Evolution of endoscopic mitral valve surgery in the era of transcatheter edge-to-edge repair: an 11 year experience at a high-volume centre

Jonas Pausch (Hamburg)1, O. Bhadra (Hamburg)1, X. Hua (Hamburg)1, E. Girdauskas (Augsburg)2, H. Reichenspurner (Hamburg)1, L. Conradi (Hamburg)1

1Universitäres Herz- und Gefäßzentrum Hamburg Klinik und Poliklinik für Herz- und Gefäßchirurgie Hamburg, Deutschland; 2Universitätsklinikum Augsburg Klinik für Anästhesiologie Augsburg, Deutschland


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.



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.


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 procedurese.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(174.9-240.0mins (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) mmHgAt 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%.



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.

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