Mid-term Outcomes after Totally Video Guided Thoracoscopic Mitral Valve Surgery

Mid-term Outcomes after Totally Video Guided Thoracoscopic Mitral Valve Surgery | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Mid-term Outcomes after Totally Video Guided Thoracoscopic Mitral Valve Surgery Giorgio Mastroiacovo, Alice Bonomi, Chiara Morocutti, Severgnini Gaia, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8929107/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 28 Apr, 2026 Read the published version in Journal of Cardiothoracic Surgery → Version 1 posted 14 You are reading this latest preprint version Abstract Objective Totally video-guided thoracoscopic surgery (TVTS) has emerged as a minimally invasive alternative to conventional surgery with full sternotomy for mitral valve surgery. Evaluation of clinical outcomes of TVTS mitral valve surgery is essential for guiding patient selection and surgical planning. Methods We conducted a retrospective study of 368 consecutive patients who underwent TVTS for mitral valve repair at a tertiary academic center to evaluate the safety and efficacy of this minimally invasive approach. Results Mitral valve repair was accomplished using the respect technique in 96.4% %, using two PTFE artificial-cordae on the posterior leaflet in 61.7% of patients. In-hospital mortality was 0.8%, stroke 1.2% and ECMO support was required for 1.4% of patients. The median follow-up was 2.5 years (q1; q3 1.18;4.15) and it was complete in 98.6% of patients. At 7-year, all-cause mortality was 3.3% and the rate of major cardiac and cerebrovascular events and reoperations were respectively 1.9% and 1.7%. Conclusions Provided adequate surgical expertise, TVTS mitral valve surgery can be performed with excellent early and late clinical outcomes. Figures Figure 1 Figure 2 Introduction Totally Video-guided thoracoscopic surgery (TVTS) has emerged as a minimally invasive alternative to conventional median sternotomy for mitral valve repair and replacement. By utilizing small thoracic ports and high-definition thoracoscopic visualization, this approach aims to reduce surgical trauma while achieving comparable valve repair quality. The growing body of literature has increasingly focused on clinical outcomes to assess the true benefits and limitations of TVTS in this context. Several retrospective and prospective studies have demonstrated that TVTS mitral valve surgery is associated with low perioperative mortality, typically ranging between 0.5% and 2.0%, comparable to outcomes observed with conventional open procedures [1,2]. Reoperation rates due to recurrent mitral regurgitation or prosthetic dysfunction remain low in experienced centers, generally under 5% at 5-year follow-up [3]. Moreover, functional recovery is notably improved, with patients experiencing reduced postoperative pain, earlier mobilization, and faster return to daily activities compared to those undergoing sternotomy [4,5]. Hospital length of stay is also significantly shortened, often by 2–4 days, reflecting enhanced recovery protocols associated with minimally invasive techniques. As the demand for less invasive cardiac interventions grows, understanding the clinical outcomes of TVTS mitral valve surgery is essential for guiding patient selection and surgical planning. However, real world data on TVTS are lacking and we therefore conducted a retrospective study on 368 consecutive patients who underwent TVTS for mitral valve repair to evaluate the safety, efficacy, and short and mid-term outcomes of this minimally invasive approach. The aim was to contribute real-world data from a single-center experience and assess short and long-term clinical performance in terms of mortality, reoperation, and post-operative outcomes. Material and method Study Design and Patient Population This is a retrospective, single-center cohort study including a consecutive series of patients who underwent elective or emergent mitral valve repair interventions via thoracoscopic approach procedure at the Centro Cardiologico Monzino IRCCS, Milan, Italy, from May 2018 to August 2025. The Data Governance Board of the Centro Cardiologico Monzino IRCCS, Milan, Italy, approved this study (date 10/12/2024, diary no. NP1090). Patients’ written consent was waived because of the retrospective nature of this study. Prior cardiac surgery was considered exclusion criteria for TVTS mitral valve surgery. Data on patients’ risk factors, echocardiographic and operative and post-operative data were retrospectively collected from electronic medical records. The operative risk was estimated using the EuroSCORE II [6]. Outcomes The primary outcomes of the study were short (intended as the index hospitalization) and long-term both survival and freedom from reoperation from on the mitral valve. The secondary outcomes of the study were: length of postoperative in-hospital stay, in-hospital acute kidney injury, permanent pace-maker implantation, sepsis, moderate-to-severe pericardial effusion, atrial fibrillation, myocardial infarction, reoperation for bleeding and stroke. Data on late adverse events were gathered from clinical records and by contacting the patients or her/his relatives. Follow-up data was considered complete for all patients except for five. The median follow-up was 2.5 years (q1; q3 1.18;4.15) Surgical Technique TVTS mitral valve surgery is performed via a 2–4 cm right peri-areolar skin incision for men and almost 4 cm above the mammal sulcus for women, followed by a thoracotomy at the 4th or 5th intercostal space. A small soft tissue retractor (Edwards Lifesciences TRM thruport soft tissue retractor) is used to improve surgical exposure. Cardio-pulmonary bypass (CPB) is established through peripheral femoral arterial and venous cannulation. We use the double stage 25 Fr Medtronic Bio-Medicus venous cannula for all patients, with the distal end positioned in the superior vena cava under transesophageal echocardiographic (TEE) guidance. The thoracoscope is inserted on a 5 mm working port via a small skin incision of 1–2 cm at the 2nd/3rd right intercostal space on the anterior axillary line. A small longitudinal pericardial incision is performed laterally to the ascending aorta and extended downwards to the right atrium, almost 2 cm above the phrenic nerve. The cardiotomy vent and pericardial stay suture are placed through a small skin incision of 1–2 cm in the 7th/8th right intercostal space on the anterior axillary line. After aortic cross-clamping with the Cygnet Aortic Cross Clamp (Straight Peters Surgical, Bobigny Cedex, France), Del Nido cardioplegia is delivered anterogradely. Normothermic CPB is conducted in all patients. Left atriotomy is performed. An atrial retractor is passed through the thoracotomy and fixed on a metal support inserted through a small skin incision of 1 cm at the 4th/5th intercostal space along the right parasternal line. Mitral valve repair is usually performed with artificial chords of expanded polytetrafluoroethylene and a ring (Cosgrove-Edwards, MEMO 4D-LivaNova) when feasible, otherwise a biological or mechanical valve is implanted using 2 − 0 Ti-Cron stitches tied with the Cor-Knot system (LSI Solutions, Victor, NY). Following re-warming, the heart is commonly de-aired both through a left atrial and an aortic vent. The procedure of de-airing is performed under continuous echocardiographic monitoring. Once completed, the vents are removed and checked for surgical bleeding points. Atriotomy is closed with 3 − 0 Prolene as standard fashion. Pericardium is left open at the end of the procedure and two chest tubes are inserted (one in the right pleural space and another one in the pericardium. Then the space between the ribs is closed with a Ethicon PDS II suture to avoid lung herniation and the subcutaneous tissue and the derma are sewed in a standard fashion. Statistical Analysis Continuous variables are summarized as mean ± standard deviation (SD) for normally distributed variables, or as median and interquartile range (IQR) if not. A logarithmic adjustment is applied to variables with a right-skewed distribution prior to analysis. When data cannot be normalized through transformation, non-parametric methods are applied. Categorical variables are expressed as absolute frequencies and percentages. In order to estimate survival functions, Kaplan–Meier curves are presented for time-to-event outcomes (MACCE and overall mortality, MACCE and reoperation over time). All statistical analyses are performed using SASSoftwareversion 9.4(Copyright © 2002–2012 by SAS Institute Inc., Cary, NC, USA). Results Patient Population A total of 368 consecutive patients who underwent TVTS mitral valve repair were included in the analysis. Baseline clinical characteristics are summarized in Table 1 . Table 1 Baseline characteristics (N = 368) Clinical variables Age, years 60(54;68) Male sex 283(76.9%) Weight (Kg) 74.32 ± 12.87 BMI (Kg/m 2 ) 24.56 ± 3.12 Dyslipidemia 69(18.75%) Smoker Active smoker 39(10.6%) Former smoker 52(14.13%) Hypertension 227(61.68%) Diabetes Diabetes I type 6(1.63%) Diabetes II type 7(1.9%) Haemoglobin, g/dL 14.4(13.5;15.3) Creatinine, mg/dL 0.95(0.84;1.08) COPD 7(1.9%) Previous myocardial