Tricuspid valve repair with echocardiographic guiding.

BACKGROUND: In this study we discuss the conditions of four patients with severe tricuspid valve (TV) regurgitation, in which a differentiated intraoperative transesophageal echocardiographic (TEE) analysis - as performed in TV-clipping procedures - provided major guidance for refined TV repair. METHODS: Between January 2019 and March 2020, four patients with central tricuspid regurgitation and an intercommisural jet underwent annuloplasty with an echo-guided plication stitch on the affected leaflet basis, especially anteroseptal. RESULTS: All patients underwent complex multiple valve (aortic- and/or mitral valve) surgery with concomitant TV-repair. No or mild TV regurgitation after TV repair was confirmed in the predischarge echocardiography in all patients. CONCLUSIONS: We conclude, that differentiated intraoperative TEE is essential for the surgical TV repair strategy. Plication of the anteroseptal commissure additionally performed to TV annuloplasty, is an easy and effective add-on in selected patients.

Is the pulmonary pressure directly correlated with the operative risk in patients with isolated tricuspid valve surgery?

BACKGROUND: Severe pulmonary hypertension is a relative contraindication for isolated tricuspid valve (TV) surgery. However, some patients may still benefit from TV surgery. We hypothesized that pulmonary pressure alone is an inadequate predictor of outcomes post-TV surgery, and that aorto-pulmonary pressure quotient (AoP/PAP) is a better predictor. METHODS: From 2005 to 2019, a total of 122 patients (mean age: 68.5±10.5 years; 43.3% male) with isolated TV regurgitation and preoperative right heart catheterization referred to our institution for isolated TV surgery were included. Patients with concomitant procedures were excluded from this analysis. All data were retrospectively analyzed. Follow-up was 97% complete. RESULTS: The mean follow-up time was 4.3±3.6 years. The mean preoperative New York Heart Association (NYHA) class was 2.9±0.7, left ventricular ejection fraction was 52.3±11.3%, creatinine level was 124.8±102.6µmol/l, mean pulmonary artery pressure was 25.5±9.4mmHg, mean MELD-XI score 13.5±4.2, and mean AoP/PAP was 4.1±1.9 mmHg. Thirty-day mortality was 10.9%, and 5-years survival was 56.6±4.9%. Cox regression analysis revealed age (P=0.001; HR: 1.058; CI 95%: 1.023-1.094), the mean arterial pressure (P=0.002; HR: 0.969; CI 95%: 0.950-0.988) and systolic pulmonary artery pressure (P=0.035; HR: 1.054; CI 95%: 1.004-1.107), as well as mean AoP/PAP>4 (P=0.001; HR: 6.678; CI 95%: 2.197-20.294) as predictors for long-term mortality. CONCLUSIONS: Regardless of the degree of pulmonary hypertension, a mean AoP/PaP quotient ≤4 impacts the postoperative survival of patients undergoing isolated TV surgery. However, further research is still required to verify this finding.

Mid-term results after isolated tricuspid valve surgery in the presence of right ventricular leads.

BACKGROUND: Patients with tricuspid valve (TV) disease and indication for TV surgery frequently have permanent pacemaker (PM) or defibrillator (AICD) leads, placed in the right ventricle (RV). The aim of this study was to analyze postoperative results and mid-term outcomes after isolated TV surgery (with no further concomitant cardiac procedures) in the presence of permanent RV leads. METHODS: From January 2005 to January 2019 a total of 80 patients (mean age: 67.7±10.3 yrs; 56.3% male) with isolated TV disease and presence of at least one permanent RV lead in place were referred to our institution for isolated TV repair/replacement; patients with concomitant procedures were excluded for this analysis. All data were retrospectively analyzed. The follow-up was 98% complete. RESULTS: Mean follow-up time was 4.3±3.9 years. Mean preoperative clinical NYHA status was 3.0±0.8, left ventricular ejection fraction 50.7±12.9%, mean pulmonary artery pressure 23.8±9.3mmHg, creatinine 125.7±57.5µmol/L, mean MELD-XI Score (Model of End-stage-Liver Disease excluding INR) was 14.6±5.0 µmol/L. Thirty-day mortality was 6.3% with a 5-years survival of 58.2±6.0%. Cox regression analysis revealed the MELD-XI-Score as the only highly significant predictor for postoperative mortality (P=0.002). CONCLUSIONS: Hepatorenal dysfunction - possibly indicating long lasting TV failure - could be a factor for limited postoperative survival in our patient cohort. This finding could underline our hypothesis, that early TV surgery may achieve better postoperative survival, even in patients with TV disease caused by RV leads. Therefore, further investigations are needed.

