The robot-based approach has been the most significant advancement in minimally invasive surgery over the past decade. Robotic coronary heart surgery represents half of the total cases of robotics-based cardiac surgery. Since 1998, it has emerged as a revolutionary approach to standard coronary surgery. However, despite its promising beginning, there has been a growing interest in the application of robotics in surgical fields other than cardiac surgery, such as urology and general surgery. In various waves of enthusiasm, single pioneers or visionary cardiac surgeons have tried to extend robotic surgery to different heart procedures, but they still struggled to practice it as a routine approach. Over the last 20 years, robotic platforms have gained importance in minimally invasive heart surgery, with proven safety and efficacy. However, despite its feasibility, safety, and efficacy, less than 0.5%–1.0% of coronary artery bypass grafting procedures are performed using a robot-assisted setup. We believe that in cardiac surgery, the time is ripe to open up new surgical strategies that are increasingly devoted to robotics, hybrid, and augmented-reality-based assistance. With this in mind, we wish to propose an excursus on the state of the art of coronary robotic surgery, its promising results, and its possible future perspectives, with a focus on the most recent achievements. This narrative minireview addresses, therefore, experiences and all aspects related to such a technique, with particular attention gained in robotic coronary revascularization, to the anaesthesiologic as well as surgical aspects, on the learning curve, patient outcome, and related costs, wishing to enlarge the portfolio of the younger generation of cardiac surgeons. In effect, according to the literature data, we are confident that robotic heart surgery is burgeoning, and the new generation of cardiac surgeons must face a gorgeous future if we invest in training and technology.

1. Liu J, Al’Aref SJ, Singh G, et al. An augmented reality system for image guidance of transcatheter procedures for structural heart disease. PLOS ONE. 2019; 14(7): e0219174. doi: 10.1371/journal.pone.0219174
2. Linte CA, White J, Eagleson R, et al. Virtual and augmented medical imaging environments: Enabling technology for minimally invasive cardiac Interventional guidance. IEEE Reviews in Biomedical Engineering. 2010; 3: 25–47. doi: 10.1109/rbme.2010.2082522
3. Pugin F, Bucher P, Morel P. History of robotic surgery: From AESOP® and ZEUS® to da Vinci®. Journal of Visceral Surgery. 2011; 148(5): e3–e8. doi: 10.1016/j.jviscsurg.2011.04.007
4. Abbou CC, Hoznek A, Salomon L, et al. Remote laparoscopic radical prostatectomy carried out with a robot. Report of a case (French). Prog Urol. 2000; 10(4): 520–3.
5. Yanagawa F, Perez M, Bell T, et al. Critical outcomes in nonrobotic vs robotic-assisted cardiac surgery. JAMA Surgery. 2015; 150(8): 771–777. doi: 10.1001/jamasurg.2015.1098
6. Shahin GMM, Bruinsma GJBB, Stamenkovic S, Cuesta MA. Training in robotic thoracic surgery—the European way. Annals of Cardiothoracic Surgery. 2019; 8(2): 202–209. doi: 10.21037/acs.2018.11.06
7. Cerfolio RJ, Cichos KH, Wei B, et al. Robotic lobectomy can be taught while maintaining quality patient outcomes. The Journal of Thoracic and Cardiovascular Surgery. 2016; 152(4): 991–997. doi: 10.1016/j.jtcvs.2016.04.085
8. Endo Y, Nakamura Y, Kuroda M, et al. The utility of a 3D endoscope and robot-assisted system for MIDCAB. Annals of Thoracic and Cardiovascular Surgery. 2019; 25(4): 200–204. doi: 10.5761/atcs.oa.18-00254
9. Lewis CTP, Stephens RL, Tyndal CM, Cline JL. Concomitant robotic mitral and tricuspid valve repair: Technique and early experience. The Annals of Thoracic Surgery. 2014; 97(3): 782–787. doi: 10.1016/j.athoracsur.2013.09.049
10. Ju MH, Huh JH, Lee CH, et al. Robotic-assisted surgical ablation of atrial fibrillation combined with mitral valve surgery. The Annals of Thoracic Surgery. 2019; 107(3): 762–768. doi: 10.1016/j.athoracsur.2018.08.059