infarction 5(1.36%) Previous stroke 1(0.27%) Prior endocarditis 1(0.27%) EuroSCORE II, % 0.9(0.67;1.35) Heart rhythm Sinus rhythm 299(81.25%) Atrial Flutter 1(0.27%) Paroxysmal Atrial Fibrillation 36(9.78%) Persistent Atrial Fibrillation 11(2.99%) Permanent Atrial Fibrillation 16(4.35%) Pacemaker 5(1.36%) Values are mean ± standard deviation, median and interquartile range (in brackets), or counts and percentages (in parentheses). COPD = Chronic Obstructive Pulmonary Disease. The median age was 60 years (IQR 54–68), and 283 patients (76.9%) were male. Hypertension was present in 61.7%, dyslipidemia in 18.8%, and diabetes mellitus in 3.5% of patients. The median EuroSCORE II was 0.9% (0.67–1.35), reflecting a low predicted operative risk. Most patients were in sinus rhythm (81.3%), while 17.1% had a history of atrial fibrillation. Preoperative echocardiographic characteristics are presented in Table 2 . Table 2 Preoperative echocardiographic data (N 368) Preoperative echocardiographic variables LV ejection fraction, % 65(61;68) Aortic peak gradient, mmHg 7(6;9) Aortic valve velocity, cm/s 1.3(1.1;1.5) End-diastolic volume, mL 125(85.5;158) End-systolic volume, mL 42.5(29;56) End-diastolic diameter, mm 52(35;59) End-systolic diameter, mm 30(21;35) LV index diastolic diameter (mm/m2) 30(27;32) PAPs 34(29;42) TAPSE, mm 26(23;29) Values are mean ± standard deviation, median and interquartile range (in brackets), or counts and percentages (in parentheses). LV = Left Ventricular; PAP=Pulmonary Arterial Pressure systolic; TAPSE=tricuspid annular plane systolic excursion The median left ventricular ejection fraction (LVEF) was 65% (61–68). The mean left ventricular end-diastolic diameter was 52 mm (35–59), and the median pulmonary artery systolic pressure (PAPs) was 34 mmHg (29–42), indicating preserved ventricular function in the majority of patients. Intraoperative Data Intraoperative variables are shown in Table 3 . Table 3 Intraoperative variables (N 3 68 ) Pathology Mitral Regurgitation 368(100%) Elective 366(99.5%) Emergency 2(0.4%) Mitral Valve Repair 362(98.4%) Number of artificial cordae 0 19(5.2%) 1 52(14.1%) 2 227(61.7%) 3 52(14.1%) 4 13(3.5%) 5 5(1.4%) Position of the artificial cordae Posterior Leaflet 282(76.6%) Anterior and posterior Leaflet 33(9%) Anterior Leaflet 17(4.6%) Anterior and posterior leaflets and posteromedial commisure 4(1.1%) Posterior leaflet and posteromedial commissure 4(1.1%) Posteromedial commissure 3(0.8%) Anterior leaflet and posteromedial commissure 1(0.3%) Posterior leaflet and anterolateral commissure 1(0.3%) Posterior leaflet, anterolateral commisure and posteromedial commissure 1(0.3%) Posterior and anterior leaflet and anterolateral commisure 1(0.3%) Anterior leaflet and anterolateral commissure 1(0.3%) Resect Technique 1(0.3%) Paneth Technique 1(0.3%) Mitral valve Replacement 6(1.6%) Biological prostheses 4(1.1%) Mechanical Prostheses 2(0.5%) Conversion to Sternotomy 11(3%) Unstoppable bleeding 9(2.4%) Aortic dissection 2(0.5%) Concomitant procedures Tricuspid valve repair 25 (7%) Tricuspid valve Ring 21(5.7%) De Vega 4(1.1%) AVR 2 (0.5%) Inspiris Resilia 25 1(0.3%) Perceval 1(0.3%) MAZE and LAAC 27(5.4%) Second run CPB 17(4.6%) Residual Moderate Mitral Regurgitation 9(1.9%) Haemorrhage 5(1.4%) Stunning Myocardium 2(0.5%) Prostheses malfunction 1(0.3%) Location of Haemorrhage Pacemaker wire 5(1.4%) Aortic vent 2(0.5%) Aortic suture 1(0.3%) Atrial suture 1(0.3%) Diffuse bleeding 1(0.3%) Aortic cross-clamp time, min 103 ± 38 Cardiopulmonary bypass time, min 119 ± 48 Values are mean ± standard deviation, median and interquartile range (in brackets), or counts and percentages (in parentheses). AVR = Aortic Valve Replacement; CPB = Cardio Pulmonary Bypass; LAAC = Left Atrial Appendage Closure; All patients presented with mitral regurgitation, and 98.4% underwent successful mitral valve repair, while 1.6% required valve replacement (4 biological, 2 mechanical prostheses). The vast majority of repairs (96.4%) were performed using the respect technique with two PTFE artificial chordae placed on the posterior leaflet (61.7%). The median cardiopulmonary bypass (CPB) and aortic cross-clamp times were 119 ± 48 minutes and 103 ± 38 minutes, respectively. A conversion to sternotomy was required in 11 patients (3%), primarily for uncontrollable bleeding (2.4%) and aortic dissection (0.5%). A second CPB run was performed in 17 patients (4.6%), mainly due to residual mitral regurgitation (1.9%), bleeding (1.4%), prosthetic dysfunction (0.3%), or myocardial stunning (0.5%). Concomitant procedures were performed in 54 patients (14.7%), including tricuspid valve repair (7%), aortic valve replacement (0.5%), and MAZE or left atrial appendage closure (5.4%). Early Postoperative Outcomes Early postoperative outcomes are summarized in Table 4 . Table 4 Early postoperative outcomes. Outcomes In-hospital mortality 3(0.8%) Cardiac death 2(0.5%) Cardio Pulmonary Resuscitation 3(0.8%) Ventricular arrhythmia (Ventricular tachycardia or fibrillation) 3(0.8%) Atrial fibrillation 160(43.5%) Pleural effusion undergone to thoracentesis 33(9%) Reintervention for bleeding 22(6%) Chest wall hematoma 17(4.6%) Acute kidney injury 14(3.8%) Permanent pacemaker implantation 14(3.8%) Respiratory Insufficiency 13(3.5%) Hemidiaphragm elevation 12(3.3%) Pericarditis 10(2.7%) Lymphocele 9(2.4%) Haemothorax 8(2.2%) Subcutaneous emphysema 7(1.9%) Post CPB cardiogenic shock 7(1.9%) Right ventricular shock 5(1.4%) Left ventricular shock 3(0.8%) Biventricular dysfunction 2(0.5%) Hemofiltration 6(1.6%) Thoracic empyema 5(1.4%) ECMO 5(1.4%) Stroke 4(1.2%) TIA 3(0.8%) Tracheostomy 3(0.8%) Use of VAC therapy to treat inguinal wound dehiscence 3(0.8%) Vascular complications on the femoral artery 2(0.5%) Coma 2(0.6%) PCI + DES post OR 2(0.5%) Sepsis 2(0.5%) Severe pericardial effusion 2(0.5%) Haemorrhagic shock 2(0.5%) Myocardial Infarction 2(0.5%) Haeparin induced Haematoma of the Iliopsoas muscle 1(0.3%) Delirium 1(0.3%) DVT 1(0.3%) Bowl ischemia 1(0.3%) Acute cholecystitis 1(0.3%) ARDS 1(0.3%) Lung haerniation 1(0.3%) Post-operative IABP 1(0.3%) Impella 1(0.3%) Postoperative in-hospital stay, days 11(8;14) Pre-discharged Haemoglobin, g/dL 10.3(9.3;11.5) Post-operative serum creatinine, mg/dL 0.86 ± 0.71 Values are mean ± standard deviation, median and interquartile range (in brackets), or counts and percentages (in parentheses). ARDS = Acute Respiratory Distress Syndrome; DES = Drug Eluting Stent; ECMO = Extra Corporeal Membrane Oxygenation; PCI = Percutaneous Coronary Intervention; TIA = Transient Ischaemic Attack; VAC = Vacuum Assisted Closure. The in-hospital mortality rate was 0.8% (3 patients), including two cardiac-related deaths (0.5%). The most frequent postoperative event was atrial fibrillation, occurring in 160 patients (43.5%). Re-exploration for bleeding was required in 22 patients (6%), and 17 (4.6%) developed chest wall hematoma. Permanent pacemaker implantation was necessary in 14 patients (3.8%), primarily for complete atrioventricular block. Other complications included pleural effusion requiring thoracentesis (9%), acute kidney injury (3.8%), respiratory insufficiency (3.5%), and stroke (1.2%). Severe pericardial effusion requiring surgical drainage occurred in 0.5%. The median hospital stay was 11 days (IQR 8–14). Follow-up Follow-up was complete for 363 patients (98.6%), with a median duration of 2.5 years (IQR 1.18–4.15). The 7-year all-cause mortality rate was 3.3% (Fig. 1), and the 7-year reoperation rate for recurrent mitral valve dysfunction was 1.7% (Fig. 2A). The cumulative major adverse cardiac and cerebrovascular events (MACCE) rate was 1.9% (Fig. 2B). Echocardiographic Outcomes Postoperative echocardiographic data prior to discharge are presented in Supplementary Materials. Median postoperative LVEF was 58% (53–62), with only 2 patients (0.5%) showing moderate or severe residual mitral regurgitation and 2 patients (0.5%) with moderate mitral stenosis. At a median echocardiographic follow-up of 3.5 years (IQR 0–10.7), results remained stable (Table 5 ). Table 5 Follow-up echocardiographic data. Left ventricular ejection fraction, % 57.93 ± 6.13 Severe Mitral Valve Regurgitation 5(1.9%) Moderate Mitral Valve Regurgitation 7(2.7%) Mitral Valve Mean Gradient (mmHg) 3(2;4) Endocarditis 2(0.84%) End-diastolic volume, mL 101.67 ± 30.66 End-systolic volume, mL 40(33;53) End-diastolic diameter, mm 46.95 ± 8.17 End-systolic diameter, mm 31.67 ± 8.46 Systolic PA pressure, mmHg 28(24;31) TAPSE, mm 20(18;22) Values are mean ± standard deviation, median and interquartile range (in brackets), or counts and percentages (in parentheses). TAPSE=tricuspid annular plane systolic excursion Mitral regurgitation recurrence occurred in 18 patients (6%), of which 7 (2.4%) were moderate and 1 (0.3%) severe. Mitral stenosis was observed in 4 patients (1.4%), severe in only one. The mean mitral valve gradient was 3 mmHg (IQR 2–4), and mean LVEF remained preserved at 57.9 ± 6.1%. Discussion Our study demonstrates that totally video-guided thoracoscopic surgery (TVTS) for mitral valve repair is a safe and effective technique, achieving excellent short- and mid-term outcomes when performed in experienced