Totally Endoscopic Mitral Valve Repair for Degenerative Mitral Regurgitation Using a Non-Robotic Approach: Defining “Totally Endoscopic?” Early Outcomes from a Single Center

Abstract

Objective:

To evaluate early clinical and echocardiographic outcomes of totally endoscopic non-robotic mitral valve repair for degenerative mitral regurgitation and to clarify the concept of “totally endoscopic” surgery using a standardized DCT approach.

Methods:

Between July 2023 and January 2026, 84 consecutive patients with severe degenerative mitral regurgitation meeting surgical indications according to the 2021 ESC/EACTS guidelines underwent totally endoscopic mitral valve repair using a non-robotic approach with three-dimensional endoscopic visualization. A standardized technique with a primary skin incision ≤3 cm and no rib spreading was applied in all cases. Early clinical outcomes and echocardiographic findings within 30 days were analyzed.

Results:

Mitral valve repair was successfully achieved in all patients (100%) without conversion to sternotomy or valve replacement. Annuloplasty was performed in all cases, with neochordal implantation in 69 patients. The mean primary skin incision length was 2.9 ± 0.3 cm. Mean cardiopulmonary bypass and cross-clamp times were 147.7 ± 51.5 and 127.8 ± 49.4 minutes, respectively. There was no operative mortality. Major complications included re-exploration for bleeding (1.2%), intracranial hemorrhage (1.2%), and femoral artery occlusion (1.2%). Median intensive care unit and hospital stays were 2 (interquartile range, 2–3) and 10 (interquartile range, 9–14) days, respectively. Echocardiography within 30 days demonstrated no residual mitral regurgitation ≥ moderate and preserved ventricular function in all patients.

Conclusions:

Totally endoscopic non-robotic mitral valve repair using a standardized DCT approach appears to be safe and reproducible, with favorable early outcomes. This technique also contributes to a clearer operational definition of totally endoscopic mitral valve repair and may facilitate wider adoption of fully endoscopic mitral surgery in experienced centers.