11. Rillig A, Schmidt B, Biase LD, et al. Manual versus robotic catheter ablation for the treatment of atrial fibrillation: The man and machine trial. JACC: Clinical Electrophysiology. 2017; 3(8): 875–883. doi: 10.1016/j.jacep.2017.01.024
12. Ward AF, Applebaum RM, Toyoda N, et al. Totally endoscopic robotic left atrial appendage closure demonstrates high success rate. Innovations: Technology and Techniques in Cardiothoracic and Vascular Surgery. 2017; 12(1): 46–49. doi: 10.1097/imi.0000000000000330
13. Lewis CTP, Stephens RL, Horst VD, et al. Application of an epicardial left atrial appendage occlusion device by a robotic-assisted, right-chest approach. The Annals of Thoracic Surgery. 2016; 101(5): e177–e178. doi: 10.1016/j.athoracsur.2015.11.028
14. Xiao C, Gao C, Yang M, et al. Totally robotic atrial septal defect closure: 7-year single-institution experience and follow-up. Interactive CardioVascular and Thoracic Surgery. 2014; 19(6): 933–937. doi: 10.1093/icvts/ivu263
15. Onan B, Aydin U, Kadirogullari E, et al. Robotic repair of partial anomalous pulmonary venous connection: the initial experience and technical details. Journal of Robotic Surgery. 2019; 14(1): 101–107. doi: 10.1007/s11701-019-00943-0
16. Onan B, Aydin U, Turkvatan A, et al. Robot-assisted repair of right partial anomalous pulmonary venous return. Journal of Cardiac Surgery. 2016; 31(6): 394–397. doi: 10.1111/jocs.12753
17. Lewis CTP, Bethencourt DM, Stephens RL, et al. Robotic repair of sinus venosus atrial septal defect with partial anomalous pulmonary venous return and persistent left superior vena cava. Innovations: Technology and Techniques in Cardiothoracic and Vascular Surgery. 2014; 9(5): 388–390. doi: 10.1097/imi.0000000000000093
18. Onan B, Aydin U, Basgoze S, et al. Totally endoscopic robotic repair of coronary sinus atrial septal defect. Interactive CardioVascular and Thoracic Surgery. 2016; 23(4): 662–664. doi: 10.1093/icvts/ivw200
19. Bakir I, Onan B, Kadirogullari E. Robotically assisted repair of partial atrioventricular canal defect. Artificial Organs. 2016; 40(9): 917–918. doi: 10.1111/aor.12800
20. Gao C, Yang M, Wang G, et al. Totally endoscopic robotic ventricular septal defect repair. Innovations: Technology and Techniques in Cardiothoracic and Vascular Surgery. 2010; 5(4): 278–280. doi: 10.1097/imi.0b013e3181ee94cb
21. Gao C, Yang M, Wang G, et al. Totally robotic resection of myxoma and atrial septal defect repair. Interactive Cardio Vascular and Thoracic Surgery. 2008; 7(6): 947–950. doi: 10.1510/icvts.2008.185991
22. Murphy ET. Robotic excision of aortic valve papillary fibroelastoma and concomitant maze procedure. Global Cardiology Science and Practice. 2013; 2012(2): 93–100. doi: 10.5339/gcsp.2012.27
23. Woo YJ, Grand TJ, Weiss SJ. Robotic resection of an aortic valve papillary fibroelastoma. The Annals of Thoracic Surgery. 2005; 80(3): 1100–1102. doi: 10.1016/j.athoracsur.2004.02.108
24. Folliguet TA, Vanhuyse F, Magnano D, et al. Robotic aortic valve replacement: Case report. The Heart Surgery Forum. 2004; 7(6): E551–E553. doi: 10.1532/hsf98.20041025
25. Folliguet TA, Vanhuyse F, Konstantinos Z, et al. Early experience with robotic aortic valve replacement. European Journal of Cardio-Thoracic Surgery. 2005; 28(1): 172–173. doi: 10.1016/j.ejcts.2005.03.021
26. Balkhy HH, Lewis CTP, Kitahara H. Robot‐assisted aortic valve surgery: State of the art and challenges for the future. The International Journal of Medical Robotics and Computer Assisted Surgery. 2018; 14(4): e1913. doi: 10.1002/rcs.1913
27. Malhotra SP, Le D, Thelitz S, et al. Robotic-assisted endoscopic thoracic aortic anastomosis in juvenile lambs. The Heart Surgery Forum. 2002; 6(1): 38–42. doi: 10.1532/hsf.879
28. Srivastava SP, Patel KN, Skantharaja R, et al. Off-pump complete revascularization through a left lateral thoracotomy (ThoraCAB): The first 200 cases. The Annals of Thoracic Surgery. 2003; 76(1): 46–49.
