Comparative outcomes of totally endoscopic versus direct vision mini-thoracotomy mitral valve repair: A propensity score-matched retrospective analysis.

BACKGROUND

Totally endoscopic mitral valve repair has emerged as an alternative minimally invasive approach to direct vision mini-thoracotomy (DVMT) repair, using 3-dimensional thoracoscopic guidance and a smaller working incision without rib spreading. Whether these technical differences translate into improved outcomes remains uncertain.

METHODS

A propensity score-matched, retrospective analysis was conducted on 114 patients undergoing elective mitral valve repair for degenerative mitral regurgitation (MR) via totally endoscopic or DVMT approaches at 2 UK tertiary centers between 2015 and 2024. Patients were matched 1:1 on key preoperative variables. The primary outcome was clinically significant recurrent MR on follow-up echocardiography. Secondary outcomes assessed operative parameters and recovery metrics. Multivariate regression identified predictors of relevant outcomes.

RESULTS

Totally endoscopic repair was associated with lower odds of developing clinically significant recurrent MR (odds ratio, 0.05; 95% confidence interval, 0-0.32; P = .0094) compared with DVMT. Intraoperative metrics were broadly comparable in the 2 groups, with the totally endoscopic procedure associated with marginal, nonsignificant increases in cardiopulmonary bypass and cross-clamp times. Immediate postrepair transesophageal echocardiography demonstrated no greater than mild residual MR in either cohort. Procedural safety was similar in the 2 groups, with no 30-day mortality and low complication rates. Trends toward shorter intensive care and postoperative hospital stays were seen in totally endoscopic patients, although these were not statistically significant.

CONCLUSIONS

The totally endoscopic approach achieved more durable repairs, with comparable perioperative safety to DVMT. The observed improvement in early repair durability remains hypothesis-generating and warrants further evaluation in larger studies with standardized long-term follow-up.