Search Results (60)

Background: Minimally invasive approaches for multivalve surgery have attracted increasing interest; however, data on combined aortic and mitral valve replacement or repair using via right anterior minithoracotomy remain quite limited. This study aimed to evaluate the feasibility, safety, and early outcomes of minimally invasive concomitant aortic and mitral valve replacement or repair using this approach. Methods: This retrospective study included 24 patients who underwent simultaneous aortic and mitral valve procedures via right anterior minithoracotomy. We collected preoperative, intraoperative, and postoperative data, assessing echocardiographic parameters. Early clinical outcomes, complications, and mortality rates were analyzed, with correlations between EuroSCORE II and outcomes explored. Results: The median follow-up was 412 days. All procedures were completed successfully without conversion to sternotomy. Postoperative echocardiography demonstrated a significant reduction in transvalvular gradients, with aortic mean pressure gradient decreasing from 51.3 ± 23.0 mmHg to 6.7 ± 1.7 mmHg (p < 0.001) and mitral mean pressure gradient from 19.3 ± 26.7 mmHg to 4.0 ± 1.4 mmHg (p < 0.001), while left ventricular ejection fraction remained unchanged (p = 0.67). During the study period, one patient died from a non-cardiac cause. EuroSCORE II showed a moderate positive correlation with intensive care unit length of stay (p = 0.011) but not with hospital stay or operative times. Conclusions: Minimally invasive aortic and mitral valve replacement or repair via right anterior minithoracotomy is feasible and was associated with favorable early hemodynamic and clinical outcomes in this single-center cohort. Full article

Background and Objectives: Left atrial appendage (LAA) closure is a Class I recommendation in patients with atrial fibrillation to reduce the risk of cardioembolic stroke. Achieving reliable and complete LAA exclusion during minimally invasive mitral valve surgery via right minithoracotomy remains technically challenging. We report here to our knowledge the largest series of a novel technique for LAA exclusion using an epicardial clip device applied via right minithoracotomy during minimally invasive mitral valve surgery. Materials and Methods: Between June 2023 and May 2026, 40 patients with atrial fibrillation underwent minimally invasive mitral valve surgery via right minithoracotomy with concomitant LAA exclusion. Cardiopulmonary bypass was established via percutaneous femoral cannulation. Following completion of the intracardiac procedure and prior to aortic cross-clamp removal, a suture was placed around the LAA base via the transverse sinus and used to guide clip deployment under direct vision. Successful closure was confirmed by intraoperative transesophageal echocardiography. Results: Mean patient age was 66.6 ± 8.0 years; 21 patients (53%) were female. Mitral valve repair was performed in 36 patients (90%) and replacement in 4 (10%). Concomitant cryoablation for AF was performed in 31 patients (78%). Successful LAA clip deployment was achieved in all 40 patients (100%). The 35 mm clip was used in 36 patients (90%), the 40 mm clip in 3 patients (8%), and the 45 mm clip in 1 patient (2%). Mean total operative time was 183 ± 58 min; mean CPB time was 134 ± 42 min; mean aortic cross-clamp time was 70 ± 27 min. In-hospital mortality was 0%. One patient (3%) required re-thoracotomy for bleeding, one developed a postoperative stroke, and two required ECMO support. Median hospital stay was 9 days. At discharge, 18 patients (45%) were in sinus rhythm; among the 31 who underwent concomitant cryoablation, 16 (52%) were discharged in sinus rhythm. Conclusions: Minimally invasive LAA exclusion is feasible and safe when performed via right minithoracotomy during minimally invasive mitral valve surgery. The technique achieves high rates of successful deployment and avoids the need for additional incisions or access sites. This approach represents a valuable addition to the armamentarium of concomitant stroke prevention strategies in patients with AF undergoing minimally invasive valvular surgery. Full article

