Deactivation of LVAD Support for Myocardial Recovery - Surgical Perspectives.

Left ventricular assist devices (LVAD) are excellent therapies for advanced heart failure patients either bridged to transplant or for lifetime use. LVADs also allow for reverse remodeling of the failing heart that is often associated with functional improvement. Indeed, growing enthusiasm exists to better understand this population of patients whereby the LVAD is used as an adjunct to mediate myocardial recovery. When patients achieve benchmarks suggesting that they no longer need LVAD support, questions related to discontinuation of LVAD therapy become front and center. The purpose of this review is to provide a surgical perspective to the practical and technical issues surrounding LVAD deactivation.

Predictive Value of Serial Model of End-Stage Liver Disease Score Determination in Patients with Postcardiotomy Extracorporeal Membrane Oxygenation.

(1) Background: The use of extracorporeal membrane oxygenation (ECMO) in low cardiac output states after cardiac surgery may aid in patient recovery. However, in some patients, the clinical state may worsen, resulting in multiple organ failure and high mortality rates. In these circumstances, calculating a model of end-stage liver disease (MELD) score was shown to determine organ dysfunction and predicting mortality. (2) Methods: We evaluated whether serial MELD score determination increases mortality prediction in patients with postcardiotomy ECMO support. (3) Results: Statistically, a cutoff of a 2.5 MELD score increase within 48 h of ECMO initiation revealed an AUC of 0.722. Further, we found a significant association between hospital mortality and 48 h MELD increase (HR: 2.5, 95% CI: 1.33-4.75, p = 0.005) after adjustment for possible confounders. (4) Conclusions: Therefore, serial MELD score determinations on alternate days may be superior to single measurements in this special patient cohort.

Pacemaker implantation after concomitant tricuspid valve repair in patients undergoing minimally invasive mitral valve surgery: Results from the Mini-Mitral International Registry.

Objective: Randomized evidence suggests a high risk of pacemaker implantation for patients undergoing mitral valve (MV) surgery with concomitant tricuspid valve repair (cTVR). We investigated the impact of cTVR on outcomes in the Mini-Mitral International Registry. Methods: From 2015 to 2021, 7513 patients underwent minimally invasive MV with or without cTVR in 17 international centers (MV: n = 5609, cTVR: n = 1113). Propensity matching generated 1110 well-balanced pairs. Multivariable analysis was applied. Results: Patients with cTVR were older and had more comorbidities. Propensity matching eliminated most differences except for more TR in patients who underwent cTVR (77.2% vs 22.1% MV, P < .001). Mean matched age was 71 years, and 45% were male. European System for Cardiac Operative Risk Evaluation II was still 2.68% (interquartile range [IQR], 0.80-2.63) vs 1.9% (IQR, 1.12-3.9) in matched MV (P < .001). MV replacement (30%) and atrial fibrillation surgery (32%) were similar in both groups. Cardiopulmonary bypass (161 minutes [IQR, 133-203] vs MV: 130 minutes [IQR, 103-166]; P < .001) and crossclamp times (93 minutes [IQR, 66-123] vs MV: 83 minutes [IQR, 64-107]; P < .001) were longer with cTVR. Although in-hospital mortality was similar (cTVR: 3.3% vs MV: 2.2%; P = .5), postoperative pacemaker implantations (9% vs MV: 5.8%; P = .02), low cardiac output syndrome (7.7% vs MV: 4.4%; P = .02), and acute kidney injury (13.8% vs MV: 10%; P = .01) were more frequent with cTVR. cTVR eliminated relevant TR in most patients (greater-than-moderate TR: 6.8%). Multivariable analysis identified MV replacement, atrial fibrillation, and cTVR as risk factors of postoperative pacemaker implantation. Conclusions: cTVR in minimally invasive MV surgery is an independent risk factor for pacemaker implantation in this international registry. It is also associated with more bleeding, low output syndrome, and acute kidney injury. It remains unclear whether technical or patient factors (or both) explain these differences.

Temporary Mechanical Circulatory Support in Cardiogenic Shock Patients after Cardiac Procedures: Selection Algorithm and Weaning Strategies.

Mechanical circulatory support has proven effective in managing postcardiotomy cardiogenic shock by stabilizing patients' hemodynamics and ensuring adequate organ perfusion. Among the available device modalities, the combination of extracorporeal life support and a microaxial flow pump for left ventricular unloading has emerged as a valuable tool in the surgical armamentarium. In this publication, we provide recommendations for the application and weaning of temporary mechanical circulatory support in cardiogenic shock patients, derived from a consensus among leading cardiac centers in German-speaking countries.

