Robotic Aortic Valve Replacement in Severe Scoliosis with Markedly Narrow Chest

INTRODUCTION: Robotic-assisted aortic valve replacement (AVR) has emerged as an extension of minimally invasive cardiac surgery, offering enhanced visualization and articulated instrument control. However, patients with severe thoracic deformities and markedly narrow chest anatomy are generally considered challenging candidates because restricted operative space may compromise annular exposure, instrument maneuverability, and aortotomy closure. Reports describing robotic-assisted AVR in such patients remain limited. We describe a successful robotic-assisted AVR in a patient with severe scoliosis and a markedly narrow thoracic cavity, highlighting technical modifications that enabled safe valve implantation. CASE PRESENTATION: A 61-year-old man presented with progressive exertional dyspnea and fatigue caused by severe aortic regurgitation. CT demonstrated severe scoliosis with marked narrowing of the thoracic cavity, resulting in a sternovertebral distance of 6.5 cm. The patient also had a stable chronic type B aortic dissection extending from the descending thoracic aorta to the level of the superior mesenteric artery without involvement of the ascending aorta or aortic arch. After multidisciplinary discussion and informed consent, robotic-assisted AVR was performed using the da Vinci Xi system (Intuitive Surgical, Sunnyvale, CA, USA). Technical modifications included the placement of the service-port robotic arm in the fifth intercostal space to improve the working angle and avoid arm interference, and the creation of a longitudinal aortotomy to facilitate valve exposure in the restricted operative field. Exposure of the noncoronary and left coronary annulus was achieved through robotic retraction and bedside suction assistance. A 23-mm bioprosthetic valve was successfully implanted without intraoperative complications. The patient was extubated within 5 h and discharged on POD 20. Postoperative echocardiography demonstrated normal prosthetic valve function without paravalvular leakage. CONCLUSIONS: Robotic-assisted AVR may be feasible in carefully selected patients with scoliosis-associated narrow chest anatomy. Detailed preoperative assessment and tailored technical strategies, including longitudinal aortotomy and modified port placement, may facilitate adequate exposure and safe valve implantation in anatomically challenging cases.