centers. The reoperation rate in our series was comparable to that reported in studies of conventional sternotomy approaches, underscoring the durability of repair achieved via the minimally invasive route. TVTS has emerged as a refined alternative to median sternotomy for mitral valve repair and replacement. By employing small thoracic ports and high-definition visualization, this technique minimizes surgical trauma while maintaining repair quality. An expanding body of evidence supports its clinical efficacy, with reported perioperative mortality rates typically between 0.5% and 2.0%, comparable to conventional open procedures [7;8]. Reoperation rates in experienced centers generally remain below 5% at five-year follow-up [9;10]. Additionally, patients benefit from reduced postoperative pain, faster mobilization, and shorter hospital stays, often by 2–4 days, compared to those undergoing sternotomy [11–13]. In our retrospective analysis of 368 consecutive patients undergoing TVTS mitral valve repair, the in-hospital mortality rate was 0.8%, consistent with or superior to published benchmarks from both minimally invasive and conventional approaches. Large series, such as those by Glauber et al. [1] and Seeburger et al. [2] have reported similar mortality rates of 1.1% and 0.9%, respectively. Likewise, the European multicenter registry reported rates ranging from 0.5% to 2.0% depending on patient risk profiles [14]. These data collectively affirm that TVTS mitral valve surgery, when performed by experienced teams, ensures excellent perioperative safety. The conversion rate to sternotomy in our cohort was 3%, aligning well with previously reported rates (1–5%). Most conversions were performed for safety reasons, reflecting appropriate intraoperative judgment rather than technical failure. Seeburger et al. [2] and Casselman et al. [14] reported similar conversion rates of 3.2% and 2.4%, respectively. Our low conversion rate likely reflects rigorous preoperative imaging, patient selection, and cumulative institutional experience with the TVTS technique. Postoperative recovery in our cohort was notably favorable, with shorter ICU and hospital stays and earlier return to daily activities compared to conventional surgery. These findings, consistent with prior literature, highlight the benefits of TVTS in enhancing recovery and optimizing resource utilization. At a median follow-up of 2.5 years, our patients demonstrated excellent mid-term outcomes, with a reoperation rate of 1.7% and an overall mortality of 3.3% at 7 years. These results compare favorably with those from large-scale registries—such as the STS database [15], which reported a 5-year reoperation rate of 3.1%—and long-term series like Glauber et al. (2011), who observed a 2.8% reoperation rate at 4 years. Similarly, Casselman et al. (2020) documented a 96% 3-year survival rate, supporting the long-term durability of TVTS mitral repair. Collectively, these findings confirm that TVTS mitral valve surgery provides reproducible, durable, and safe outcomes when performed in high-volume centers by dedicated teams. The low mortality, low reoperation rate, and accelerated recovery profile highlight its clinical advantages over traditional open surgery. Nevertheless, certain limitations must be acknowledged. This study was retrospective and single-center in design, which may limit generalizability. Selection bias and unmeasured confounders inherent to retrospective analyses cannot be excluded. Moreover, the technique demands specialized equipment, a dedicated surgical team, and a significant learning curve. Not all patients—particularly those with dense pleural adhesions—are ideal candidates for TVTS. Conclusions In summary, TVTS mitral valve surgery can be performed with excellent safety, efficacy, and durability in experienced hands. Our results—featuring an in-hospital mortality of 0.8%, low reoperation rates, and favorable recovery—demonstrate that this minimally invasive approach achieves outcomes equivalent to, or better than, those of conventional sternotomy. These findings support the continued integration of TVTS into standard surgical practice and underscore the need for prospective multicenter studies and standardized training programs to facilitate broader and safer adoption of this technique. Declarations Financial support: This study was supported by the Italian Ministry of Health – Ricerca Corrente to Centro Cardiologico Monzino IRCCS. References Glauber M, Miceli A, Canarutto D, et al. Video-assisted mitral valve surgery: a 15-year single-center experience. Eur J Cardiothorac Surg. 2011;39(6):861–867. Seeburger J, Rinaldi M, Nielsen SL, et al. Minimal invasive mitral valve surgery: results and predictors of conversion to full sternotomy. Eur J Cardiothorac Surg. 2015;48(2):e38–e44. Gammie JS, Zhao Y, Peterson ED, et al. Less-invasive mitral valve operations: trends and outcomes from the Society of Thoracic Surgeons Adult Cardiac Surgery Database. Ann Thorac Surg. 2018;105(3):707–715. Modi P, Hassan A, Chitwood WR. Minimally invasive mitral valve surgery: a systematic review. J Heart Valve Dis. 2006;15(6):673–679. Casselman F, Van Slycke S, Dom H, et al. Endoscopic mitral valve surgery: from the right thoracic approach to totally endoscopic surgery. Ann Cardiothorac Surg. 2013;2(6):744–746. Nashef SA, Roques F, Sharples LD et al. EuroSCORE II. Eur J Cardiothorac Surg. 2012;41:734-744. Pham TD, Tran TH, Le NT, et al. Totally endoscopic mitral valve repair with novel technique of left atrial exposure: five years experience from a single center. J Cardiothorac Surg. 2025 Jan 6;20(1):28. Razan Salem, Katharina Fay, Philipp Kaiser, et al. Minimally Invasive Mitral Valve Surgery: Long-Term (20-Year) Follow-Up After Right Anterolateral Minithoracotomy, CJC Open, Volume 7, Issue 7, 2025, Pages 879-886, Modi P, Rodriguez E, Hargrove WC, et al. Minimally invasive video-assisted mitral valve surgery: a 12-year experience. Eur J Cardiothorac Surg. 2009;36(3):535–539. Truong S, Petersen J, Schmiegelow MDS, et al. Incidence and factors associated with mitral valve reoperation in patients undergoing surgery for mitral regurgitation: A nationwide cohort study. Int J Cardiol. 2025 Jan 1; 418:132608. Heine M, Saggu JS, Nabzdyk CGS, et al. Minimally Invasive, Maximally Effective: Anesthetic Management for Endoscopic Cardiac Surgery. J Cardiothorac Vasc Anesth. 2025 Sep 13:S1053-0770(25)00784-0. Huang LC, Chen DZ, Chen LW, et al. Health-related quality of life following minimally invasive totally endoscopic mitral valve surgery. J Cardiothorac Surg. 2020 Jul 28;15(1):194. Chitwood WR Jr, Elbeery JR, Chapman WH, et al. Video-assisted minimally invasive mitral valve surgery. J Thorac Cardiovasc Surg. 1997;113(2):413–422 Filip Casselman, Jose Aramendi, Mohamed Bentala, et al. Endoaortic Clamping Does Not Increase the Risk of Stroke in Minimal Access Mitral Valve Surgery: A Multicenter Experience, The Annals of Thoracic Surgery, Volume 100, Issue 4, 2015, Pages 1334-1339, Gammie JS, Zhao Y, Peterson ED, et al. Less-invasive mitral valve operations: trends and outcomes from the Society of Thoracic Surgeons Adult Cardiac Surgery Database. Ann Thorac Surg. 2018;105(3):707–715. Additional Declarations No competing interests reported. Supplementary Files SupplementaryMaterials.docx Cite Share Download PDF Status: Published Journal Publication published 28 Apr, 2026 Read the published version in Journal of Cardiothoracic Surgery → Version 1 posted Editorial decision: Revision requested 03 Apr, 2026 Reviews received at journal 29 Mar, 2026 Reviews received at journal 25 Mar, 2026 Reviewers agreed at journal 24 Mar, 2026 Reviewers agreed at journal 21 Mar, 2026 Reviewers agreed at journal 21 Mar, 2026 Reviews received at journal 20 Mar, 2026 Reviewers agreed at journal 20 Mar, 2026 Reviewers agreed at journal 19 Mar, 2026 Reviewers agreed at journal 19 Mar, 2026 Reviewers invited by journal 19 Mar, 2026 Editor assigned by journal 02 Mar, 2026 Submission checks completed at journal 02 Mar, 2026 First submitted to journal 20 Feb, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Mastroiacovo","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABE0lEQVRIie3OwUrDMBjA8cxAdgnk+hVH+wothamwu6+xIuyU3ncYpRLoLmNeC76EIHhOCdRLHyCgB3EvIAgyEMbaKsVDgtcd8r98IeHHF4RcrlMMD6dR3g8G/YDJnycjgYF4ZX8CirDNDOS3UP9giixrgmssz/Qqyy7W4vZjv1R+/CKe3/XqkqIxkyYSKTLHvFYwaSrhbRoVT1/rRPDa/rFI0BBzIgEgyc9HxSJ50jwSnPxHDllHxHdHHsuOHOwkwC1JC9yRot0ySx6gJWlhJyEmc5VulVfSqrjaNLMY9CK5T7dACcahccudqnb8K2MwXu/0fgk+K2/kZ3vjM1a9GbdIhKRxPyLmaxTklgeXy+VyDR0BGd5UhaGTtnMAAAAASUVORK5CYII=","orcid":"","institution":"Centro Cardiologico Monzino","correspondingAuthor":true,"prefix":"","firstName":"Giorgio","middleName":"","lastName":"Mastroiacovo","suffix":""},{"id":609946707,"identity":"3c3b9cba-2bf4-48ff-8356-9c67c57ff1f5","order_by":1,"name":"Alice Bonomi","email":"","orcid":"","institution":"Centro Cardiologico 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Monzino","correspondingAuthor":false,"prefix":"","firstName":"Vittoria","middleName":"","lastName":"Iennaco","suffix":""},{"id":609946711,"identity":"c45083cc-693c-412f-8b87-9b57a31f6d0b","order_by":5,"name":"Nicola