Background: Totally endoscopic mitral valve surgery has gained increasing interest as an evolution of minimally invasive cardiac surgery. However, concerns remain regarding the implementation of endoscopic techniques and their potential impact on procedural safety and operative efficiency. The present study aimed to evaluate the early experience of transitioning from direct-view minimally invasive mitral surgery to a totally endoscopic approach in an experienced minimally invasive center. Methods: A retrospective analysis of consecutive patients undergoing minimally invasive mitral valve surgery was performed. The study included 209 patients, comprising 36 totally endoscopic and 173 direct-view minimally invasive procedures. Propensity score matching was performed using age, left ventricular ejection fraction, and New York Heart Association functional class, resulting in 36 matched pairs. Continuous variables were compared using Student’s t-test and categorical variables using Fisher’s exact test. Results: After propensity score matching, baseline characteristics were well balanced between groups. The endoscopic cohort demonstrated significantly shorter cardiopulmonary bypass time compared with the direct-view group (120.4 ± 44.3 vs. 153.1 ± 40.1 min; p = 0.001). Aortic cross-clamp time was also significantly shorter in the endoscopic cohort (77.1 ± 23.9 vs. 97.8 ± 32.0 min; p = 0.002). Postoperative outcomes remained comparable between groups. The incidence of de novo atrial fibrillation was similar (11.1% vs. 13.9%; p = 1.0), as were blood transfusion requirements (47.2% vs. 50.0%; p = 1.0). Major postoperative complications occurred infrequently in both cohorts. Procedural success was achieved in 94.4% of direct-view procedures and 100% of endoscopic procedures (p = 0.493). Conclusions: Transition from direct-view minimally invasive mitral surgery to a totally endoscopic approach was associated with significantly shorter cardiopulmonary bypass and aortic cross-clamp times while maintaining comparable early postoperative outcomes. These findings suggest that implementation of totally endoscopic mitral surgery can be achieved safely in experienced minimally invasive centers and may be associated with shorter operative times while maintaining comparable early postoperative outcomes. Further multicenter studies are warranted to better define the impact of endoscopic techniques on operative performance and clinical outcomes. Full article

Background: Mitral regurgitation (MR) is one of the most prevalent valvular heart diseases, with a rising global incidence. The 2025 European Society of Cardiology (ESC) guidelines introduced updated pathophysiological and morphological concepts for secondary MR, distinguishing ventricular and atrial mechanisms. Concurrent advances in cardiovascular imaging and therapeutic technologies have transformed the diagnostic and management landscape of MR. Methods: This review summarizes current evidence on the diagnosis and treatment of MR, with a focus on the updated ESC classification, multimodality cardiovascular imaging, minimally invasive surgical techniques, and contemporary transcatheter repair strategies. Recent literature was evaluated to highlight advances in anatomical assessment and individualized therapeutic approaches. Results: Multimodality imaging provides comprehensive evaluation of mitral valve anatomy, ventricular remodeling, and disease mechanisms, enabling accurate patient selection and procedural planning. Surgical management has evolved from conventional repair or replacement to minimally invasive approaches, including video-assisted right thoracotomy and robotic-assisted surgery, which have demonstrated favorable perioperative and clinical outcomes. In parallel, transcatheter interventions have expanded the therapeutic armamentarium for patients at high surgical risk or with complex anatomy. These include direct and indirect annuloplasty, transcatheter edge-to-edge repair, and emerging catheter-based repair technologies targeting specific structural abnormalities of the mitral valve apparatus. Conclusions: Contemporary management of MR requires an integrated understanding of disease pathophysiology, advanced imaging, and patient-specific anatomical characteristics. The combination of minimally invasive surgical techniques and rapidly evolving transcatheter interventions has broadened treatment options and supports a tailored, multidisciplinary approach to improve clinical outcomes and expand access to effective therapy for patients with severe MR. Full article

