Objectives
Mitral regurgitation (MR) is the second most frequent valvular heart disease in Europe representing an important cause of morbidity and mortality. Despite increasing use of transcatheter edge-to-edge repair (TEER), endoscopic Mitral Valve Surgery (MVS) remains an established treatment 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
Patient 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). Consequently, median STS Prom Score increasedsignificantly 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%.The frequency of concomitant procedures, e.g., 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 systolic 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%, whereas all-cause mortality was 7.2%.
Conclusion
Despite a continuous increase of patient age, prevalence of outcome-relevant comorbidities and surgical risk within the last decade, perioperative and mid-term outcome of patients undergoing endoscopic MVS remain favorable. Particularly the possibility of concomitant cardiac procedures (e.g., tricuspid valve repair, ablation and LAA-occlusion) during endoscopic MVS, should be taken in consideration during routine heart-team discussion to determine the appropriate treatment option.