Cosentino","email":"","orcid":"","institution":"Centro Cardiologico Monzino","correspondingAuthor":false,"prefix":"","firstName":"Nicola","middleName":"","lastName":"Cosentino","suffix":""},{"id":609946712,"identity":"6dd252ab-fb23-4c42-a388-19f758f629b8","order_by":6,"name":"Manuela Muratori","email":"","orcid":"","institution":"Centro Cardiologico Monzino","correspondingAuthor":false,"prefix":"","firstName":"Manuela","middleName":"","lastName":"Muratori","suffix":""},{"id":609946713,"identity":"17561f5c-b547-4110-b8fc-8b61c885b452","order_by":7,"name":"Giorgia Bonalumi","email":"","orcid":"","institution":"Centro Cardiologico Monzino","correspondingAuthor":false,"prefix":"","firstName":"Giorgia","middleName":"","lastName":"Bonalumi","suffix":""},{"id":609946714,"identity":"65e5268e-b9d4-4990-8e10-bf20ce3e3739","order_by":8,"name":"Eleonora Penza","email":"","orcid":"","institution":"Centro Cardiologico Monzino","correspondingAuthor":false,"prefix":"","firstName":"Eleonora","middleName":"","lastName":"Penza","suffix":""},{"id":609946715,"identity":"9e4aa75c-4a7e-455c-a605-535258c762d1","order_by":9,"name":"Emad Al jaber","email":"","orcid":"","institution":"Centro Cardiologico Monzino","correspondingAuthor":false,"prefix":"","firstName":"Emad","middleName":"Al","lastName":"jaber","suffix":""}],"badges":[],"createdAt":"2026-02-20 21:09:07","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8929107/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8929107/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s13019-026-04234-2","type":"published","date":"2026-04-28T15:57:30+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":105195971,"identity":"6484ef05-982c-446a-9f29-7982cf5e41e9","added_by":"auto","created_at":"2026-03-23 10:18:04","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":130583,"visible":true,"origin":"","legend":"\u003cp\u003eKaplan-Meier Survival Curve for Overall-mortality\u003c/p\u003e","description":"","filename":"image1.png","url":"https://assets-eu.researchsquare.com/files/rs-8929107/v1/5967a3d54d5df5b679d2fdfc.png"},{"id":105195972,"identity":"dc035e5c-3121-4672-bc87-d0b4cb6c6c08","added_by":"auto","created_at":"2026-03-23 10:18:04","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":185244,"visible":true,"origin":"","legend":"\u003cp\u003eA: Kaplan-Meier Survival Curve for Re-intervention\u003c/p\u003e\n\u003cp\u003eB: Kaplan-Meier Survival Curve for MACCE\u003c/p\u003e","description":"","filename":"image2.png","url":"https://assets-eu.researchsquare.com/files/rs-8929107/v1/d325f4f2926acce03a4c56ff.png"},{"id":108438068,"identity":"233e409e-60a9-4213-a081-562732140da2","added_by":"auto","created_at":"2026-05-04 16:06:37","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":706322,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8929107/v1/af77b31d-9dcc-4d35-8c06-19dd6ccc2984.pdf"},{"id":105563998,"identity":"528f2bd5-462a-4f82-9666-cba2bc70bef2","added_by":"auto","created_at":"2026-03-27 12:48:25","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":14035,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryMaterials.docx","url":"https://assets-eu.researchsquare.com/files/rs-8929107/v1/594d58b1cfed8914a231f878.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Mid-term Outcomes after Totally Video Guided Thoracoscopic Mitral Valve Surgery","fulltext":[{"header":"Introduction","content":"\u003cp\u003eTotally Video-guided thoracoscopic surgery (TVTS) has emerged as a minimally invasive alternative to conventional median sternotomy for mitral valve repair and replacement. By utilizing small thoracic ports and high-definition thoracoscopic visualization, this approach aims to reduce surgical trauma while achieving comparable valve repair quality. The growing body of literature has increasingly focused on clinical outcomes to assess the true benefits and limitations of TVTS in this context.\u003c/p\u003e \u003cp\u003eSeveral retrospective and prospective studies have demonstrated that TVTS mitral valve surgery is associated with low perioperative mortality, typically ranging between 0.5% and 2.0%, comparable to outcomes observed with conventional open procedures [1,2]. Reoperation rates due to recurrent mitral regurgitation or prosthetic dysfunction remain low in experienced centers, generally under 5% at 5-year follow-up [3]. Moreover, functional recovery is notably improved, with patients experiencing reduced postoperative pain, earlier mobilization, and faster return to daily activities compared to those undergoing sternotomy [4,5]. Hospital length of stay is also significantly shortened, often by 2\u0026ndash;4 days, reflecting enhanced recovery protocols associated with minimally invasive techniques.\u003c/p\u003e \u003cp\u003eAs the demand for less invasive cardiac interventions grows, understanding the clinical outcomes of TVTS mitral valve surgery is essential for guiding patient selection and surgical planning.\u003c/p\u003e \u003cp\u003eHowever, real world data on TVTS are lacking and we therefore conducted a retrospective study on 368 consecutive patients who underwent TVTS for mitral valve repair to evaluate the safety, efficacy, and short and mid-term outcomes of this minimally invasive approach. The aim was to contribute real-world data from a single-center experience and assess short and long-term clinical performance in terms of mortality, reoperation, and post-operative outcomes.\u003c/p\u003e"},{"header":"Material and method","content":"\u003cp\u003eStudy Design and Patient Population\u003c/p\u003e \u003cp\u003eThis is a retrospective, single-center cohort study including a consecutive series of patients who underwent elective or emergent mitral valve repair interventions via thoracoscopic approach procedure at the Centro Cardiologico Monzino IRCCS, Milan, Italy, from May 2018 to August 2025. The Data Governance Board of the Centro Cardiologico Monzino IRCCS, Milan, Italy, approved this study (date 10/12/2024, diary no. NP1090). Patients\u0026rsquo; written consent was waived because of the retrospective nature of this study.\u003c/p\u003e \u003cp\u003ePrior cardiac surgery was considered exclusion criteria for TVTS mitral valve surgery.\u003c/p\u003e \u003cp\u003eData on patients\u0026rsquo; risk factors, echocardiographic and operative and post-operative data were retrospectively collected from electronic medical records. The operative risk was estimated using the EuroSCORE II [6].\u003c/p\u003e \u003cp\u003eOutcomes\u003c/p\u003e \u003cp\u003eThe primary outcomes of the study were short (intended as the index hospitalization) and long-term both survival and freedom from reoperation from on the mitral valve. The secondary outcomes of the study were: length of postoperative in-hospital stay, in-hospital acute kidney injury, permanent pace-maker implantation, sepsis, moderate-to-severe pericardial effusion, atrial fibrillation, myocardial infarction, reoperation for bleeding and stroke. Data on late adverse events were gathered from clinical records and by contacting the patients or her/his relatives. Follow-up data was considered complete for all patients except for five. The median follow-up was 2.5 years (q1; q3 1.18;4.15)\u003c/p\u003e \u003cp\u003eSurgical Technique\u003c/p\u003e \u003cp\u003eTVTS mitral valve surgery is performed via a 2\u0026ndash;4 cm right peri-areolar skin incision for men and almost 4 cm above the mammal sulcus for women, followed by a thoracotomy at the 4th or 5th intercostal space. A small soft tissue retractor (Edwards Lifesciences TRM thruport soft tissue retractor) is used to improve surgical exposure.\u003c/p\u003e \u003cp\u003eCardio-pulmonary bypass (CPB) is established through peripheral femoral arterial and venous cannulation. We use the double stage 25 Fr Medtronic Bio-Medicus venous cannula for all patients, with the distal end positioned in the superior vena cava under transesophageal echocardiographic (TEE) guidance.\u003c/p\u003e \u003cp\u003eThe thoracoscope is inserted on a 5 mm working port via a small skin incision of 1\u0026ndash;2 cm at the 2nd/3rd right intercostal space on the anterior axillary line.\u003c/p\u003e \u003cp\u003eA small longitudinal pericardial incision is performed laterally to the ascending aorta and extended downwards to the right atrium, almost 2 cm above the phrenic nerve.\u003c/p\u003e \u003cp\u003eThe cardiotomy vent and pericardial stay suture are placed through a small skin incision of 1\u0026ndash;2 cm in the 7th/8th right intercostal space on the anterior axillary line.\u003c/p\u003e \u003cp\u003eAfter aortic cross-clamping with the Cygnet Aortic Cross Clamp (Straight Peters Surgical, Bobigny Cedex, France), Del Nido cardioplegia is delivered anterogradely. Normothermic CPB is conducted in all patients.\u003c/p\u003e \u003cp\u003eLeft atriotomy is performed. An atrial retractor is passed through the thoracotomy and fixed on a metal support inserted through a small skin incision of 1 cm at the 4th/5th intercostal space along the right parasternal line.\u003c/p\u003e \u003cp\u003eMitral valve repair is usually performed with artificial chords of expanded polytetrafluoroethylene and a ring (Cosgrove-Edwards, MEMO 4D-LivaNova) when feasible, otherwise a biological or mechanical valve is implanted using 2\u0026thinsp;\u0026minus;\u0026thinsp;0 Ti-Cron stitches tied with the Cor-Knot system (LSI Solutions, Victor, NY).