Background/Objectives: Minimally invasive (MIS) mitral valve surgery has been proven to be a safe and effective alternative to median sternotomy (ST), with advantages in postoperative recovery and morbidity. However, its role in the setting of infective endocarditis (IE) remains uncertain. This meta-analysis aims to evaluate the outcomes of MIS in mitral valve surgery for infective endocarditis. Methods: A PRISMA-compliant search for studies including patients undergoing MIS for mitral valve IE was performed through 14 January 2026, in PubMed, Scopus and Cochrane. Time-to-event data were reconstructed from published Kaplan–Meier curves. A secondary comparative analysis focusing on MIS versus ST techniques was conducted. Results: Fourteen retrospective studies comprising 949 patients were analyzed. In the MIS cohort, early mortality was 4.2% (95%CI: 1.8%, 7.4%). Overall survival was 86.7% at 1 year, 75.2% at 5 years and 56.2% at 10 years. Freedom from IE-related reoperation remained high at 97.5%, 95.9%, and 90.7% at 1, 5, and 10 years, respectively. Mitral valve repair was performed in 52.5% of patients. In secondary comparative analyses, overall survival at 4-year follow-up was not different between MIS and ST [HR: 0.82 (95%CI: 0.43, 1.57), p = 0.55]. MIS was associated with a significantly shorter intensive care unit (ICU) stay [MD: −1.52 days (95%CI: −2.08, −0.97), p < 0.01]. Conclusions: MIS for mitral valve IE is associated with favorable early and long-term outcomes, comparable survival with sternotomy, and reduced ICU stay. These findings suggest that MIS may be considered as a feasible and potentially effective alternative for the management of mitral valve IE in carefully selected patients. Further prospective comparative studies are warranted. Full article

Transcatheter edge-to-edge repair (TEER) is a recent minimally invasive method of managing mitral regurgitation (MR) in dogs with myxomatous mitral valve disease (MMVD). As the goal of intervention is to minimize MR severity, this study aimed to determine the association between reduced MR and changes in myocardial work indices after TEER in dogs. Ten client-owned dogs with moderate-to-severe MR were enrolled in the study, and all underwent TEER with multimodal imaging guidance. Myocardial work was analyzed before and after the procedure, and the MR severity, transmitral pressure gradients, left atrial and ventricular measurements, and index of myocardial work (GWI: the total myocardial work during systole; GCW: work contributing to LV ejection; GWW: ineffective work that contributes to no forward displacement; and GWE: ratio of constructive work to total work) were calculated. TEER significantly reduced MR severity in the majority of dogs, and this MR decrease was associated with a greater efficiency of myocardial work, more constructive work, and less wasted energy. No significant negative associations of moderate post-procedure gradients with short-term clinical outcomes emerged. TEER-mediated reduction in MR improves myocardial function in dogs. However, long-term studies are also needed to examine the effects of residual MR and transmitral gradients on cardiac function and clinical outcome. Full article

Background: Reintervention after mitral valve repair represents a relevant clinical challenge, yet the mechanisms and timing of repair failure remain incompletely defined. Understanding how the interval between index repair and reoperation affects failure mechanisms and the feasibility of repeat repair may help refine surgical strategies. Methods: We retrospectively analyzed 194 patients undergoing repeat mitral valve surgery between 2010 and 2025 after prior repair. Median age was 70 years and 61.3% were male. Patients were stratified by time to reoperation: 0–5 years (n = 91), 6–10 years (n = 42), and >10 years (n = 61). Median left ventricular ejection fraction was 58%, atrial fibrillation prevalence 32.5%, minimally invasive approach 21.6%, and EuroSCORE II 4.8%. Results: Baseline characteristics and operative risk were comparable across groups. However, mechanisms of repair failure differed significantly. Early failures were more commonly due to recurrent leaflet prolapse (47.8%), whereas late failures showed a higher incidence of mitral stenosis (63.9%). The rate of repeat mitral repair decreased over time, being higher in early failures compared with intermediate and late failures (17.6% vs. 14.3% vs. 8.2%). Conclusions: Timing of mitral repair failure is associated with distinct mechanisms and influences surgical management. Early failures are more frequently related to prolapse recurrence and are more amenable to re-repair, whereas late failures are characterized by structural degeneration and more often require valve replacement. Full article