29. Neumann FJ, Sousa-Uva M, Ahlsson A, et al. 2018 ESC/EACTS Guidelines on myocardial revascularization. EuroIntervention. 2019; 14(14): 1435–1534. doi: 10.4244/EIJY19M01_01
30. Patel MR, Calhoon JH, Dehmer GJ, et al. Correction to: ACC/AATS/AHA/ASE/ASNC/SCAI/SCCT/STS 2017 appropriate use criteria for coronary revascularization in patients with stable ischemic heart disease. Journal of Nuclear Cardiology. 2018; 25(6): 2191–2192. doi: 10.1007/s12350-018-1292-x
31. Patel MR, Calhoon JH, Dehmer GJ, et al. ACC/AATS/AHA/ASE/ASNC/SCAI/SCCT/STS 2016 appropriate use criteria for coronary revascularization in patients with acute coronary syndromes. Journal of the American College of Cardiology. 2017; 69(5): 570–591. doi: 10.1016/j.jacc.2016.10.034
32. Tajstra M, Hrapkowicz T, Hawranek M, et al. Hybrid coronary revascularization in selected patients with multivessel disease. JACC: Cardiovascular Interventions. 2018; 11(9): 847–852. doi: 10.1016/j.jcin.2018.01.271
33. Guan Z, Zhang Z, Gu K, et al. Minimally invasive CABG or hybrid coronary revascularization for multivessel coronary diseases: Which is best? A Systematic Review and Metaanalysis. The Heart Surgery Forum. 2019; 22(6): E493–E502. doi: 10.1532/hsf.2499
34. Gorki H, Patel NC, Balacumaraswami L, et al. Long-term survival after minimal invasive direct coronary artery bypass (MIDCAB) surgery in patients with low ejection fraction. Innovations: Technology and Techniques in Cardiothoracic and Vascular Surgery. 2010; 5(6): 400–406. doi: 10.1177/155698451000500604
35. Dhawan R, Roberts JD, Wroblewski K, et al. Multivessel beating heart robotic myocardial revascularization increases morbidity and mortality. The Journal of Thoracic and Cardiovascular Surgery. 2012; 143(5): 1056–1061. doi: 10.1016/j.jtcvs.2011.06.023
36. Wang S, Zhou J, Cai JF. Traditional coronary artery bypass graft versus totally endoscopic coronary artery bypass graft or robot-assisted coronary artery bypass graft--meta-analysis of 16 studies. Eur Rev Med Pharmacol Sci. 2014;18(6): 790–7.
