Transaxillary minimally invasive mitral valve surgery: early and mid-term outcomes in 763 patients

Background: The transaxillary (TAxA) approach has been developed as a simplified direct-vision minimally invasive access for heart valve surgery. We report a large single-center cohort of patients undergoing TAxA minimally invasive mitral valve surgery and evaluate early safety, procedural efficacy, recovery and mid-term outcomes. Methods: Consecutive patients who underwent TAxA mitral valve surgery at the University Hospital of Marche, Ancona, Italy, between January 2017 and April 2026 were included. Mitral repair or replacement procedures were considered with or without concomitant tricuspid valve repair, atrial fibrillation ablation or left atrial appendage occlusion. Early outcomes were analyzed in the overall cohort. Mid-term survival and reoperation were assessed in patients undergoing repair for degenerative mitral regurgitation. Results: The study included 763 patients. Mitral valve repair was performed in 640 patients and replacement in 123. The repair rate was 89% in patients with mitral regurgitation and 92% in patients with degenerative mitral regurgitation. Concomitant tricuspid repair, atrial fibrillation ablation and left atrial appendage occlusion were performed in 17%, 5% and 10% of patients, respectively. Mean cardiopulmonary bypass and cross-clamp times were 103 and 63 minutes. Thirty-day mortality was 0.4%, stroke or transient ischemic attack occurred in 0.7%, and conversion to sternotomy was required in 0.7%; no conversion was due to poor exposure. Median ventilation time was 2 [interquartile range (IQR), 0-6] hours, 54% of patients were extubated in theatre and 80% were extubated within 6 hours. Median intensive care unit and hospital stays were 24 (IQR, 22-48) hours and 7 (IQR, 6-9) days. In the degenerative repair cohort, Kaplan-Meier survival was 97.0% at 5 years, and cumulative incidence of reoperation was 4.3% at 5 years. Conclusions: In this large contemporary experience, TAxA minimally invasive mitral valve surgery was associated with low early mortality and morbidity, reasonable operative times, frequent ultra fast-track extubation, and satisfactory mid-term results.