Background/Objectives: Totally endoscopic mitral valve repair reduces surgical trauma and accelerates recovery but can be technically challenging, particularly for precise annuloplasty suturing. The VirtuoSEW^® (LSI Solutions, Victor, NY 14564m, USA) automated annular suturing system was developed to standardize and simplify suture placement. This study was an early evaluation of this technology’s safety, efficacy, and feasibility in totally endoscopic microInvasive mitral valve repair (µMVr). Methods: We conducted a retrospective observational study of 20 patients with severe mitral valve disease of various etiologies. All patients underwent mitral valve repair using the VirtuoSEW^® system for automated placement of annuloplasty sutures, combined with leaflet resection or chordal management as appropriate. Postoperative outcomes were assessed at one month using echocardiography and clinical evaluation. Perioperative and postoperative complications and early mortality were systematically recorded. Results: VirtuoSEW^®-assisted mitral valve repair was safe and effective, achieving complete elimination of severe mitral regurgitation in all patients (N = 20, 100%). Annuloplasty rings included Physio-ring (N = 12, 60%), Memo 3D (N = 4, 20%), and Memo 4D (N = 4, 20%), combined with leaflet repair techniques: leaflet plication (N = 5, 25%), neochordae implantation (N = 7, 35%), sliding plasty (N = 2, 10%), commissural repair (N = 1, 5%), and hemibutterfly repair (N = 1, 5%). Concomitant procedures included: tricuspid valve repair (N = 1, 5%) and atrial septal defect closure (N = 1, 5%). Mitral annulus diameter decreased from 42.0 ± 5.3 mm to 34.2 ± 2.2 mm (p = 0.001). Mean total surgery, cardiopulmonary bypass, and aortic cross-clamp times were 170.3 ± 21.3, 143.4 ± 21.5, and 80.4 ± 7.9 min, respectively. ICU stay was 1.0 ± 0.2 days, with a hospital stay of 8.0 ± 1.9 days. No perioperative complications—including bleeding (N = 0, 0%), stroke (N = 0, 0%), infections (N = 0, 0%), or 30-day mortality (N = 0, 0%)—occurred. Conclusions: µMVR invasive mitral valve repair using the VirtuoSEW^® system is safe, effective, and reproducible, as well as compatible with almost all repair techniques, providing complete restoration of valve competence with no early device-related complications. To our knowledge, this is the first clinical study reporting outcomes with this device, supporting its potential to streamline mitral repair and improve procedural efficiency. Full article

Background: Annuloplasty ring sizing is critical for durable outcomes in surgical mitral valve repair (MVr). However, there is no clear consensus on optimal sizing strategies. Artificial intelligence (AI)-based imaging tools may help to reduce uncertainty in preoperative decision-making by providing objective, reproducible and reliable measurements. This study evaluated the predictive capability of a fully automated, computed tomography (CT)-based AI-driven tool for annuloplasty ring sizing in patients undergoing minimally invasive MVr (MI-MVr). Methods: A total of 71 consecutive patients undergoing MI-MVr for Carpentier type II mitral valve insufficiency during the study period were included. Preoperative CT scans were analyzed using a cloud-based, fully automated AI tool to quantify mitral valve geometric parameters. Correlations between AI-derived measurements and implanted ring sizes were assessed using the Pearson correlation test. Univariable and multivariable linear regression analyses were performed to identify independent predictors of ring size selection. Results: Several AI-derived parameters correlated significantly with implanted ring size, with the strongest correlations observed for commissural width (R = 0.693, p < 0.001) and mitral annular area (R = 0.693, p < 0.001). In multivariable regression analysis, these parameters were the strongest predictors of annuloplasty ring size (R² = 0.504, p < 0.001). Using this model, accurate annuloplasty ring sizing could be predicted in 78.8% of patients. There were no in-hospital mortality and residual mitral regurgitation at discharge. Conclusions: A fully automated, CT-based AI-driven tool demonstrated good accuracy for preoperative annuloplasty ring size prediction in MI-MVr and may have the potential to support surgical decision-making, reduce operator dependence, and improve reproducibility. Full article