37. Srivastava S, Barrera R, Quismundo S. One One hundred sixty-four consecutive beating heart totally endoscopic coronary artery bypass cases without intraoperative conversion. The Annals of Thoracic Surgery. 2012; 94(5): 1463–1468. doi: 10.1016/j.athoracsur.2012.05.028
38. Bonatti JO, Zimrin D, Lehr EJ, et al. Hybrid coronary revascularization using robotic totally endoscopic surgery: Perioperative outcomes and 5-year results. The Annals of Thoracic Surgery. 2012; 94(6): 1920–1926. doi: 10.1016/j.athoracsur.2012.05.041
39. Bonaros N, Schachner T, Lehr E, et al. Five hundred cases of robotic totally endoscopic coronary artery bypass grafting: Predictors of success and safety. The Annals of Thoracic Surgery. 2013; 95(3): 803–812. doi: 10.1016/j.athoracsur.2012.09.071
40. Bonaros N, Schachner T, Kofler M, et al. Advanced hybrid closed chest revascularization: an innovative strategy for the treatment of multivessel coronary artery disease. European Journal of Cardio-Thoracic Surgery. 2014; 46(6): e94–e102. doi: 10.1093/ejcts/ezu357
41. Cavallaro P, Rhee AJ, Chiang Y, et al. In-hospital mortality and morbidity after robotic coronary artery surgery. Journal of Cardiothoracic and Vascular Anesthesia. 2015; 29(1): 27–31. doi: 10.1053/j.jvca.2014.03.009
42. Zaouter C, Imbault J, Labrousse L, et al. Association of robotic totally endoscopic coronary artery bypass graft surgery associated with a preliminary cardiac enhanced recovery after surgery program: A retrospective analysis. Journal of Cardiothoracic and Vascular Anesthesia. 2015; 29(6): 1489–1497. doi: 10.1053/j.jvca.2015.03.003
43. Kofler M, Schachner T, Sebastian JR, et al. Comparative analysis of perioperative and mid-term results of TECAB and MIDCAB for revascularization of anterior wall. Innovations: Technology and Techniques in Cardiothoracic and Vascular Surgery. 2017; 12(3): 207–213. doi: 10.1097/imi.0000000000000378
44. Alaj E, Seidiramool V, Ciobanu V, et al. Short-term clinical results of minimally invasive direct coronary artery bypass (MIDCAB) procedure. Journal of Clinical Medicine. 2024; 13(11): 3124. doi: 10.3390/jcm13113124
45. Algoet M, Verbelen T, Jacobs S, et al. Robot-assisted MIDCAB using bilateral internal thoracic artery: A propensity score–matched study with OPCAB patients. Innovations: Technology and Techniques in Cardiothoracic and Vascular Surgery. 2024; 19(2): 184–191. doi: 10.1177/15569845241245422
46. Weymann A, Amanov L, Beltsios E, et al. Minimally invasive direct coronary artery bypass grafting: Sixteen years of single-center experience. Journal of Clinical Medicine. 2024; 13(11): 3338. doi: 10.3390/jcm13113338
47. Vassiliades TA, Nielsen JL, Lonquist JL. Effects of obesity on outcomes in endoscopically assisted coronary artery bypass operations. The Heart Surgery Forum. 2003; 6(2): 99–101. doi: 10.1532/hsf.569
48. Hemli JM, Darla LS, Panetta CR, et al. Does body mass index affect outcomes in robotic-assisted coronary artery bypass procedures? Innovations: Technology and Techniques in Cardiothoracic and Vascular Surgery. 2012; 7(5): 350–353. doi: 10.1097/imi.0b013e31827e1ea9
49. Balacumaraswami L, Patel NC, Gorki H, et al. Minimally invasive direct coronary artery bypass as a primary strategy for reoperative myocardial revascularization. Innovations: Technology and Techniques in Cardiothoracic and Vascular Surgery. 2010; 5(1): 22–27. doi: 10.1097/imi.0b013e3181cef8a6
50. Cheng Y, Liu X, Zhao Y, et al. Risk factors for postoperative events in patients on antiplatelet therapy undergoing off-pump coronary artery bypass grafting surgery. Angiology. 2020; 71(8): 704–712. doi: 10.1177/0003319720919319
51. Kon ZN, Brown EN, Tran R, et al. Simultaneous hybrid coronary revascularization reduces postoperative morbidity compared with results from conventional off-pump coronary artery bypass. The Journal of Thoracic and Cardiovascular Surgery. 2008; 135(2): 367–375. doi: 10.1016/j.jtcvs.2007.09.025