Postoperative outcome after reoperative isolated tricuspid valve surgery-is there a predictor for survival?

OBJECTIVES: Reoperative tricuspid valve (TV) surgery is considered high risk even in the absence of additional concomitant cardiac procedures. The purpose of this study was to evaluate preoperative clinical parameters as predictors for survival after isolated reoperative TV surgery. METHODS: From January 2005 to January 2019, 85 patients (mean age: 66.7 ± 10.3 years, 34 male) with severe isolated TV regurgitation and prior cardiac surgery were referred to our centre for elective or urgent TV repair/replacement; patients with endocarditis were excluded. We retrospectively analysed preoperative hepatorenal function [reflected by widely used clinical and laboratory parameters and the Model of End-stage-Liver Disease excluding International Normalized Ratio (MELD-XI) score] as a predictor for postoperative survival. RESULTS: At hospital admission, the patients' average preoperative New York Heart Association class was 2.9 ± 0.6, left ventricular ejection fraction 52.5 ± 10.6%, mean pulmonary artery pressure 24.7 ± 8.0 mmHg, creatinine 115.4 ± 66.6 µmol/l, bilirubin 20.0 ± 19.6 µmol/l and the mean MELD-XI score was 13.3 ± 4.0 µmol/l. The mean follow-up was 5.4 ± 4.2 years. Thirty-day mortality was 5%, 5-year survival was 60.6 ± 5.4% and 10-year survival was 42.9 ± 6.5%. The multivariable Cox regression analysis evaluated the MELD-XI score [hazard ratio (HR 1.144, confidence interval 95% 1.0-1.3, P = 0.005] and diabetes mellitus (HR 2.27, confidence interval 95% 1.0-5.0, P = 0.04) as significant predictors for excess mortality while age and mean pulmonary artery pressure did not reliably predict clinical outcome. CONCLUSIONS: Hepatorenal dysfunction was one main factor accounting for limited postoperative survival in our patient cohort. The MELD-XI score is easy to calculate and seems to reliably predict the perioperative risk in patients with prior cardiac surgery and indication for TV surgery.

Loop neochord versus leaflet resection techniques for minimally invasive mitral valve repair: long-term results.

OBJECTIVES: Non-leaflet resection techniques including loop chordal replacement are being used with increasing frequency, but the long-term results of these techniques are still unknown. The aim of this study was to compare the long-term results of loop neochord replacement with leaflet resection techniques in patients undergoing minimally invasive mitral valve (MV) repair for MV prolapse. METHODS: Between 1999 and 2014, 2134 consecutive MV prolapse patients underwent minimally invasive MV repair with isolated loop (n = 1751; 82.1%) or resection techniques (n = 383, 17.9%) at our institution. Follow-up data were available for 86% of patients with a mean follow-up time of 6.1 ± 4.3 years. RESULTS: The 30-day mortality was 0.8% for all patients (loop: 0.7%, resection: 1.6%; P = 0.09). Leaflet resection was associated with more moderate or more mitral regurgitation on predischarge echocardiography (P = 0.003). The 1-, 5- and 10-year survival rates were 98 ± 1%, 95 ± 1% and 86 ± 2% for the loop technique versus 97 ± 1%, 92 ± 1% and 81 ± 2% for resection patients, respectively (P = 0.003). Significant predictors for late mortality were MV repair technique (P = 0.004), left ventricular ejection fraction (P < 0.001), age (P < 0.001) and myocardial infarction (P < 0.001). Freedom from MV reoperation at 1, 5 and 10 years was 98 ± 1%, 97 ± 1%, 97 ± 1% and 97 ± 1%, 97 ± 1%, 96 ± 1% for patients operated on with the loop technique and leaflet resection (P = 0.4). CONCLUSIONS: In our patient cohort, MV repair with loop chordal replacement is associated with less early recurrent mitral regurgitation and very good long-term results when compared to classical leaflet resection techniques for MV prolapse and is therefore an excellent option for such patients.

Performance of pacemaker leads in alternative lead positions after tricuspid valve replacement.