\u003c/p\u003e \u003cp\u003eFollowing re-warming, the heart is commonly de-aired both through a left atrial and an aortic vent. The procedure of de-airing is performed under continuous echocardiographic monitoring. Once completed, the vents are removed and checked for surgical bleeding points.\u003c/p\u003e \u003cp\u003eAtriotomy is closed with 3\u0026thinsp;\u0026minus;\u0026thinsp;0 Prolene as standard fashion. Pericardium is left open at the end of\u003c/p\u003e \u003cp\u003ethe procedure and two chest tubes are inserted (one in the right pleural space and another one in the pericardium.\u003c/p\u003e \u003cp\u003eThen the space between the ribs is closed with a Ethicon PDS II suture to avoid lung herniation and the subcutaneous tissue and the derma are sewed in a standard fashion.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eContinuous variables are summarized as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD) for normally distributed variables, or as median and interquartile range (IQR) if not. A logarithmic adjustment is applied to variables with a right-skewed distribution prior to analysis. When data cannot be normalized through transformation, non-parametric methods are applied. Categorical variables are expressed as absolute frequencies and percentages. In order to estimate survival functions, Kaplan\u0026ndash;Meier curves are presented for time-to-event outcomes (MACCE and overall mortality, MACCE and reoperation over time).\u003c/p\u003e \u003cp\u003eAll statistical analyses are performed using SASSoftwareversion 9.4(Copyright \u0026copy; 2002\u0026ndash;2012 by SAS Institute Inc., Cary, NC, USA).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003ePatient Population\u003c/p\u003e \u003cp\u003eA total of 368 consecutive patients who underwent TVTS mitral valve repair were included in the analysis. Baseline clinical characteristics are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline characteristics (N\u0026thinsp;=\u0026thinsp;368)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinical variables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e60(54;68)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale sex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e283(76.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWeight (Kg)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e74.32\u0026thinsp;\u0026plusmn;\u0026thinsp;12.87\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI (Kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24.56\u0026thinsp;\u0026plusmn;\u0026thinsp;3.12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDyslipidemia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e69(18.75%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSmoker\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eActive smoker\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e39(10.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFormer smoker\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e52(14.13%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypertension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e227(61.68%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes I type\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6(1.63%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes II type\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7(1.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHaemoglobin, g/dL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14.4(13.5;15.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCreatinine, mg/dL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.95(0.84;1.08)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCOPD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7(1.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrevious myocardial infarction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5(1.36%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrevious stroke\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1(0.27%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrior endocarditis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1(0.27%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEuroSCORE II, %\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.9(0.67;1.35)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHeart rhythm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSinus rhythm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e299(81.25%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAtrial Flutter\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1(0.27%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParoxysmal Atrial Fibrillation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36(9.78%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePersistent Atrial Fibrillation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11(2.99%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePermanent Atrial Fibrillation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16(4.35%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePacemaker\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5(1.36%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eValues are mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation, median and interquartile range (in brackets), or counts and percentages (in parentheses). COPD\u0026thinsp;=\u0026thinsp;Chronic Obstructive Pulmonary Disease.\u003c/p\u003e \u003cp\u003eThe median age was 60 years (IQR 54\u0026ndash;68), and 283 patients (76.9%) were male. Hypertension was present in 61.7%, dyslipidemia in 18.8%, and diabetes mellitus in 3.5% of patients. The median EuroSCORE II was 0.9% (0.67\u0026ndash;1.35), reflecting a low predicted operative risk. Most patients were in sinus rhythm (81.3%), while 17.1% had a history of atrial fibrillation.\u003c/p\u003e \u003cp\u003ePreoperative echocardiographic characteristics are presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePreoperative echocardiographic data (N 368)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative echocardiographic variables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLV ejection fraction, %\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e65(61;68)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAortic peak gradient, mmHg\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7(6;9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAortic valve velocity, cm/s\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.3(1.1;1.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEnd-diastolic volume, mL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e125(85.5;158)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEnd-systolic volume, mL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42.5(29;56)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEnd-diastolic diameter, mm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e52(35;59)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEnd-systolic diameter, mm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30(21;35)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLV index diastolic diameter (mm/m2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30(27;32)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePAPs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34(29;42)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTAPSE, mm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26(23;29)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eValues are mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation, median and interquartile range (in brackets), or counts and percentages (in parentheses).\u003c/p\u003e \u003cp\u003eLV\u0026thinsp;=\u0026thinsp;Left Ventricular; PAP=Pulmonary Arterial Pressure systolic; TAPSE=tricuspid annular plane systolic excursion\u003c/p\u003e \u003cp\u003eThe median left ventricular ejection fraction (LVEF) was 65% (61\u0026ndash;68). The mean left ventricular end-diastolic diameter was 52 mm (35\u0026ndash;59), and the median pulmonary artery systolic pressure (PAPs) was 34 mmHg (29\u0026ndash;42), indicating preserved ventricular function in the majority of patients.\u003c/p\u003e \u003cp\u003eIntraoperative Data\u003c/p\u003e \u003cp\u003eIntraoperative variables are shown in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eIntraoperative variables (N 3\u003cem\u003e68\u003c/em\u003e)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePathology\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMitral Regurgitation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e368(100%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eElective\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e366(99.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmergency\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2(0.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMitral Valve Repair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e362(98.