Three-port (one incision plus two-port) endoscopic mitral valve surgery without robotic assistance†

<span class="paragraphSection"><div class="boxTitle">Abstract</div><strong>OBJECTIVES:</strong> Totally endoscopic minimally invasive mitral valve surgery (MIMVS) is technically demanding and often performed with robotic assistance. We hypothesized that three-port video-assisted thoracic surgery (VATS) would facilitate endoscopic MIMVS and evaluated its feasibility and safety.<strong>METHODS:</strong> From October 2010 to June 2016, we performed first-time MIMVS in 250 consecutive patients (122 male), with median age of 65 years (54–73 years, 25–75 percentile). The thoracic access ports comprised one small (3–5 cm) thoracotomy without a rib spreader plus two trocars (one for the endoscope and one for left-handed instruments), thus establishing triangular three-port VATS. Cannulas, an aortic clamp, and a left atrial retractor were inserted through the thoracotomy, and right-handed instruments were inserted through the remaining space. Cardiopulmonary bypass was established through a groin incision.<strong>RESULTS:</strong> The etiology of the mitral valve lesion was myxomatous degeneration in 70% of patients, rheumatic disease in 9%, infectious endocarditis in 6%, and other conditions in 15%. Mitral valve repair was performed in 233 patients and replacement in 27. Two patients underwent conversion to replacement after attempted repair. Forty-nine patients underwent tricuspid annuloplasty, and 45 underwent the Maze procedure. One in-hospital death occurred within 30 days. Two patients developed stroke, three underwent re-exploration for bleeding, one developed low output syndrome, and one required new haemodialysis. The aortic clamp, bypass, and total operation times were 119 (94–149), 166 (134–200) and 237 (204–285) min, respectively, median (25–75%). The 5-year survival and reoperation-free rates were 98.3% ± 0.9% and 96.9% ± 1.2%, respectively. <strong>CONCLUSIONS:</strong> Three-port endoscopic MIMVS appears reproducible and safe.</span>

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