BACKGROUND: Bradycardic arrhythmias requiring pacemaker (PM) implantation are still common in patients in need of tricuspid valve replacement (TVR). Leaving an existing PM lead in an extravalvular position may represent a helpful alternative in special situations like the implantation of a mechanical TV. This study aimed to examine the short- to mid-term outcome of paravalvular leads concerning lead survival and prosthesis dysfunction in patients after TVR. METHODS: A retrospective case-control study of patients with TVR and ventricular pacing was conducted. Patients from the database of the Leipzig Heart Center were included. Data of the paravalvular lead group (PVG) and coronary sinus lead group (CSG) were compared to a control group with conventional transvalvular leads (TVG). RESULTS: Eighty patients with TVR and cardiac PM (TVG [n = 13], PVG [n = 40], and CSG [n = 27]) were included. The mean follow-up was 2.8 years. The rate of lead revisions (TVG 15.4%, PVG 2.5%, and CSG 7.5%) was lower in PVG but without significance (P = .286). The CSG demonstrated significantly higher pacing thresholds (1.4 V/0.8 ms) than TVG (0.5 V/0.4 ms), P = .004. However, the deterioration of threshold amplitudes during follow-up was similar in CSG (7.4%) and PVG (7.5%) compared with controls (7.7%). Function of TV prosthesis regarding development of stenosis or regurgitation showed a similarity between the groups (regurgitation PVG P = .692, CSG P = 1; stenosis PVG P = .586, CSG P = 0.69). CONCLUSION: Paravalvular positioning of PM leads seems to represent a reasonable alternative to the conventional transvalvular lead positioning concerning the lead and Tricuspid Valve prosthesis's function and durability in selected patients.

Concomitant Tricuspid Valve Repair during Minimally Invasive Mitral Valve Repair.

BACKGROUND: Concomitant use of tricuspid valve (TV) surgery and minimally invasive mitral valve (MV) repair is debatable due to a prolonged time of surgery with presumably elevated operative risk. Herein, we examined cardiopulmonary bypass times and 30-day mortality in patients who underwent MV repair with and without concomitant TV surgery. METHODS: We retrospectively evaluated 3,962 patients with MV regurgitation who underwent minimally invasive MV repair without (n = 3,463; MVr group) and with (n = 499; MVr + TVr group) concomitant TV surgery between 1999 and 2014. Preoperative parameters between the groups were significantly different; therefore, propensity score matching was performed. RESULTS: Mean cardiopulmonary bypass time for all patients was 125.5 ± 55.8 minutes in MVr and 162.0 ± 58.0 minutes in MVr + TVr (p < 0.001). Overall 30-day mortality was significantly different between these groups (4.8 vs. 2.1%; p < 0.001); however, after adjustment, there was no significant difference (3.3 vs. 1.2%; p = 0.07). Backward logistic regression revealed that cardiopulmonary bypass time was not a significant predictor for early mortality within the MVr + TVr cohort. CONCLUSION: Concomitant TV repair using prosthetic rings through a minimally invasive approach is safe and does not lead to elevated early mortality in our patient cohort. Therefore, prolonged cardiopulmonary bypass time should not be the sole reason to rule out MV repair with concomitant TV repair and to prefer the use of suture techniques, which saves only a few minutes compared with prosthetic ring implantation.

Annuloplasty ring dehiscence after mitral valve repair: incidence, localization and reoperation.

OBJECTIVES: Mitral valve (MV) annuloplasty ring dehiscence with subsequent recurrent mitral regurgitation represents an unusual but challenging clinical problem. Incidence, localization and outcomes for this complication have not been well defined. METHODS: From 1996 to 2016, a total of 3478 patients underwent isolated MV repair with ring annuloplasty at the Leipzig Heart Centre. Of these patients, 57 (1.6%) underwent reoperation due to annuloplasty ring dehiscence. Echocardiographic data, operative and early postoperative characteristics as well as short- and long-term survival rates after MV reoperation were analysed. RESULTS: Occurrences of ring dehiscence were acute (<30 days), early (≤1 year) and late (>1 year) in 44%, 33% and 23% of patients, respectively. Localization of annuloplasty ring dehiscence was found most frequently in the P3 segment (68%), followed by the P2 (51%) and the P1 segments (47%). The 30-day mortality rate and 1- and 5-year survival rates after MV reoperation were 2%, 89% and 74%, respectively. During reoperation, MV replacement was performed in 38 (67%) and MV re-repair in 19 (33%) patients. CONCLUSIONS: Annuloplasty ring dehiscence is clinically less common, localized more frequently on the posterior annulus and occurs mostly acutely or early after MV repair. MV reoperation can be performed safely in such patients.

