Percutaneous Versus Surgical Femoral Cannulation in Endoscopic Minimally Invasive Heart Valve Surgery: A Single-Centre Retrospective Comparison of Cut-Down, ProGlide and MANTA Closure Strategies.

Background/Objectives: Femoral cannulation is the cornerstone of endoscopic minimally invasive heart valve surgery (MICS). We compared three femoral access strategies-surgical cut-down, suture-based percutaneous closure (ProGlide®) and plug-based percutaneous closure (MANTA®)-for access-site outcomes, operative times and 30-day morbidity. Methods: This is a retrospective single-centre analysis of 445 consecutive patients undergoing endoscopic MICS (February 2021-May 2025). Access strategy (cut-down n = 119; ProGlide n = 219; MANTA n = 107) was selected by preoperative CT angiography and the surgeon's discretion, with hostile anatomy triaged to cut-down. Baseline characteristics, intraoperative timing, primary haemostasis, conversion and 30-day outcomes were compared; a multivariable model within the percutaneous cohort adjusted for arterial cannula size and baseline covariates was used. Results: The mean age was 61.6 ± 11.3 years; 60.8% were male. EuroSCORE II was comparable between the percutaneous and cut-down groups (1.89 ± 2.55 vs. 2.03 ± 2.41; p = 0.594). Primary haemostasis was higher with MANTA than ProGlide (96.2% vs. 83.1%; p = 0.001; adjusted OR 4.79). Conversion to cut-down was similar (3.7% vs. 3.6%; p = 1.000). Intervention-requiring groin complications were fewer with percutaneous access (3.7% vs. 7.5%; p = 0.232). Cross-clamp, bypass and total operative times were shortest with MANTA (all p < 0.001). In-hospital mortality was 2.1% vs. 1.6% (p = 1.000). Conclusions: In appropriately selected patients, percutaneous femoral cannulation in MICS is safe and is associated with fewer groin complications and shorter operative times than cut-down. Within the percutaneous arm, MANTA was associated with a higher rate of primary haemostasis in our institutional experience. Cut-down remains indispensable for hostile femoral anatomy.