Background and Objectives: Minimally invasive surgery (MIS) has become a cornerstone approach in cardiac surgery. A debate persists regarding the optimal aortic clamp occlusion strategy, with limited comparative data. The two principal strategies, which are transthoracic cross-clamping (TTCC) and endo-aortic balloon occlusion (EABO), offer distinct advantages, but comparative clinical data remain limited. This study compares the two techniques in terms of procedural safety and early outcome. Materials and Methods: This single-center retrospective study included consecutive adult patients undergoing elective MIS via video-assisted right mini-thoracotomy between 2012 and 2018 for mitral valve surgery. Tricuspid repair, atrial fibrillation and redo surgery were included in the final cohort. Aortic occlusion was performed with transthoracic cross-clamping (TTCC) or endo-aortic balloon occlusion (EABO). Primary endpoints were intra-operative complications and the rate of conversion to full sternotomy; secondary outcomes were overall mortality and Society of Thoracic Surgeons (STS)-defined comorbidities. Results: A total of 163 patients were analyzed (TTCC: n = 99, 60%; EABO: n = 64, 40%). While both techniques demonstrated equivalent safety profiles (overall mortality: 0%), EABO was associated with higher conversion to full sternotomy [(n = 7, 10.9%) vs. TTCC (n = 1, 1.3%), p = 0.016]. In a generalized estimation equations (GEE) model, no patient-level covariate predicted conversion, suggesting technical or procedural factors as the primary contributors. In addition, EABO was associated with longer cross-clamp time [median: 87 min (IQR: 73, 100) vs. TTCC median: 77 min (IQR: 65.5, 87.5), p = 0.03]. Stroke, acute kidney injury, respiratory failure, reoperation and wound infection did not differ significantly; also, hospital stay was similar between groups. Conclusions: In this single-center series, EABO showed longer operative times and a higher conversion rate to sternotomy, but without excess mortality or major complications. This may be correlated with the initial learning phase and redo cases; further comparison is needed to assess the benefits of EABO. Full article

Intracardiac echocardiography (ICE) is increasingly recognized as a valuable imaging modality in structural heart interventions, offering high-resolution, real-time visualization from within the cardiac chambers. Originally developed for electrophysiologic procedures, ICE has expanded its use across a broad spectrum of structural interventions, including atrial septal defect (ASD) and patent foramen ovale (PFO) closure, left atrial appendage occlusion (LAAO), transseptal puncture guidance, transcatheter edge-to-edge repair (TEER), balloon mitral valvuloplasty, and both mitral and tricuspid valve therapies. This review outlines the current role and technical principles of ICE, with an emphasis on catheter design, image acquisition protocols, and the emerging potential of 3D ICE. Comparisons with transesophageal echocardiography (TEE) and fluoroscopy are discussed, highlighting ICE’s ability to support minimally invasive, sedation-sparing procedures while maintaining procedural precision. We provide a focused analysis of ICE-guided applications in specific clinical scenarios, emphasizing its role in anatomical assessment, device navigation, and intra-procedural monitoring. Data from recent clinical studies and registries are reviewed to assess safety, feasibility, and outcomes. Practical considerations including operator learning curve, workflow integration, and limitations such as cost and field of view are also addressed. Lastly, we explore future directions including advanced 3D imaging, fusion imaging, artificial intelligence integration, and robotic catheter systems. Full article

Background: The advantage of employing multidisciplinary heart teams (MDHT) for the selection process of minimally invasive (MIS) mitral valve repair (MVr) and mitral valve replacement (MVR) has been previously substantiated. Here, we outline the contributions each member of the MDHT at our institution made during the intra-operative and peri-operative periods and describe their impacts on short-term outcomes. Patients and Methods: This is a single-center retrospective review of all 278 adult patients who underwent MIS MVR or MVr by a single surgeon at our institution between 2006 and 2023. The repair’s efficacy was assessed intraoperatively and at 1 year post-operation. The surgical technique involved a mini-thoracotomy and valve repair or replacement. Outcomes included post-operative mortality, complications, operative time, repair success rate, hospital length of stay (LOS), and post-operative ejection fraction. There was no control group, as all patients undergoing MIS MVR/MVr were treated within an MDHT model. Results: Delivery of regional anesthesia via paravertebral catheter (PVC) was associated with a statistically significant shorter hospital LOS (6.52 vs. 7.81 days, p = 0.028). Enhanced Recovery After Surgery (ERAS) implementation by nurses was associated with a potentially clinically important, although not statistically significant, reduction in LOS (6.7 vs. 10.1 days, p = 0.168). Introduction of the COR-KNOT^® DEVICE for securing annuloplasty sutures was associated with a statistically significant reduction in operative time (288 vs. 326 min, p < 0.001). Percutaneous cannulation, proctored by interventional cardiology in 2019, was associated with a decrease in lymphocele rate from 6.2% before 2019 to 0% after 2019. Conclusions: Initiatives implemented by our MDHT were associated with reduced post-operative LOS, shorter operative times, and lower incidence of post-operative complications. Full article

