Evolution of Endoscopic Mitral Valve Surgery Over a 11-year Period at a High-volume Center

Background: Mitral regurgitation (MR) is the second most frequent valvular heart disease in Europe representing an important cause of morbidity and mortality. Endoscopic mitral valve surgery (MVS) has evolved to become the standard surgical approach aiming at reduced surgical trauma and improved recovery.

Methods: Between 2012 and 2022, a total of 1,055 consecutive patients (62.4% male, 82.9% primary MR, 77.8% posterior prolapse/flail) underwent fully endoscopic MVS. Patients received limited right-sided anterolateral skin incision and 3D-camera visualization. Data was retrospectively analyzed.

Results: Patients’ age increased significantly during the study period from 56.0 (47.0–64.2) to 61.0 (55.0–68.0) years (p = 0.018). Most prevalent comorbidities were hypertension (44.5%) and atrial fibrillation (32.5%), which showed an increased prevalence over time (p = 0.028). Accordingly, median STS PROM Score increased significantly from 0.33 (0.26–0.46) to 0.43 (0.29–0.93) (p < 0.001). Patients predominantly presented with NYHA class II symptoms (48.3%). MV repair was performed in 92.9%. Median annuloplasty ring size was 32 (30–36) mm. Additional chordal replacement was performed in 72.9% and leaflet resection in 32.8%. Frequency of concomitant procedures (closure of left atrial appendage [21.0%], atrial ablation [19.9%] or tricuspid valve repair [6.6%]) increased significantly over time (p < 0.001). Nevertheless, median cross-clamp and procedural times decreased significantly from 111.0 (91.0–129.7) and 282.5 (250.0–335.0) to 90.0 (78.0–106.6) and 206.0 (174.9–240.0) mins (p < 0.001). Median postoperative ventilation time was 5.0 (3.3–7.0) hours and decreased significantly during the study period (p = 0.002). Length of intensive care unit and overall in-hospital stay were 2.0 (1.0–3.0) and 7.0 (5.0–9.0) days, respectively. At discharge, 76.9% of patients showed no/trivial MR, whereas mild MR was found in 23.1%. Median peak and mean MV gradients were 8.0 (6.0–11.0) and 3.0 (2.0–4.0) mmHg. At 30 days, overall mortality was 0.7%. During a median follow-up of 58 (29–86) months, reoperation rate was 3.1%.

Conclusion: Despite an increase in patients’ age, prevalence of outcome-relevant comorbidities, overall surgical risk, and frequency of concomitant procedures, perioperative and mid-term outcome of patients undergoing endoscopic MVS remain excellent. Therefore, endoscopic MVS has evolved to become our default approach for MVS.

Publication History

Article published online:
11 February 2025