Minimally invasive mitral valve repair

### Learning objectives Modified cardiopulmonary bypass techniques, including vacuum-assisted venous drainage, were introduced in 1995 and enabled safe and effective minimally invasive mitral valve (MV) surgery. Approaches have evolved since the first successful right parasternal, trans-sternal and right mini-thoracotomy heart valve surgeries.1–3 However, difficulties performing complex MV repair using two-dimensional vision and long-shafted instruments limited adoption. Development of the da Vinci Surgical System (Intuitive Surgical, Sunnyvale, California) addressed this limitation and allowed surgeons to perform complex reconstructive operations using three-dimensional (3D) visualisation. Falk and colleagues reported on the first robotic system for valvular heart surgery.4 Soon thereafter, Carpentier and colleagues performed the first successful robotic MV repair using the da Vinci Surgical System (Intuitive Surgical).5 In 2000, Chitwood and colleagues carried out the first robotically assisted MV repair in the USA as part of the initial Food and Drug Administration clinical trial.6 The most important benefits of robotic MV surgery include enhanced surgical dexterity with precise movements of instruments in the closed chest, excellent visualisation of the subvalvular apparatus and quicker patient return to normal activity with superior cosmetic results compared with sternotomy approaches. In this review, we delineate different aspects of mini-thoracotomy and robotic approaches to MV repair. Over the past decade, there has been a growing body of data highlighting the deleterious consequences of uncorrected severe degenerative mitral regurgitation (MR). Evidence supporting early MV repair in patients with severe asymptomatic MR and preserved cardiac structure and function includes (1) reduced severity of degenerative MR with MV repair; (2) excess long-term mortality and risk of heart failure in patients with severe uncorrected MR …