Is There a Future for Minimal Access and Robots in Cardiac Surgery?

Minimally invasive techniques in cardiac surgery have found increasing use in recent years. Both patients and physicians often associate smaller incisions with improved outcomes (i.e., less risk, shorter hospital stay, and a faster recovery). Videoscopic and robotic assistance has been introduced, but their routine use requires specialized training and is associated with potentially longer operating times and higher costs. Randomized evidence is scarce and transcatheter treatment alternatives are increasing rapidly. As a result, the concept of minimally invasive cardiac surgery may be viewed with skepticism. In this review, we examine the current status and potential future perspectives of minimally invasive and robotic cardiac surgery.

Outcomes of Concomitant Coronary Artery Bypass Grafting in Patients With Infective Endocarditis: A Systematic Review and Meta-Analysis.

It is current practice to perform concomitant coronary artery bypass grafting (CABG) in patients with infective endocarditis who have relevant coronary artery disease. However, CABG may add complexity to the operation. We performed a systematic review and a meta-analysis of studies that presented outcomes from patients who underwent valve surgery because of infective endocarditis with or without concomitant CABG. Three databases were assessed. Perioperative mortality was the primary outcome. Long-term mortality and postoperative stroke were the secondary outcomes. Inverse variance method and random model were performed. Five studies with a total of 5,408 patients were included. Mean follow-up was 8.2 years. Just 1 study addressed exclusively patients with documented coronary artery disease. Perioperative mortality did not differ between patients with or without concomitant CABG (odds ratio 1.53, 95% confidence interval 0.52 to 4.48, p = 0.44). Long-term mortality did not differ between patients who received and those who did not receive concomitant CABG (odds ratio 1.79, confidence interval 0.88 to 3.65, p = 0.11). Only 1 study from a multicenter registry reported data on the occurrence of postoperative stroke, which demonstrated that its incidence after adjustment was 26% in patients with concomitant CABG versus 21% in patients without concomitant CABG (p = 0.003). The results suggest that in endocarditis patients, adding CABG to valve surgery does not affect perioperative or long-term mortality. Data available on the impact of concomitant CABG on neurologic outcomes are limited to a retrospective multicenter registry and suggest that concomitant CABG may be associated with higher postoperative stroke.

Impact of preoperative mitral regurgitation on left ventricular assist device patients: propensity score-matched analysis of the EUROMACS dataset.

OBJECTIVES: Mitral regurgitation (MR) is frequently observed in patients undergoing left ventricular assist device implantation. We investigated the impact of preoperative MR on left ventricular assist device patients. METHODS: A retrospective propensity score-matched analysis of adult patients enrolled in the EUROMACS registry between 1 January 2011 and 30 November 2021 was performed. Patients were divided into 2 groups according to the grade of preoperative MR: none-to-mild (MR 0-II) or moderate-to-severe (MR III-IV). RESULTS: Following 1:1 propensity score matching, each group consisted of 914 patients. Incidence of postoperative temporary right ventricular support, reoperation for bleeding and dialysis was similar. MR III-IV demonstrated shorter median intensive care unit stay [14 days (6; 27.8) vs 10 days (5; 22), P = 0.004] and ventilation time [72 h (22, 320) vs 31 h (18, 150), P < 0.001]. Mortality was lower for MR III-IV patients [subdistribution hazard ratio: 0.66, 95% confidence interval (CI): 0.59-0.73, P < 0.001]. The 1-year survival was 68.1% (95% CI: 65.1-71.3%) in MR 0-II and 75% (95% CI: 72.1-78%) in MR III-IV. A lower incidence of total complications [odds ratio (OR): 0.93 (0.89-0.98), P = 0.003] and trend towards a lower risk of neurological dysfunction (subdistribution hazard ratio: 0.79; 95% CI: 0.61-1.01, P = 0.063) and sustained ventricular tachycardia [OR: 0.93 (0.54-1.03), P = 0.074] were demonstrated for MR III-IV. The risk of fatal stroke and pump thrombosis was similar. CONCLUSIONS: Moderate-to-severe MR in patients undergoing left ventricular assist device implantation is associated with better mid-term survival and lower incidence of total major adverse events and complications. The incidence of severe postoperative complications including fatal stroke and device thrombosis was similar.

Intraoperative Cell Savage, Infection and Organ Failure in Infective Endocarditis Patients-A Retrospective Single Center Evaluation.