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of artificial cordae\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19(5.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e52(14.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e227(61.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e52(14.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13(3.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5(1.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePosition of the artificial cordae\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePosterior Leaflet\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e282(76.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnterior and posterior Leaflet\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33(9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnterior Leaflet\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17(4.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnterior and posterior leaflets and posteromedial commisure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4(1.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePosterior leaflet and posteromedial commissure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4(1.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePosteromedial commissure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3(0.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnterior leaflet and posteromedial commissure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1(0.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePosterior leaflet and anterolateral commissure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1(0.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePosterior leaflet, anterolateral commisure and posteromedial commissure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1(0.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePosterior and anterior leaflet and anterolateral commisure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1(0.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnterior leaflet and anterolateral commissure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1(0.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResect Technique\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1(0.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePaneth Technique\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1(0.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMitral valve Replacement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6(1.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBiological prostheses\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4(1.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMechanical Prostheses\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2(0.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConversion to Sternotomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11(3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnstoppable bleeding\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9(2.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAortic dissection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2(0.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConcomitant procedures\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTricuspid valve repair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25 (7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTricuspid valve Ring\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21(5.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDe Vega\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4(1.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAVR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (0.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInspiris Resilia 25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1(0.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePerceval\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1(0.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMAZE and LAAC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27(5.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSecond run CPB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17(4.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResidual Moderate Mitral Regurgitation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9(1.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHaemorrhage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5(1.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStunning Myocardium\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2(0.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProstheses malfunction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1(0.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLocation of Haemorrhage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePacemaker wire\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5(1.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAortic vent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2(0.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAortic suture\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1(0.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAtrial suture\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1(0.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiffuse bleeding\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1(0.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAortic cross-clamp time, min\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e103\u0026thinsp;\u0026plusmn;\u0026thinsp;38\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCardiopulmonary bypass time, min\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e119\u0026thinsp;\u0026plusmn;\u0026thinsp;48\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eValues are mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation, median and interquartile range (in brackets), or counts and percentages (in parentheses).\u003c/p\u003e \u003cp\u003eAVR\u0026thinsp;=\u0026thinsp;Aortic Valve Replacement; CPB\u0026thinsp;=\u0026thinsp;Cardio Pulmonary Bypass; LAAC\u0026thinsp;=\u0026thinsp;Left Atrial Appendage Closure;\u003c/p\u003e \u003cp\u003eAll patients presented with mitral regurgitation, and 98.4% underwent successful mitral valve repair, while 1.6% required valve replacement (4 biological, 2 mechanical prostheses). The vast majority of repairs (96.4%) were performed using the respect technique with two PTFE artificial chordae placed on the posterior leaflet (61.7%).\u003c/p\u003e \u003cp\u003eThe median cardiopulmonary bypass (CPB) and aortic cross-clamp times were 119\u0026thinsp;\u0026plusmn;\u0026thinsp;48 minutes and 103\u0026thinsp;\u0026plusmn;\u0026thinsp;38 minutes, respectively.\u003c/p\u003e \u003cp\u003eA conversion to sternotomy was required in 11 patients (3%), primarily for uncontrollable bleeding (2.4%) and aortic dissection (0.5%).\u003c/p\u003e \u003cp\u003eA second CPB run was performed in 17 patients (4.6%), mainly due to residual mitral regurgitation (1.9%), bleeding (1.4%), prosthetic dysfunction (0.3%), or myocardial stunning (0.5%).\u003c/p\u003e \u003cp\u003eConcomitant procedures were performed in 54 patients (14.7%), including tricuspid valve repair (7%), aortic valve replacement (0.5%), and MAZE or left atrial appendage closure (5.4%).\u003c/p\u003e \u003cp\u003eEarly Postoperative Outcomes\u003c/p\u003e \u003cp\u003eEarly postoperative outcomes are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eEarly postoperative outcomes.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOutcomes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIn-hospital mortality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3(0.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCardiac death\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2(0.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCardio Pulmonary Resuscitation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3(0.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVentricular arrhythmia (Ventricular tachycardia or fibrillation)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3(0.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAtrial fibrillation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e160(43.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePleural effusion undergone to thoracentesis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33(9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReintervention for bleeding\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22(6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChest wall hematoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17(4.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAcute kidney injury\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14(3.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePermanent pacemaker implantation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14(3.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRespiratory Insufficiency\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13(3.