Totally endoscopic port access for rheumatic mitral valve replacement: Clinical outcomes and a single surgeon's learning curve experience.

OBJECTIVES

This study evaluates the safety and efficacy of totally endoscopic surgery for rheumatic mitral valve disease (RMVD) and analyzes the learning curve using cumulative sum control chart (CUSUM) and risk-adjusted (RA)-CUSUM failure models.

METHODS

From March 2018 to November 2023, 242 consecutive patients with RMVD underwent totally endoscopic surgery via three 5.5-mm trocars and a 3- to 4-cm working port. Optimized management for atrial fibrillation (AF) included (1) mitral valve replacement, (2) tricuspid valve repair, (3) AF ablation, and (4) left atrial reduction. CUSUM and RA-CUSUM failure analyses were used to evaluate the learning curve progression, and comparisons were made between different learning curve phases.

RESULTS

The median aortic crossclamp and cardiopulmonary bypass times were 98.5 (81-116) minutes and 178 (146-202) minutes, respectively, with a median follow-up of 37 months. Among 187 patients with long-standing persistent AF, 53 received optimized treatment, and a 91% AF-free rate was achieved at 1-year follow-up. In-hospital mortality occurred in 2 cases, attributable to intestinal infarction, and 1 late mortality resulted from massive intracranial hemorrhage. Major complications included 5 reoperations, 5 cases of severe unilateral pulmonary edema, and 4 cases of low cardiac output syndrome. CUSUMACCtime and RA-CUSUM failure analyses in 130 patients demonstrated significant improvements in operative times and recovery across different learning curve phases.

CONCLUSIONS

Totally endoscopic surgery for RMVD, including optimized AF management, is safe and feasible. Mastery of isolated endoscopic mitral valve replacement requires 86 cases to optimize aortic crossclamp time and 60 cases to effectively manage perioperative complications.