Surgery is indicated in about 50% of infective endocarditis patients, and bleeding or the transfusion of blood a common finding. The intraoperative use of cell salvage may reduce the perioperative transfusion requirement, but its use is limited in the underlying disease. In this retrospective study, we therefore evaluated n = 335 patients fulfilling the modified Duke criteria for infective endocarditis characterized by the use of intraoperative cell salvage with autologous blood retransfusion. Inflammation markers and organ dysfunction, including catecholamine dependency, were evaluated by using linear regression analysis. Between 2015 and 2020, 335 patients underwent surgery for left-sided heart valve endocarditis. Intraoperative cell salvage was used in 40.3% of the cases, especially in complex scenarios and reoperation. Intraoperative cell salvage significantly altered the white blood cell count after surgery. On average, leucocytes were 3.0 Gpt/L higher in patients with intraoperative cell salvage compared to patients without after adjustment for confounders (95% CI: 0.39-5.54). Although the difference in WBC was statistically significant, i.e., higher in the ICS group compared to the no-ICS group, this difference may be clinically unimportant. Organ dysfunction, including hemodynamic instability and lactate values, were comparable between groups. In conclusion, intraoperative cell salvage enhanced the re-transfusion of autologous blood, with minor effects on the postoperative course of inflammatory markers, but was not associated with increased hemodynamic instability or organ dysfunction in general. The restriction of intraoperative cell salvage in surgery for infective endocarditis should be re-evaluated, and more prospective data in this topic are needed.

A multicenter evaluation of external outflow graft obstruction with a fully magnetically levitated left ventricular assist device.

BACKGROUND: The HeartMate 3 (HM 3; Abbott) left ventricular assist device (LVAD) has improved hemocompatibility-related adverse outcomes. In sporadic cases, external compression of the outflow graft causing obstruction (eOGO) can result from substance accumulation between the outflow graft and its bend relief. We sought to evaluate the prevalence, course, and clinical implications of eOGO in an international study. METHODS: A multicenter retrospective analysis of HM 3 LVADs implanted between November 2014 and April 2021 (n = 2108) was conducted across 17 cardiac centers in 8 countries. We defined eOGO as obstruction >25% in the cross-sectional area in imaging (percutaneous angiography, computed tomography, or intravascular ultrasound). The prevalence and annual incidence were calculated. Serious adverse events and outcomes (death, transplantation, or device exchange) were analyzed for eOGO cases. RESULTS: Of 2108 patients, 62 were diagnosed with eOGO at a median LVAD support duration of 953 (interquartile range, 600-1267) days. The prevalence of eOGO was 3.0% and the incidence at 1, 2, 3, 4, and 5 years of support was 0.6%, 2.8%, 4.0%, 5.2%, and 9.1%, respectively. Of 62 patients, 9 were observed, 27 underwent surgical revision, 15 underwent percutaneous stent implantation, 8 received a heart transplant, and 2 died before intervention. One patient underwent surgical revision and later stent implantation. The mortality with therapeutic intervention was 9/53 (17.0%). CONCLUSIONS: Although uncommon, HM 3 LVAD-supported patients might develop eOGO with an increasing incidence after 1 year of support. Although engineering efforts to reduce this complication are under way, clinicians must maintain a focus on early detection and remain vigilant.

Association of liver dysfunction with outcomes after cardiac surgery-a meta-analysis.

OBJECTIVES: The aim of this study was to perform a meta-analysis of studies reporting outcomes in patients with liver dysfunction addressed by the model of end-stage liver disease and Child-Turcotte-Pugh scores undergoing cardiac surgery. METHODS: A systematic literature search was conducted to identify contemporary studies reporting short- and long-term outcomes in patients with liver dysfunction compared to patients with no or mild liver dysfunction undergoing cardiac surgery (stratified in high and low score group based on the study cut-offs). Primary outcome was perioperative mortality. Secondary outcomes were perioperative neurological events, prolonged ventilation, sepsis, bleeding and/or need for transfusion, acute kidney injury and long-term mortality. RESULTS: A total of 33 studies with 48 891 patients were included. Compared with the low score group, being in the high score group was associated with significantly higher risk of perioperative mortality [odds ratio (OR) 3.72, 95% confidence interval (CI) 2.75-5.03, P < 0.001]. High score group was also associated with a significantly higher rate of perioperative neurological events (OR 1.49, 95% CI 1.30-1.71, P < 0.001), prolonged ventilation (OR 2.45, 95% CI 1.94-3.09, P < 0.001), sepsis (OR 3.88, 95% CI 2.07-7.26, P < 0.001), bleeding and/or need for transfusion (OR 1.95, 95% CI 1.43-2.64, P < 0.001), acute kidney injury (OR 3.84, 95% CI 2.12-6.98, P < 0.001) and long-term mortality (incidence risk ratio 1.29, 95% CI 1.14-1.46, P < 0.001). CONCLUSIONS: The analysis suggests that liver dysfunction in patients undergoing cardiac surgery is independently associated with higher risk of short and long-term mortality and also with an increased occurrence of various perioperative adverse events.