52. Patel NC, Hemli JM, Kim MC, et al. Short- and intermediate-term outcomes of hybrid coronary revascularization for double-vessel disease. The Journal of Thoracic and Cardiovascular Surgery. 2018; 156(5): 1799–1807.e3. doi: 10.1016/j.jtcvs.2018.04.078
53. Sardar P, Kundu A, Bischoff M, et al. Hybrid coronary revascularization versus coronary artery bypass grafting in patients with multivessel coronary artery disease: A meta‐analysis. Catheterization and Cardiovascular Interventions. 2018; 91(2): 203–212. doi: 10.1002/ccd.27098
54. Hemli JM, Patel NC. Robotic cardiac surgery. Surgical Clinics of North America. 2020; 100(2): 219–236. doi: 10.1016/j.suc.2019.12.005
55. Loulmet D, Carpentier A, d’Attellis N, et al. Endoscopic coronary artery bypass grafting with the aid of robotic assisted instruments. The Journal of Thoracic and Cardiovascular Surgery. 1999; 118(1): 4–10. doi: 10.1016/S0022-5223(99)70133-9
56. Mohr FW, Falk V, Diegeler A, et al. Computer-enhanced coronary artery bypass surgery. The Journal of Thoracic and Cardiovascular Surgery. 1999; 117(6): 1212–1214. doi: 10.1016/S0022-5223(99)70261-8
57. Göbölös L, Ramahi J, Obeso A, et al. Robotic totally endoscopic coronary artery bypass grafting: Systematic review of clinical outcomes from the past two decades. Innovations: Technology and Techniques in Cardiothoracic and Vascular Surgery. 2019; 14(1): 5–16. doi: 10.1177/1556984519827703
58. Caimmi PPR, Fossaceca R, Lanfranchi M, et al. Cardiac Cardiac angio-CT scan for planning MIDCAB. The Heart Surgery Forum. 2004; 7(2): E113–6. doi: 10.1532/hsf98.200328101
59. Moodley S, Schoenhagen P, Gillinov AM, et al. Preoperative multidetector computed tomograpy angiography for planning of minimally invasive robotic mitral valve surgery: Impact on decision making. The Journal of Thoracic and Cardiovascular Surgery. 2013; 146(2): 262–268. doi: 10.1016/j.jtcvs.2012.06.052
60. Morris MF, Suri RM, Akhtar NJ, et al. Computed tomography as an alternative to catheter angiography prior to robotic mitral valve repair. The Annals of Thoracic Surgery. 2013; 95(4): 1354–1359. doi: 10.1016/j.athoracsur.2012.12.010
61. Leonard JR, Henry M, Rahouma M, et al. Systematic preoperative CT scan is associated with reduced risk of stroke in minimally invasive mitral valve surgery: A meta-analysis. International Journal of Cardiology. 2019; 278: 300–306. doi: 10.1016/j.ijcard.2018.12.025
62. Fitzgerald MM, Bhatt HV, Schuessler ME, et al. Robotic Cardiac Surgery Part Ⅰ: Anesthetic Considerations in Totally Endoscopic Robotic Cardiac Surgery (TERCS). Journal of Cardiothoracic and Vascular Anesthesia. 2020; 34(1): 267–277. doi: 10.1053/j.jvca.2019.02.039
63. Bhatt HV, Schuessler ME, Torregrossa G, et al. Robotic cardiac surgery Part Ⅱ: Anesthetic considerations for robotic coronary artery bypass grafting. Journal of Cardiothoracic and Vascular Anesthesia. 2020; 34(9): 2484–2491. doi: 10.1053/j.jvca.2019.11.005
64. Oehlinger A, Bonaros N, Schachner T, et al. Robotic endoscopic left internal mammary artery harvesting: What have we learned after 100 cases? The Annals of Thoracic Surgery. 2007; 83(3): 1030–1034. doi: 10.1016/j.athoracsur.2006.10.055
65. Bonatti J, Schachner T, Bernecker O, et al. Robotic totally endoscopic coronary artery bypass: program development and learning curve issues. The Journal of Thoracic and Cardiovascular Surgery. 2004; 127(2): 504–510. doi: 10.1016/j.jtcvs.2003.09.005
66. Kappert U, Cichon R, Schneider J, et al. Robotic coronary artery surgery–the evolution of a new minimally-invasive approach in coronary artery surgery. The Thoracic and Cardiovascular Surgeon. 2000; 48(4): 193–197. doi: 10.1055/s-2000-6904
67. Hemli JM, Henn LW, Panetta CR, et al. Defining the learning curve for robotic-assisted endoscopic harvesting of the left internal mammary artery. Innovations: Technology and Techniques in Cardiothoracic and Vascular Surgery. 2013; 8(5): 353–358. doi: 10.1097/imi.0000000000000017