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHemidiaphragm elevation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12(3.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePericarditis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10(2.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLymphocele\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9(2.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHaemothorax\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8(2.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSubcutaneous emphysema\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7(1.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePost CPB cardiogenic shock\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7(1.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRight ventricular shock\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5(1.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeft ventricular shock\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3(0.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBiventricular dysfunction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2(0.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHemofiltration\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6(1.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThoracic empyema\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5(1.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eECMO\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5(1.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStroke\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4(1.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTIA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3(0.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTracheostomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3(0.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUse of VAC therapy to treat inguinal wound dehiscence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3(0.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVascular complications on the femoral artery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2(0.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComa\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2(0.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePCI\u0026thinsp;+\u0026thinsp;DES post OR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2(0.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSepsis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2(0.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSevere pericardial effusion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2(0.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHaemorrhagic shock\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2(0.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMyocardial Infarction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2(0.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHaeparin induced Haematoma of the Iliopsoas muscle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1(0.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDelirium\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1(0.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDVT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1(0.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBowl ischemia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1(0.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAcute cholecystitis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1(0.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eARDS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1(0.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLung haerniation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1(0.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePost-operative IABP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1(0.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImpella\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1(0.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative in-hospital stay, days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11(8;14)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePre-discharged Haemoglobin, g/dL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10.3(9.3;11.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePost-operative serum creatinine, mg/dL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.86\u0026thinsp;\u0026plusmn;\u0026thinsp;0.71\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eValues are mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation, median and interquartile range (in brackets),\u003c/p\u003e \u003cp\u003eor counts and percentages (in parentheses).\u003c/p\u003e \u003cp\u003eARDS\u0026thinsp;=\u0026thinsp;Acute Respiratory Distress Syndrome; DES\u0026thinsp;=\u0026thinsp;Drug Eluting Stent; ECMO\u0026thinsp;=\u0026thinsp;Extra Corporeal Membrane Oxygenation; PCI\u0026thinsp;=\u0026thinsp;Percutaneous Coronary Intervention; TIA\u0026thinsp;=\u0026thinsp;Transient Ischaemic Attack; VAC\u0026thinsp;=\u0026thinsp;Vacuum Assisted Closure.\u003c/p\u003e \u003cp\u003eThe in-hospital mortality rate was 0.8% (3 patients), including two cardiac-related deaths (0.5%).\u003c/p\u003e \u003cp\u003eThe most frequent postoperative event was atrial fibrillation, occurring in 160 patients (43.5%).\u003c/p\u003e \u003cp\u003eRe-exploration for bleeding was required in 22 patients (6%), and 17 (4.6%) developed chest wall hematoma.\u003c/p\u003e \u003cp\u003ePermanent pacemaker implantation was necessary in 14 patients (3.8%), primarily for complete atrioventricular block.\u003c/p\u003e \u003cp\u003eOther complications included pleural effusion requiring thoracentesis (9%), acute kidney injury (3.8%), respiratory insufficiency (3.5%), and stroke (1.2%). Severe pericardial effusion requiring surgical drainage occurred in 0.5%.\u003c/p\u003e \u003cp\u003eThe median hospital stay was 11 days (IQR 8\u0026ndash;14).\u003c/p\u003e \u003cp\u003eFollow-up\u003c/p\u003e \u003cp\u003eFollow-up was complete for 363 patients (98.6%), with a median duration of 2.5 years (IQR 1.18\u0026ndash;4.15). The 7-year all-cause mortality rate was 3.3% (Fig.\u0026nbsp;1),\u003c/p\u003e \u003cp\u003e \u003cdiv description=\"\" class=\"Drawing\" id=\"2\" name=\"Immagine 2\"\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eand the 7-year reoperation rate for recurrent mitral valve dysfunction was 1.7% (Fig.\u0026nbsp;2A). The cumulative major adverse cardiac and cerebrovascular events (MACCE) rate was 1.9% (Fig.\u0026nbsp;2B).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eEchocardiographic Outcomes\u003c/p\u003e \u003cp\u003ePostoperative echocardiographic data prior to discharge are presented in Supplementary Materials.\u003c/p\u003e \u003cp\u003eMedian postoperative LVEF was 58% (53\u0026ndash;62), with only 2 patients (0.5%) showing moderate or severe residual mitral regurgitation and 2 patients (0.5%) with moderate mitral stenosis.\u003c/p\u003e \u003cp\u003eAt a median echocardiographic follow-up of 3.5 years (IQR 0\u0026ndash;10.7), results remained stable (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFollow-up echocardiographic data.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeft ventricular ejection fraction, %\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e57.93\u0026thinsp;\u0026plusmn;\u0026thinsp;6.13\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSevere Mitral Valve Regurgitation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5(1.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModerate Mitral Valve Regurgitation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7(2.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMitral Valve Mean Gradient (mmHg)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3(2;4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEndocarditis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2(0.84%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEnd-diastolic volume, mL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e101.67\u0026thinsp;\u0026plusmn;\u0026thinsp;30.66\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEnd-systolic volume, mL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40(33;53)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEnd-diastolic diameter, mm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46.95\u0026thinsp;\u0026plusmn;\u0026thinsp;8.17\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEnd-systolic diameter, mm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31.67\u0026thinsp;\u0026plusmn;\u0026thinsp;8.46\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSystolic PA pressure, mmHg\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28(24;31)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTAPSE, mm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20(18;22)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eValues are mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation, median and interquartile range (in brackets), or counts and percentages (in parentheses).