Minimally Invasive Mitral Valve Repair: From Total Endoscopic To Closed-Chest Robotic


  • Javier Gallego-Poveda Thoracic Surgery Department, Hospital Lusíadas Lisboa; UMICS, Unit for Minimally Invasive Cardiothoracic Surgery
  • Nelson Paulo UMICS, Unit for Minimally Invasive Cardiothoracic Surgery
  • Mário Jorge Amorim UMICS, Unit for Minimally Invasive Cardiothoracic Surgery
  • Diego González-Rivas UMICS, Unit for Minimally Invasive Cardiothoracic Surgery
  • Elena Sandoval Cardiovascular Surgery Department, Hospital Clínic Barcelona
  • Daniel Pereda Cardiovascular Surgery Department, Hospital Clínic Barcelona
  • André Rato Serviço de Anestesiologia, Hospital Lusíadas, Lisboa, Portugal



Minimally invasive cardiac surgery has evolved over the past few decades, thanks to advancements in technology and surgical techniques. These advancements have allowed surgeons to perform cardiac interventions through small incisions, reducing surgical trauma and improving patient outcomes1. However, despite these advancements, thoracoscopic mitral repair has not been widely adopted by the cardiac surgery community, possibly due to the lack of familiarity with video-assisted procedures1. Over the years, various minimally invasive mitral valve surgery (MIMVS) techniques have been developed to achieve comparable or better results while minimizing surgical trauma. These techniques have evolved from direct-vision procedures performed through a right thoracotomy with a rib retractor to video-directed approaches using long-shafted instruments1. Robotic surgery, introduced in the late 90s, has also played a significant role in mitral valve repair. The da Vinci system, the only robotic platform currently used for cardiac surgery, provides surgeons with enhanced dexterity and high-definition 3D visualization, allowing for precise and accurate procedure2, and is now the preferred approach for mitral repair in many programs3. The first mitral repair using the da Vinci system was performed in Europe by Carpentier and Mohr in 1998, followed by the first mitral replacement by Chitwood in the USA in 20002-4. The advantages of robotic technology allow surgeons to perform complex repair techniques such as papillary muscle repositioning and sliding leaflet plasty4. Studies have shown that robotic mitral surgery results in shorter ICU and hospital stays, better quality of life postoperatively, and improved cosmesis compared to conventional surgery5,6. In our experience, we have also observed significant benefits with robotic surgery, including reduced blood loss and the need for transfusions. This can be attributed to the closed-chest technique, which eliminates the need for a thoracotomy and rib retractor, reducing the risk of bleeding associated with these approaches7. In this article, we will compare the surgical steps of endoscopic and robotic mitral valve repair, providing detailed information on patient selection, operative techniques, and the requirements for building a successful program. By understanding the advantages and challenges of both approaches, surgeons can make informed decisions and provide the best possible care for their patients. Combined ablation and multivalvular procedures are mostly performed in few centers by minimally invasive techniques.


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Fann JI, Pompili MF, Burdon TA, Stevens JH, St Goar FG, Reitz BA. Minimally invasive mitral valve surgery. Semin Thorac Cardiovasc Surg 1997;9: 320-30. PMID: 9352947

Carpentier A, Loulmet D, Aupècle B, Kieffer JP, Tournay D, Guibourt P et al. Computer assisted open heart surgery. First case operated on with success. C R Acad Sci III 1998;321:437-42. doi: 10.1016/s0764-4469(98)80309-0

Mohr FW, Falk V, Diegeler A, et al. Computer-enhanced coronary artery bypass surgery. J Thorac Cardiovasc Surg 1999; 117:1212-4 PMID: 10343274

Chitwood WR, Jr, Nifong LW, Elbeery JE, et al. Robotic mitral valve repair: trapezoidal resection and prosthetic annuloplasty with the da vinci surgical system. J Thorac Cardiovasc Surg 2000; 120:1171-2 doi: 10.1067/mtc.2000.110177.

Gillinov AM, Mihaljevic T, Javadikassari H, Suri RM, Mick SK, Navi JL et al. Early results of robotically assisted mitral valve surgery: Analysis of the first 1000 cases. J Thorac Cardiovasc 2018: 155 (1) 82-91 e2. doi: 10.1016/j.jtcvs.2017.07.037

Suri RM, Antiel RM, Burkhart HM, Huebner M, Li Z, Eton DT et al. Quality of life after early mitral valve repair using conventional and robotic approaches. Ann Thorac Surg 2012: 93:761-9. doi: 10.1016/j.athoracsur.2011.11.062.

