Comparative outcomes of totally endoscopic versus direct vision mini-thoracotomy mitral valve repair: A propensity score-matched retrospective analysis.

BACKGROUND: Totally endoscopic mitral valve repair has emerged as an alternative minimally invasive approach to direct vision mini-thoracotomy (DVMT) repair, using 3-dimensional thoracoscopic guidance and a smaller working incision without rib spreading. Whether these technical differences translate into improved outcomes remains uncertain. METHODS: A propensity score-matched, retrospective analysis was conducted on 114 patients undergoing elective mitral valve repair for degenerative mitral regurgitation (MR) via totally endoscopic or DVMT approaches at 2 UK tertiary centers between 2015 and 2024. Patients were matched 1:1 on key preoperative variables. The primary outcome was clinically significant recurrent MR on follow-up echocardiography. Secondary outcomes assessed operative parameters and recovery metrics. Multivariate regression identified predictors of relevant outcomes. RESULTS: Totally endoscopic repair was associated with lower odds of developing clinically significant recurrent MR (odds ratio, 0.05; 95% confidence interval, 0-0.32; P = .0094) compared with DVMT. Intraoperative metrics were broadly comparable in the 2 groups, with the totally endoscopic procedure associated with marginal, nonsignificant increases in cardiopulmonary bypass and cross-clamp times. Immediate postrepair transesophageal echocardiography demonstrated no greater than mild residual MR in either cohort. Procedural safety was similar in the 2 groups, with no 30-day mortality and low complication rates. Trends toward shorter intensive care and postoperative hospital stays were seen in totally endoscopic patients, although these were not statistically significant. CONCLUSIONS: The totally endoscopic approach achieved more durable repairs, with comparable perioperative safety to DVMT. The observed improvement in early repair durability remains hypothesis-generating and warrants further evaluation in larger studies with standardized long-term follow-up.