68. Yanagawa F, Perez M, Bell T, et al. Critical outcomes in nonrobotic vs robotic assisted cardiac surgery. JAMA Surgery. 2015; 150(8): 771. doi: 10.1001/jamasurg.2015.1098
69. Barbash GI, Glied SA. New technology and health care costs–the case of robot-assisted surgery. New England Journal of Medicine. 2010; 363(8): 701–704. doi: 10.1056/nejmp1006602
70. Whellan DJ, McCarey MM, Taylor BS, et al. Trends in robotic-assisted coronary artery bypass grafts: A study of the society of thoracic surgeons adult cardiac surgery database, 2006 to 2012. The Annals of Thoracic Surgery. 2016; 102(1): 140–146. doi: 10.1016/j.athoracsur.2015.12.059
71. Balkhy HH, Amabile A, Torregrossa G. A shifting paradigm in robotic heart surgery: From single-procedure approach to establishing a robotic heart center of excellence. Innovations: Technology and Techniques in Cardiothoracic and Vascular Surgery. 2020; 15(3): 187–194. doi: 10.1177/1556984520922933
72. Brown LM, Kratz A, Verba S, et al. Pain and opioid use after thoracic surgery: Where we are and where we need to go. The Annals of Thoracic Surgery. 2020; 109(6): 1638–1645. doi: 10.1016/j.athoracsur.2020.01.056
73. Pirelli L, Patel NC, Scheinerman JS, et al. Hybrid minimally invasive approach for combined obstructive coronary artery disease and severe aortic stenosis. Innovations: Technology and Techniques in Cardiothoracic and Vascular Surgery. 2020; 15(2): 131–137. doi: 10.1177/1556984519896581
74. Kobayashi J, Shimahara Y, Fujita T, et al. Early results of simultaneous transaortic transcatheter aortic valve implantation and total arterial off-pump coronary artery revascularization in high-risk patients. Circulation Journal. 2016; 80(9): 1946–1950. doi: 10.1253/circj.cj-16-0329
75. Giustino G, Serruys PW, Sabik JF, et al. Mortality after repeat revascularization following PCI or CABG for left main disease. JACC: Cardiovascular interventions. 2020; 13(3): 375–387. doi: 10.1016/j.jcin.2019.09.019
76. Baquero GA, Azarrafiy R, de Marchena EJ, et al. Hybrid off‐pump coronary artery bypass grafting surgery and transaortic transcatheter aortic valve replacement: Literature review of a feasible bailout for patients with complex coronary anatomy and poor femoral access. Journal of Cardiac Surgery. 2019; 34(7): 591–597. doi: 10.1111/jocs.14082
77. Ahad S, Wachter K, Rustenbach C, et al. Concomitant therapy: Off-pump coronary revascularization and transcatheter aortic valve implantation. Interactive Cardio Vascular and Thoracic Surgery. 2017; 25(1): 12–17. doi: 10.1093/icvts/ivx029
78. Falk V, Baumgartner H, Bax JJ, et al. 2017 ESC/EACTS Guidelines for the management of valvular heart disease. Eur J Cardiothorac Surg. 2017; 52(4): 616–664.
79. Baumgartner H, Falk V, Bax JJ, et al. 2017 ESC/EACTS Guidelines for the management of valvular heart disease. European Heart Journal. 2017; 38(36): 2739–2791.
80. Sutter FP, Wertan MC, Spragan D, et al. Robotic-assisted coronary artery bypass grafting: how I teach it. Annals of Cardiothoracic Surgery. 2024; 13(4): 346–353. doi: 10.21037/acs-2024-rcabg-0033
81. Mori M, Geirsson A. The way forward in research on robotic cardiac surgery: the need for transatlantic robotic cardiac surgery registry. Annals of Cardiothoracic Surgery. 2024; 13(4): 376–378. doi: 10.21037/acs-2023-rcabg-0183
82. Gianoli M, de Jong AR, van der Harst P, et al. Cost analysis of robot-assisted versus on-pump and off-pump coronary artery bypass grafting: A single-center surgical and 30-day outcomes comparison. Innovations: Technology and Techniques in Cardiothoracic and Vascular Surgery. 2024; 19(4): 416–424. doi: 10.1177/15569845241269312
83. Dokollari A, Sicouri S, Prendergrast G, et al. Robotic-assisted versus traditional full-sternotomy coronary artery bypass grafting procedures: A propensity-matched analysis of hospital costs. The American Journal of Cardiology. 2024; 213: 12–19. doi: 10.1016/j.amjcard.2023.10.083