Mihaljevic T, Koprivanac M, Kelava M, Goodman A, Jarrett C, Williams SJ et al. Value of robotically assisted surgery for mitral valve disease. JAMA Surg 2014;149(7):679–86. doi: 10.1001/jamasurg.2013.5680.

Baumgartner H, Falk V, Bax JJ, De Bonis M, Hamm C, Holm PJ et al. 2017 ESC/EACTS Guidelines for the management of valvular heart disease. Eur Heart J 2017; 38: 2739-2791. doi: 10.1093/eurheartj/ehx391.

Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin III JP, Gentile F et al. 2020 ACC/AHA Guideline for the management of patients with valvular heart disease. J Am Coll Cardiol. 2021 Feb 2;77(4):e25e197. doi: 10.1016/j.jacc.2020.11.018

Perier P, Hohenberger W, Lakew F, Batz G, Diegler A. Rate of repair in minimally invasive mitral valve surgery. Ann Cardiothorac Surg 2013: 2 (6): 751-757. doi: 10.3978/j.issn.2225319X. 2013.10.12.

Taui T, Ishikawa N, Horikawa T, Seguchi R, Shigematsu S, Kiuchi R et al. First Major Clinical Outcomes of totally endoscopic robotic mitral valve5 repair in Japan. Circ J 2019; 83: 1668-1673. doi: 10.1253/circj.CJ-19-0284.

Seeburger J, Borger MA, Falk V, Kuntze T, Czesla M, Walther T et al. Minimally invasive mitral valve repair for mitral regurgitation: results of 1339 consecutive patients. Eur J Cardiothorac Surg 2008 Oct 34(4): 760-5. doi: 10.1016/j. ejcts.2008.05.015.

Suri RM, Taggarse A, Burkhart HM, Daly RC, Mauermann W, Nishimura RA et al. Robotic mitral valve repair for simple and complex degenerative disease. Midterm clinical and echocardiographic quality outcomes. Circulation 2015; 132: 1961-1968. doi: 10.1161/ CIRCULATIONAHA.115.017792.

Ascaso M, Sandoval E, Quintana E, Vidal B, Castella M, Pereda D. Early and mid-term outcomes of mitral repair due to leaflet prolapse in a national referral center. Rev Esp Cardiol (Engl Ed) 2020; Nov 4: S1885-5857. doi: 10.1016/j. rec.2020.10.002.

Lehr EJ, Guy TS, Smith RL, Grossi EA, Shemin RJ, Rodriguez E, et at. Minimally Invasive Mitral Valve Surgery III. Training and Robotic-Assisted Approaches. Innovations 2016;11: 260–267 doi: 10.1097/IMI.0000000000000299.

Rodriguez E, Nifong LW, Bonatti J, Casula R, Falk V Folliguet TA, et al. Pathway for surgeons and programs to establish and maintain a successful robot-assisted adult cardiac surgery program J Thorac Cardiovasc Surg 2016;152:9-13 doi: 10.1016/j.athoracsur.2016.02.085.

Goodman A, Koprivanac M, Kelava M, Mick SL, Gillinov AM, Rajeswaran J et al. Robotic mitral valve repair. The learning curve. Innovation 2017; 12: 390-7 doi: 10.1097/ IMI.0000000000000438.

Kesävuori R, Raivio P, Jokinen JJ, Sahlman A, Teittinen K, Vento A. Early experience with robotic mitral valve repair with intra-aortic occlusion. J Thorac Cardiovasc Surg 2018; 155: 1463-71. doi: 10.1016/j. jtcvs.2017.10.076.

Ramlawi B, Gammie JS. Mitral valve surgery: Current minimally invasive and transcatheter options. Methodist Debakey Cardiovasc J 2016; (1): 20-6. doi: 10.14797/mdcj-12-1-20.

Fiocco A, Nadali M, Speziali G, Colli A. Transcatheter mitral valve chordal repair: Current indications and future perspectives. Front Cardiovasc Med 2019; 6: 128. doi: 10.3389/ fcvm.2019.00128




How to Cite

Gallego-Poveda J, Paulo N, Amorim MJ, González-Rivas D, Sandoval E, Pereda D, Rato A. Minimally Invasive Mitral Valve Repair: From Total Endoscopic To Closed-Chest Robotic. Rev Port Cir Cardiotorac Vasc [Internet]. 2024 Feb. 9 [cited 2024 Jun. 13];30(4):15-22. Available from:



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