Propensity matched comparison of TAVI and SAVR in intermediate-risk patients with severe aortic stenosis and moderate-to-severe chronic kidney disease: a subgroup analysis from the German Aortic Valve Registry.

OBJECTIVE: We compared TAVI vs. SAVR in patients with moderate-to-severe chronic kidney disease (eGFR 15-60 ml/min/1.73 m2) for whom both procedures could possibly be considered (age ≤ 80 years, STS-score 4-8). BACKGROUND: According to both ACC/AHA and ESC/EACTS recent guidelines, aortic stenosis may be treated with either transcatheter (TAVI) or surgical (SAVR) aortic valve replacement in a subgroup of patients. A shared therapeutic decision is made by a heart team based on individual factors, including chronic kidney disease (CKD). METHODS: Data from the large nationwide German Aortic Valve Registry were used. A propensity score method was used to select 704 TAVI and 374 SAVR matched patients. Primary endpoint was 1-year survival. Secondary endpoints were clinical complications, including pacemaker implantation, vascular complications, myocardial infarction, bleeding, and the need for new-onset dialysis. RESULTS: One-year survival was similar (HR [95% CI] for TAVI 1.271 [0.795, 2.031], p = 0.316), with no divergence in Kaplan-Meier curves. In spite of post-procedural short-term survival being numerically higher for TAVI patients and 1-year survival being numerically higher for SAVR patients, such differences did not reach statistical significance (96.4% vs. 94.2%, p = 0.199, and 86.2% vs. 81.2%, p = 0.316, respectively). In weighted analyses, pacemaker implantation, vascular complications, and were significantly more common with TAVI; whereas myocardial infarction, bleeding requiring transfusion, and longer ICU-stay and overall hospitalization were higher with SAVR. Temporary dialysis was more common with SAVR (p < 0.0001); however, a probable need for chronic dialysis was rare and similar in both groups. CONCLUSION: Both TAVI and SAVR led to comparable and excellent results in patients with moderate-to-severe CKD in an intermediate-risk population of patients with symptomatic severe aortic stenosis for whom both therapies could possibly be considered.

Diabetes Is an Independent Risk Factor for Cancer after Heart and/or Lung Transplantation.

Background: De novo cancers are feared complications after heart or lung transplantation. Recent data suggest that diabetes mellitus (DM) might also be a risk factor for cancer. We hypothesized that transplanted diabetic patients are at greater risk of developing cancer compared to non-diabetic ones. Methods: We reviewed 353 patients post-heart and/or -lung transplantation from our center between October 1999 and June 2021. Patients with follow-up <180 days (n = 87) were excluded from the analysis. The remaining 266 patients were divided into patients who had preoperative DM (n = 88) or developed it during follow-up (n = 40) and patients without DM (n = 138). Results: The diabetic cohort showed higher rates of malignancies in all patients (30.33 vs. 15.97%, p = 0.005) and in the matched population (31.9 vs. 16.1%, p < 0.001). There were also significantly more solid tumors (17.9 vs. 9.4%, p = 0.042; matched: 16.6 vs. 9.1%, p = 0.09) The presence of diabetes was associated with a 13% increased risk of cancer when compared to non-diabetic patients. New-onset post-transplant diabetes doubled the likelihood of cancer development. Conclusions: Pre-transplant diabetes mellitus increases the risk of cancer after heart and/or lung transplantation. However, new-onset diabetes after transplantation is associated with a much greater cancer risk. This information is relevant for screening during follow-up.

Cytokine Hemoadsorption During Cardiac Surgery Versus Standard Surgical Care for Infective Endocarditis (REMOVE): Results From a Multicenter Randomized Controlled Trial.