Isolated Mitral Valve Repair in Patients with Reduced Left Ventricular Ejection Fraction.

PURPOSE: This study aims to analyze the clinical outcomes after isolated mitral valve (MV) repair in patients with reduced left ventricular ejection fraction (LVEF <50%) with focus on perioperative characteristics, survival, and freedom from reoperations. METHODS: Between 1997 and 2015, 557 patients with reduced LVEF (age: 62.8 ± 11.7 years, male: 320) underwent MV repair for symptomatic mitral regurgitation (MR). Etiologies were dilated non-ischemic cardiomyopathy and ischemic cardiomyopathy in 487 (87.4%) and 70 (12.6%) patients, respectively; these were classified into three different subgroups: LVEF 40%-49% (group 1), 30%-39% (group 2), and <30% (group 3). RESULTS: Overall, 294, 145, and 118 patients had an LVEF of 40%-49%, 30%-39%, and <30%, respectively. Logistic EuroSCORE was significantly higher (P <0.001) as the LVEF worsened. The survival analysis for groups 1-3, respectively, revealed the following: 30-day mortality: 1.4%, 3.4%, and 7.6% (P <0.001); 1-year survival: 93.9%, 89.4%, and 82% (P <0.001); 5-year survival: 81.2%, 75.2%, and 58% (P <0.001). CONCLUSION: MV repair in patients with impaired LVEF could be performed safely with good clinical short- and mid-term outcome. Nevertheless, reduced preoperative LVEF correlates with worse perioperative and long-term survival.

Minimally Invasive Mitral Valve Surgery for Mitral Valve Infective Endocarditis.

BACKGROUND: The feasibility of minimally invasive mitral valve (MV) surgery in infective endocarditis (IE) has not been reported in detail. We assessed the safety, efficacy, and durability of the minimally invasive approach through a right anterolateral minithoracotomy for surgical treatment of MV IE. METHODS: A review of the Leipzig Heart Center database revealed 92 eligible patients operated on between 2002 and 2013. All patients had undergone minimally invasive surgery for IE. The indication for surgery was isolated IE of the MV in all patients. Baseline and intraoperative data, as well as clinical outcomes and short-term follow-up were analyzed retrospectively. RESULTS: The patients' mean age was 60.9 ± 15.3 years, the logistic EuroSCORE II was 19.6 ± 19.1%, and 64.1% (59) were male. MV repair was feasible in 23.9% (22/92) of patients. Repair techniques included annuloplasty ring implantation, anterior mitral leaflet resection, posterior mitral leaflet resection, and implantation of neochordae. MV replacement was performed in 69 patients (75%), a mitral annulus patch in 1 patient, and concomitant tricuspid valve surgery for tricuspid regurgitation in 5 patients. Bacteriological analysis showed staphylococcus infection in 45.5%, streptococcus in 36.4%, enterococcus in 13.6%, and others in 4.5%. The 30-day-mortality rate was 9.8% (9 patients). The 1-year follow-up showed a 1-year survival rate of 77.7 ± 4.4% and freedom from reoperation within 1 year due to reendocarditis of 93.3 ± 2.1%. CONCLUSIONS: The minimally invasive approach is suitable for the treatment of IE of the MV. It is a good technique in IE in selected patients.

Mitral valve repair: Robotic and other minimally invasive approaches.

Robotic and minimally invasive mitral valve (MV) procedures have been performed with increasing frequency over time. These alternatives offer similar efficacy to that achieved via standard median sternotomy, particularly in large volume centers, along with low perioperative morbidity and mortality rates. Moreover, patient acceptance is oftentimes increased due to less postoperative pain and shorter recovery times, as well as superior cosmetic results. However, these techniques are technically complex and associated with a significant learning curve. The following review offers an overview of the most relevant aspects related to minimally invasive and robotic MV repair. Although these techniques are well established in referral centers, future innovations should concentrate on decreasing complexity and improving reproducibility of these procedures.

Tricuspid Valve Repair after Previous Mitral Valve Surgery.

Tricuspid valve (TV) regurgitation in patients after previous mitral valve surgery is usually a secondary failure and conditioned by a long-lasting left-sided valve failure. TV surgery in these patients represents a high-risk procedure regarding the operative strategy and perioperative management. This article will discuss the indication for TV surgery in patients with secondary TV regurgitation and previous mitral valve surgery, the choice of surgical access, as well as TV repair techniques and their postoperative results.

