Totally Endoscopic Mitral Valve Replacement: Reasons for Non-feasibility of Repair at a High-volume Single Center

Background: Totally endoscopic mitral valve surgery (MVS) is an established therapy with high rates of valve-sparing repair at experienced centers. However, in special subsets of patients, repair might not be feasible and chordal-sparing MV replacement remains an appropriate surgical option. In this work, we investigated reasons for totally endoscopic MV replacement and outcomes of these procedures.

Methods: From 2012 to 2022, 1,055 consecutive patients underwent totally endoscopic MVS at our institution. Of those 75 patients (7.2%) underwent chordal-sparing MV replacement. Preoperative characteristics, periprocedural data, and mid-term outcomes were retrospectively analyzed.

Results: Median age of patients was 65 (56.5–71.5) years (56.0% female, STS PROM 1.5 [1.1–2.8]). Reasons for MV replacement were: sclerotic leaflet degeneration/immobility in 28.0% (21/75 patients), rheumatic disease in 12.0% (9/75 patients), moderate/severe MV stenosis in 17.3% (13/75 patients), acute MV endocarditis in 26.7% (20/75 patients), and failed MV repair attempt in 17.3% (13/75 patients). Furthermore, 6.7% of patients presented with status post failed transcatheter edge-to-edge repair. Median cross-clamp and cardiopulmonary bypass times were 98.5 (77.5–140.8) and 158.0 (134.0–217.5) minutes. Postoperatively, 14.7% of patients underwent re-thoracotomy and 16.0% received permanent pacemaker implantation. Low cardiac output occurred in 6.7% of patients with postprocedural use of Dobutamin. No stroke occurred. At discharge, peak/mean transvalvular MV gradients were 13.0 (10.0–17.0)/5.0 (4.0–6.0) mmHg, whereas no paravalvular leakage occurred. At 30 days, overall mortality was 5.3% (2.7% without endocarditis patients). During a median follow-up of 35.2 (11.0–52.9) months, three patients underwent MV re-operation due to endocarditis (2 patients) or degeneration of the prosthesis (1 patient). Overall survival during follow-up was 86.7%.

Conclusion: Totally endoscopic MVS at an experienced high-volume center is infrequently associated with MV replacement. Main reasons included sclerotic leaflets/MV stenosis and endocarditis. However, despite the herein investigated particularly comorbid patient subset, early and mid-term outcomes were reasonable. Totally endoscopic MVS with replacement of the MV therefore remains a valid option with an adequate safety and clinical efficacy profile for selected patients.

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Artikel online veröffentlicht:
11. Februar 2025