BACKGROUND: Cardiac surgery often represents the only treatment option in patients with infective endocarditis (IE). However, IE surgery may lead to a sudden release of inflammatory mediators, which is associated with postoperative organ dysfunction. We investigated the effect of hemoadsorption during IE surgery on postoperative organ dysfunction. METHODS: This multicenter, randomized, nonblinded, controlled trial assigned patients undergoing cardiac surgery for IE to hemoadsorption (integration of CytoSorb to cardiopulmonary bypass) or control. The primary outcome (change in sequential organ failure assessment score [ΔSOFA]) was defined as the difference between the mean total postoperative SOFA score, calculated maximally to the 9th postoperative day, and the basal SOFA score. The analysis was by modified intention to treat. A predefined intergroup comparison was performed using a linear mixed model for ΔSOFA including surgeon and baseline SOFA score as fixed effect covariates and with the surgical center as random effect. The SOFA score assesses dysfunction in 6 organ systems, each scored from 0 to 4. Higher scores indicate worsening dysfunction. Secondary outcomes were 30-day mortality, duration of mechanical ventilation, and vasopressor and renal replacement therapy. Cytokines were measured in the first 50 patients. RESULTS: Between January 17, 2018, and January 31, 2020, a total of 288 patients were randomly assigned to hemoadsorption (n=142) or control (n=146). Four patients in the hemoadsorption and 2 in the control group were excluded because they did not undergo surgery. The primary outcome, ΔSOFA, did not differ between the hemoadsorption and the control group (1.79±3.75 and 1.93±3.53, respectively; 95% CI, -1.30 to 0.83; P=0.6766). Mortality at 30 days (21% hemoadsorption versus 22% control; P=0.782), duration of mechanical ventilation, and vasopressor and renal replacement therapy did not differ between groups. Levels of interleukin-1ß and interleukin-18 at the end of integration of hemoadsorption to cardiopulmonary bypass were significantly lower in the hemoadsorption than in the control group. CONCLUSIONS: This randomized trial failed to demonstrate a reduction in postoperative organ dysfunction through intraoperative hemoadsorption in patients undergoing cardiac surgery for IE. Although hemoadsorption reduced plasma cytokines at the end of cardiopulmonary bypass, there was no difference in any of the clinically relevant outcome measures. REGISTRATION: URL: https://www. CLINICALTRIALS: gov; Unique identifier: NCT03266302.

Right Mini-Thoracotomy for Aortic Plus Mitral with or without Tricuspid Valve Surgery.

OBJECTIVES: Minimally invasive surgery is increasingly performed for isolated aortic or mitral valve procedures. However, combined minimally invasive aortic and mitral valve surgery is rare. We report our initial experience performing multiple valve procedures through a right-sided mini-thoracotomy (RMT) compared with sternotomy. METHODS: A total of 264 patients underwent aortic and mitral with or without tricuspid valve surgery through RMT (n = 25) or sternotomy (n = 239). Propensity score matching was used for outcome comparisons. RESULTS: Of the 264 patients, 25 (age: 72 ± 10 years; 72% male) underwent double (n = 19) and triple valve surgery (n = 6) through RMT and 239 (age: 71 ± 11 years; 54% male) underwent double (n = 176) and triple valve surgery (n = 63) through sternotomy. Sternotomy patients had more co-morbidities and preoperative risk factors (EuroSCORE II 10.25 ± 10.89 vs. RMT 3.58. ± 4.98; p < 0.001). RMT procedures were uneventful without intraoperative complications or conversions to sternotomy. After propensity score matching, surgical procedures were comparable between groups with a higher valve repair rate in RMT. Despite longer cardiopulmonary bypass times in RMT, there was no evidence for differences in 30-day mortality (RMT: n = 2 vs. sternotomy: n = 2) and there were no significant differences in other outcomes. During 5-year follow-up, reoperation was required in sternotomy patients only (n = 2). Follow-up echocardiography showed durable results after valve surgery. RMT patients showed higher survival probability compared with sternotomy, although this difference was not significant (hazard ratio = 0.33; 95% confidence interval: 0.06-1.65; p = 0.18). CONCLUSION: Combined aortic plus mitral with or without tricuspid valve surgery can safely be performed through a RMT with a trend toward better mid-term outcomes.

Impact of an In-Hospital Endocarditis Team and a State-Wide Endocarditis Network on Perioperative Outcomes.