Tricuspid Valve Surgery in Patients with Isolated Tricuspid Valve Endocarditis: Analysis of Perioperative Parameters and Long-Term Outcomes.

Background The aim of this study was to evaluate the perioperative characteristics and the short- and mid-term outcomes in patients undergoing tricuspid valve (TV) surgery for isolated TV endocarditis. Patients and Methods A total of 56 patients with isolated TV endocarditis underwent TV surgery at a single center between June 1995 and February 2012. Mean age of patients was 53.8 ± 17.1 years, 39 (69.6%) being male. The mean left ventricular ejection fraction was 60.4 ± 13.6% and 13 (23.2%) patients had diabetes mellitus. Average logistic EuroSCORE was 19.4 ± 17.0%. Mean follow-up was 4.7 ± 3.8 years. Results Microbiological investigations revealed positive blood cultures in 89.1% of patients and positive intraoperative swabs in 51.9%. The most common pathogen (42.9%) isolated was Staphylococcus aureus, followed by coagulase-negative staphylococcus (17.9%). Discussion A history of intravenous drug abuse (IVDA) was recorded in 11 patients (19.6%), of which 8 patients additionally had hepatitis C. A total of 15 patients (26.8%) had a permanent pacemaker/implantable cardioverter-defibrillator in situ. TV replacement was performed in 22 patients (39.3%) and TV repair was performed in 34 patients (60.7%). Overall 30-day mortality was 12.5%. Five-year survival was 63.9 ± 7.2% (95% confidence interval [CI]: 64.0-137.5 months). Freedom from reoperation for recurrent TV endocarditis was 91.7 ± 4.0% (95% CI: 152.3-179.3 months) at 5 years. Conclusion Blood culture is the most important tool to detect the causative pathogen causing IE of TV. The high risk of hepatitis C in patients with IVDA and IE of the TV should be mentioned.

Surgery for infective endocarditis complicated by cerebral embolism: a consecutive series of 375 patients.

OBJECTIVE: To determine the influence of silent and symptomatic cerebral embolism on outcome of urgent/emergent surgery after acute infective endocarditis (AIE). METHODS: From a total of 1571 patients with AIE admitted to our institution between May 1995 and March 2012 about one-quarter (375 patients; mean age, 61.8 ± 13.6 years) presented with cerebral embolism confirmed by cranial computed tomography. Isolated aortic valve endocarditis was present in 165 patients (44%), 132 patients (36%) had isolated AIE of the mitral valve, and 64 (17%) patients had left-sided double valve endocarditis. RESULTS: Although the majority of patients presented with neurologic symptoms, 1 out of 3 patients experienced a so-called silent asymptomatic cerebral embolism or transient ischemic attack (n = 135). The rate of silent embolism was equivalent in patients with isolated aortic valve versus isolated mitral valve endocarditis (37% vs 34%; P = .54). Comparing patients with silent embolism versus symptomatic embolism, 18 patients with silent embolism versus 12 patients with symptomatic embolism developed postoperative hemiparesis (P = .69). Three versus 4 had severe postoperative intracerebral bleeding (P = .71). Median follow-up of survivors with cerebral embolism was 4.1 years (935 cumulative patient-years). Hospital mortality was 21.4% versus 19.6% (P = .68), with a long-term survival of 45% ± 5% versus 47% ± 4% at 5 years (P = .83) and 40% ± 6% versus 32% ± 5% at 10 years (P = .86). Independent risk factors of mortality were age at surgery (P < .01), chronic obstructive pulmonary disease (P = .01), preoperative requirement of catecholamines (P = .02), dialysis (P < .01), and duration of cardiopulmonary bypass (P < .01). CONCLUSIONS: Survival after surgery for AIE is significantly impaired once cerebral embolism has occurred; however, it does not differ in patients with symptomatic versus silent cerebral embolism. Routine computed tomography scans are therefore mandatory due to the high incidence of asymptomatic cerebrovascular embolism--which appears to be equally as dangerous as symptomatic embolism.

Applying the Gender Lens to Risk Factors and Outcome after Adult Cardiac Surgery.

