many programs. We hypothesize that in experienced hands, robotic approaches offer significant advantages in redo cardiac surgery by avoiding graft and cardiac injury during sternal reentry. We present our single-center experience with robotic redo endoscopic cardiac surgery, including midterm outcomes up to 10 years. Methods: A retrospective review of 1834 robotic cardiac surgeries from 2013 to 2024 was performed. Of these, 105 patients (6%) with previous cardiac surgery were included. Patients underwent either epicardial (n = 45) or intracardiac (n = 60) procedures. Preoperative characteristics, intraoperative and postoperative outcomes, and midterm survival were analyzed. Results: In the intracardiac group, procedures included mitral valve (n = 49), aortic valve (n = 4), tricuspid valve (n = 3), cryomaze (n = 2), myxoma (n = 1), and atrial septal defect (n = 1). Epicardial procedures included totally endoscopic coronary artery bypass (n = 31), pericardiectomy (n = 4), left ventricular leads (n = 7), and others (n = 3). The mean Society of Thoracic Surgeons score was 4.0%. Thirty-day mortality was 1.9% (observed to expected ratio 0.5), and hospital mortality was 1.9%. Conversion to sternotomy occurred in 2 cases (1.9%). Intensive care unit and hospital length of stay averaged 1.6 and 3.2 days, respectively. At a mean follow-up of 37.5 months, all-cause mortality was 15%, with 6.6% cardiac-related mortality. Conclusions: Robotic endoscopic cardiac surgery is feasible and safe in selected reoperative patients. Despite the challenges of reoperation, excellent early outcomes and acceptable midterm survival were achieved. These procedures can be successfully integrated into comprehensive robotic programs to expand minimally invasive options for complex cardiac reoperations.