BACKGROUND: Infective endocarditis (IE) requires multidisciplinary management. We established an endocarditis team within our hospital in 2011 and a state-wide endocarditis network with referring hospitals in 2015. We aimed to investigate their impact on perioperative outcomes. METHODS: We retrospectively analyzed data from patients operated on for IE in our center between 01/2007 and 03/2018. To investigate the impact of the endocarditis network on referral latency and pre-operative complications we divided patients into two eras: before (n = 409) and after (n = 221) 01/2015. To investigate the impact of the endocarditis team on post-operative outcomes we conducted multivariate binary logistic regression analyses for the whole population. Kaplan-Meier estimates of 5-year survival were reported. RESULTS: In the second era, after establishing the endocarditis network, the median time from symptoms to referral was halved (7 days (interquartile range: 2-19) vs. 15 days (interquartile range: 6-35)), and pre-operative endocarditis-related complications were reduced, i.e., stroke (14% vs. 27%, p < 0.001), heart failure (45% vs. 69%, p < 0.001), cardiac abscesses (24% vs. 34%, p = 0.018), and acute requirement of hemodialysis (8% vs. 14%, p = 0.026). In both eras, a lack of recommendations from the endocarditis team was an independent predictor for in-hospital mortality (adjusted odds ratio: 2.12, 95% CI: 1.27-3.53, p = 0.004) and post-operative stroke (adjusted odds ratio: 2.23, 95% CI: 1.12-4.39, p = 0.02), and was associated with worse 5-year survival (59% vs. 40%, log-rank < 0.001). CONCLUSION: The establishment of an endocarditis network led to the earlier referral of patients with fewer pre-operative endocarditis-related complications. Adhering to endocarditis team recommendations was an independent predictor for lower post-operative stroke and in-hospital mortality, and was associated with better 5-year survival.

A new technique for tricuspid valve repair addressing the subvalvular apparatus in functional tricuspid regurgitation.

Annular dilatation is the main mechanism for tricuspid regurgitation, but right ventricular dilatation often adds a restrictive mechanism, which may limit durability. We describe a subvalvular technique anchoring the chordal origins to the annuloplasty, with the aim to stabilize valve geometry and increase durability. A Goretex suture is attached to the anterior papillary muscle. One arm of the suture is stitched through the septal muscle and both arms are atrialized underneath the septal leaflet and tied to the annuloplasty band. In 12 patients (75 ± 6 years, EuroSCORE II 10 ± 9%), severe-torrential tricuspid regurgitation was successfully reduced to mild. Results were stable in all but one patient during follow-up (1-15 months). NYHA class and general health status was improved. This subvalvular technique is safe with the potential to generate a durable repair.

Minimally-invasive mitral valve repair of symmetric and asymmetric Barlow´s disease.

OBJECTIVES: Barlow´s disease represents a wide spectrum of mitral valve pathologies associated with regurgitation (MR), excess leaflet tissue, and prolapse. Repair strategies range from complex repairs with annuloplasty plus neochords through resection to annuloplasty-only. The latter requires symmetric prolapse patterns and central regurgitant jets. We aimed to assess repair success and durability, survival, and intraoperative outcomes with symmetric and asymmetric Barlow's disease. METHODS: Between 09/10 and 03/20, 103 patients (of 1939 with mitral valve surgery) presented with Barlow´s disease. All received surgery through mini-thoracotomy with annuloplasty plus neochords (n = 71) or annuloplasty-only (n = 31). One valve was replaced for endocarditis (repair rate: 99%). RESULTS: Annuloplasty-only patients were older (64 ± 16 vs. 55 ± 11 years, p = 0.008) and presented with higher risk (EuroSCORE II: 4.2 ± 4.9 vs. 1.6 ± 1.7, p = 0.007). Annuloplasty-only patients had shorter cross-clamp times (53 ± 18 min vs. 76 ± 23 min, p < 0.001) and received more tricuspid annuloplasty (15.5% vs. 48.4%, p < 0.001). Operating times were similar (170 ± 41 min vs. 164 ± 35, p = 0.455). In three patients, annuloplasty-only caused intraoperative systolic anterior motion (SAM), which was fully resolved by neochords to the posterior leaflet. There were no conversions to sternotomy or deaths at 30-days. Three patients required reoperation for recurrent MR (at 25 days, 2.8 and 7.8 years). At the latest follow-up, there was no MR in 81.4%, mild in 14.7%, and moderate in 2.9%. Three patients died due to non-cardiac reasons. Surviving patients report the absence of relevant symptoms. CONCLUSIONS: Minimally-invasive Barlow's repair is safe with good durability. Annuloplasty-only may be a simple solution for complex but symmetric pathologies. However, it may carry an increased risk of intraoperative SAM.