BACKGROUND: Applying the gender lens to risk factors and outcome after adult cardiac surgery is of major clinical interest, as the inclusion of sex and gender in research design and analysis may guarantee more comprehensive cardiovascular science and may consecutively result in a more effective surgical treatment as well as cost savings in cardiac surgery. METHODS: We have reviewed classical cardiovascular risk factors (diabetes, arterial hypertension, hyperlipidemia, smoking) according to a gender-based approach. Furthermore, we have examined comorbidities such as depression, renal insufficiency, and hormonal influences in regard to gender. Gender-sensitive economic aspects have been evaluated, surgical outcome has been analyzed, and cardiovascular research has been considered from a gender perspective. RESULTS: The influence of typical risk factors and outcome after cardiac surgery has been evaluated from a gender perspective, and the gender-specific distribution of these risk factors is reported on. The named comorbidities are listed. Economic aspects demonstrated a gender gap. Outcome after coronary and valvular surgeries as well as after heart transplantation are displayed in this regard. Results after postoperative use of intra-aortic balloon pump are shown. Gender-related aspects of clinical and biomedical cardiosurgical research are reported. CONCLUSIONS: Female gender has become an independent risk factor of survival after the majority of cardiosurgical procedures. Severely impaired left ventricular ejection fraction independently predicts survival in men, whereas age does in females.

Double valve replacement and reconstruction of the intervalvular fibrous body in patients with active infective endocarditis.

OBJECTIVES: Destruction of the intervalvular fibrous body, though uncommon, occurs due to paravalvular abscess formation following active infective endocarditis. This warrants a highly complex operation involving radical surgical debridement of the intervalvular fibrous body, followed by double valve (aortic and mitral) replacement with patch reconstruction of the anterior mitral annulus, the left ventricular outflow tract and the left atrial roof. The objective of this study was to review the early and mid-term outcomes in patients undergoing this operation. METHODS: A total of 25 patients underwent double valve replacement with reconstruction of the intervalvular fibrous body for extensive infective endocarditis between January 1999 and March 2012. The mean age was 64.3 ± 10.5 years. Most of the patients (60%) were in New York Heart Association Class III-IV, 12% and in cardiogenic shock. Associated comorbidities like acute renal insufficiency and cerebrovascular accidents were observed in 40 and 20% of patients, respectively. Twenty patients had previous heart valve surgeries. The logistic EuroSCORE predicted risk of mortality was 55.1 ± 22.9%. RESULTS: Overall, 30-day mortality was 32%. Postoperative complications like low cardiac output, stroke and acute renal failure developed in 16, 28 and 56%, respectively. Thirty-two percent of patients required re-exploration for bleeding. Nine patients were alive at a mean follow-up of 406 days (0-8 years). The 2- and 5-year survivals were 37.0 ± 11.1 and 24.6 ± 12.5%, respectively. CONCLUSIONS: Double valve replacement with reconstruction of the intervalvular fibrous body for infective endocarditis is a complex, technically challenging operation associated with high perioperative morbidity and mortality. Nevertheless, being the only option available for such complex disease, it should be performed in these patients who, otherwise, face 100% mortality.

Minimally invasive mitral valve surgery: "The Leipzig experience".

BACKGROUND: Minimally invasive mitral valve surgery has become a routine procedure at our institution. The present study analyzed the early and long-term outcomes of patients undergoing minimally invasive mitral valve surgery over the last decade, with special focus on mitral valve repairs (MVRp). METHODS: The preoperative variables, intraoperative data and postoperative outcomes of patients undergoing minimally invasive mitral valve surgery were prospectively collected in our database from May 1999 to December 2010. The survival and freedom from reoperation were evaluated with life tables and Kaplan-Meier analyses. RESULTS: A total of 3,438 patients underwent minimally invasive mitral valve surgery, of which 2,829 were MVRps and 609 were mitral valve replacements (MVR). Forty-five patients (1.6%) required MVR due to failure of repair. The mean age was 60.3±13 years. More than a third of patients underwent concomitant procedures like tricuspid valve surgery, atrial septal defect (ASD) closure and cryoablation. The rate of conversion to sternotomy was less than 1.4%. The 30-day mortality was 0.8%. The 5- and 10-year survival of all patients (MVR and MVRp) undergoing minimally invasive mitral valve surgery was 85.7±0.6% and 71.5±1.2%, respectively. For MVRp, the survival was 87.0±0.7% and 74.2±1.4% at 5 and 10 years, respectively. Freedom from reoperation was 96.6±0.4% and 92.9±0.9% at 5 and 10 years, respectively. CONCLUSIONS: Minimally invasive MVRp can be performed safely and effectively with very few perioperative complications. The early and long-term outcomes in these patients are acceptable.