Transition from Direct-View to Totally Endoscopic Mitral Valve Surgery in an Experienced Minimally Invasive Center: A Propensity-Matched Analysis

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.