Minimally Invasive Cardiac Surgery (MICS) was developed in the late 1990s and has taken giant strides over the last 30 years. Nowadays, it is an important part of the cardiac surgery practice, accounting for one-third of total heart surgeries globally, with remarkable results. It is mostly performed for Mitral Valve repair but also for Aortic Valve Replacement and coronary artery bypass. However, the chronological evolution that led MICS to its current status has never been properly described. The best format to share a historical journey is the state-of-the-art (SotA) review. To the best of our knowledge, there are no orthodox SotA reviews on MICS. The aim of our study is to describe the current key MICS techniques, their historical development, and to discuss their role in the future of our specialty. Full article

Over the past three decades, cardiac surgery has undergone a deep transformation, shifting from full median sternotomy to minimally invasive (MICS) and micro-invasive techniques. These approaches aim to achieve equivalent therapeutic outcomes while reducing surgical trauma, postoperative pain, hospitalization time, and healthcare costs. Minimally invasive strategies are now widely applied to aortic and mitral valve surgery, coronary artery bypass grafting, atrial fibrillation ablation, and combined procedures. Key advancements such as sutureless prostheses, video- and robotic-assisted systems, and enhanced imaging technologies have improved surgical precision and clinical outcomes while promoting faster recovery and superior cosmetic results. Evidence from randomized trials and observational studies demonstrates that MICS provides mortality and morbidity rates comparable to conventional surgery, with additional benefits in high-risk, elderly, and frail patients. Micro-invasive transcatheter interventions, particularly transcatheter aortic valve implantation (TAVI) and transcatheter mitral repair or replacement, have further expanded therapeutic options for patients unsuitable for open-heart surgery. Their success has fostered debate not between conventional and minimally invasive surgery, but between minimally invasive and micro-invasive approaches. Hybrid procedures—combining surgical and percutaneous techniques—exemplify a multidisciplinary evolution aimed at tailoring treatment to patient-specific anatomy, comorbidities, and risk profiles. Despite clear advantages, these techniques present challenges, including a steep learning curve, increased procedural costs, and the requirement for specialized equipment and institutional expertise. Optimal patient selection based on clinical risk assessment and advanced imaging remains essential. Future directions include refinement of robotic platforms, artificial intelligence-based decision support, miniaturization of instruments, and broader validation of emerging technologies in younger and low-risk populations. Minimally and micro-invasive cardiac surgery represent a paradigm shift toward patient-centered care, offering reduced physiological burden, improved functional recovery, and long-term outcomes comparable to conventional techniques. As innovation continues, these approaches are poised to become integral to modern cardiac surgical practice. Full article

Background: The minimally invasive approach is increasingly recognized as the standard for surgical management of mitral valve disease. Advances in endoscopic visualization and surgical instrumentation have enhanced precision while minimizing trauma, improving both functional and esthetic outcomes. This study presents a single-center experience with total endoscopic mitral valve repair (MVR) performed using two- or three-dimensional video-assisted technology. Methods: Between October 2022 and September 2025, 239 patients underwent total endoscopic MVR at our institution. Demographic, operative, and postoperative data were collected and analyzed. Results: Median age was 63 years, with 64.4% male. Median logistic EuroSCORE and EuroSCORE II were 2.53 and 0.83, respectively. Most patients were NYHA class II (54.4%), and 47.7% had pulmonary hypertension. Mitral annuloplasty was performed in 99.2% of cases; 78.6% received Gore-Tex chordae, 6.3% underwent posterior leaflet resection, and 11.7% edge-to-edge repair. Conversion to sternotomy occurred in 0.4%. In-hospital mortality was 1.3%; stroke occurred in 0.4%. Postoperative atrial fibrillation developed in 26.8%, while major complications such as sepsis (2.1%) and renal failure requiring dialysis (1.3%) were infrequent. Median ventilation time was 5 h, ICU stay was 2 days, and hospital stay was 7 days. Pre-discharge echocardiography showed ≤mild regurgitation in 99.2%. Conclusions: Total endoscopic MVR using two- or three-dimensional video assistance is safe, feasible, and yields excellent clinical, functional, and cosmetic results, with low morbidity and rapid recovery. Full article