\u003c/p\u003e \u003cp\u003eTAPSE=tricuspid annular plane systolic excursion\u003c/p\u003e \u003cp\u003eMitral regurgitation recurrence occurred in 18 patients (6%), of which 7 (2.4%) were moderate and 1 (0.3%) severe. Mitral stenosis was observed in 4 patients (1.4%), severe in only one.\u003c/p\u003e \u003cp\u003eThe mean mitral valve gradient was 3 mmHg (IQR 2\u0026ndash;4), and mean LVEF remained preserved at 57.9\u0026thinsp;\u0026plusmn;\u0026thinsp;6.1%.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur study demonstrates that totally video-guided thoracoscopic surgery (TVTS) for mitral valve repair is a safe and effective technique, achieving excellent short- and mid-term outcomes when performed in experienced centers. The reoperation rate in our series was comparable to that reported in studies of conventional sternotomy approaches, underscoring the durability of repair achieved via the minimally invasive route.\u003c/p\u003e \u003cp\u003eTVTS has emerged as a refined alternative to median sternotomy for mitral valve repair and replacement. By employing small thoracic ports and high-definition visualization, this technique minimizes surgical trauma while maintaining repair quality.\u003c/p\u003e \u003cp\u003eAn expanding body of evidence supports its clinical efficacy, with reported perioperative mortality rates typically between 0.5% and 2.0%, comparable to conventional open procedures [7;8]. Reoperation rates in experienced centers generally remain below 5% at five-year follow-up [9;10]. Additionally, patients benefit from reduced postoperative pain, faster mobilization, and shorter hospital stays, often by 2\u0026ndash;4 days, compared to those undergoing sternotomy [11\u0026ndash;13].\u003c/p\u003e \u003cp\u003eIn our retrospective analysis of 368 consecutive patients undergoing TVTS mitral valve repair, the in-hospital mortality rate was 0.8%, consistent with or superior to published benchmarks from both minimally invasive and conventional approaches. Large series, such as those by Glauber et al. [1] and Seeburger et al. [2] have reported similar mortality rates of 1.1% and 0.9%, respectively. Likewise, the European multicenter registry reported rates ranging from 0.5% to 2.0% depending on patient risk profiles [14]. These data collectively affirm that TVTS mitral valve surgery, when performed by experienced teams, ensures excellent perioperative safety.\u003c/p\u003e \u003cp\u003eThe conversion rate to sternotomy in our cohort was 3%, aligning well with previously reported rates (1\u0026ndash;5%). Most conversions were performed for safety reasons, reflecting appropriate intraoperative judgment rather than technical failure. Seeburger et al. [2] and Casselman et al. [14] reported similar conversion rates of 3.2% and 2.4%, respectively. Our low conversion rate likely reflects rigorous preoperative imaging, patient selection, and cumulative institutional experience with the TVTS technique.\u003c/p\u003e \u003cp\u003ePostoperative recovery in our cohort was notably favorable, with shorter ICU and hospital stays and earlier return to daily activities compared to conventional surgery. These findings, consistent with prior literature, highlight the benefits of TVTS in enhancing recovery and optimizing resource utilization.\u003c/p\u003e \u003cp\u003eAt a median follow-up of 2.5 years, our patients demonstrated excellent mid-term outcomes, with a reoperation rate of 1.7% and an overall mortality of 3.3% at 7 years. These results compare favorably with those from large-scale registries\u0026mdash;such as the STS database [15], which reported a 5-year reoperation rate of 3.1%\u0026mdash;and long-term series like Glauber et al. (2011), who observed a 2.8% reoperation rate at 4 years. Similarly, Casselman et al. (2020) documented a 96% 3-year survival rate, supporting the long-term durability of TVTS mitral repair.\u003c/p\u003e \u003cp\u003eCollectively, these findings confirm that TVTS mitral valve surgery provides reproducible, durable, and safe outcomes when performed in high-volume centers by dedicated teams. The low mortality, low reoperation rate, and accelerated recovery profile highlight its clinical advantages over traditional open surgery.\u003c/p\u003e \u003cp\u003eNevertheless, certain limitations must be acknowledged. This study was retrospective and single-center in design, which may limit generalizability. Selection bias and unmeasured confounders inherent to retrospective analyses cannot be excluded. Moreover, the technique demands specialized equipment, a dedicated surgical team, and a significant learning curve. Not all patients\u0026mdash;particularly those with dense pleural adhesions\u0026mdash;are ideal candidates for TVTS.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIn summary, TVTS mitral valve surgery can be performed with excellent safety, efficacy, and durability in experienced hands. Our results\u0026mdash;featuring an in-hospital mortality of 0.8%, low reoperation rates, and favorable recovery\u0026mdash;demonstrate that this minimally invasive approach achieves outcomes equivalent to, or better than, those of conventional sternotomy. These findings support the continued integration of TVTS into standard surgical practice and underscore the need for prospective multicenter studies and standardized training programs to facilitate broader and safer adoption of this technique.\u003c/p\u003e "},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFinancial support:\u003c/strong\u003e This study was supported by the Italian Ministry of Health \u0026ndash; Ricerca Corrente to Centro Cardiologico Monzino IRCCS.\u003c/p\u003e\n"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eGlauber M, Miceli A, Canarutto D, et al. Video-assisted mitral valve surgery: a 15-year single-center experience. Eur J Cardiothorac Surg. 2011;39(6):861\u0026ndash;867. \u003c/li\u003e\n\u003cli\u003eSeeburger J, Rinaldi M, Nielsen SL, et al. Minimal invasive mitral valve surgery: results and predictors of conversion to full sternotomy. Eur J Cardiothorac Surg. 2015;48(2):e38\u0026ndash;e44. \u003c/li\u003e\n\u003cli\u003e\u003cu\u003eGammie JS, Zhao Y, Peterson ED, et al. Less-invasive mitral valve operations: trends and outcomes from the Society of Thoracic Surgeons Adult Cardiac Surgery Database. Ann Thorac Surg. 2018;105(3):707\u0026ndash;715. \u003c/u\u003e\u003c/li\u003e\n\u003cli\u003e\u003cu\u003eModi P, Hassan A, Chitwood WR. Minimally invasive mitral valve surgery: a systematic review. J Heart Valve Dis. 2006;15(6):673\u0026ndash;679. \u003c/u\u003e\u003c/li\u003e\n\u003cli\u003e\u003cu\u003eCasselman F, Van Slycke S, Dom H, et al. Endoscopic mitral valve surgery: from the right thoracic approach to totally endoscopic surgery. Ann Cardiothorac Surg. 2013;2(6):744\u0026ndash;746. \u003c/u\u003e\u003c/li\u003e\n\u003cli\u003eNashef SA, Roques F, Sharples LD et al. EuroSCORE II. Eur J Cardiothorac Surg. 2012;41:734-744. \u003c/li\u003e\n\u003cli\u003e\u003cu\u003ePham TD, Tran TH, Le NT, et al. Totally endoscopic mitral valve repair with novel technique of left atrial exposure: five years experience from a single center. J Cardiothorac Surg. 2025 Jan 6;20(1):28. \u003c/u\u003e\u003c/li\u003e\n\u003cli\u003e\u003cu\u003eRazan Salem, Katharina Fay, Philipp Kaiser, et al. Minimally Invasive Mitral Valve Surgery: Long-Term (20-Year) Follow-Up After Right Anterolateral Minithoracotomy, CJC Open, Volume 7, Issue 7, 2025, Pages 879-886, \u003c/u\u003e\u003c/li\u003e\n\u003cli\u003eModi P, Rodriguez E, Hargrove WC, et al. Minimally invasive video-assisted mitral valve surgery: a 12-year experience. Eur J Cardiothorac Surg. 2009;36(3):535\u0026ndash;539.\u003c/li\u003e\n\u003cli\u003eTruong S, Petersen J, Schmiegelow MDS, et al. Incidence and factors associated with mitral valve reoperation in patients undergoing surgery for mitral regurgitation: A nationwide cohort study. Int J Cardiol. 2025 Jan 1; 418:132608.\u003c/li\u003e\n\u003cli\u003eHeine M, Saggu JS, Nabzdyk CGS, et al. Minimally Invasive, Maximally Effective: Anesthetic Management for Endoscopic Cardiac Surgery. J Cardiothorac Vasc Anesth. 2025 Sep 13:S1053-0770(25)00784-0. \u003c/li\u003e\n\u003cli\u003eHuang LC, Chen DZ, Chen LW, et al. Health-related quality of life following minimally invasive totally endoscopic mitral valve surgery. J Cardiothorac Surg. 2020 Jul 28;15(1):194. \u003c/li\u003e\n\u003cli\u003eChitwood WR Jr, Elbeery JR, Chapman WH, et al. Video-assisted minimally invasive mitral valve surgery. J Thorac Cardiovasc Surg. 1997;113(2):413\u0026ndash;422\u003c/li\u003e\n\u003cli\u003eFilip Casselman, Jose Aramendi, Mohamed Bentala, et al. Endoaortic Clamping Does Not Increase the Risk of Stroke in Minimal Access Mitral Valve Surgery: A Multicenter Experience, The Annals of Thoracic Surgery, Volume 100, Issue 4, 2015, Pages 1334-1339,\u003c/li\u003e\n\u003cli\u003eGammie JS, Zhao Y, Peterson ED, et al. Less-invasive mitral valve operations: trends and outcomes from the Society of Thoracic Surgeons Adult Cardiac Surgery Database. Ann Thorac Surg. 2018;105(3):707\u0026ndash;715. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-cardiothoracic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jcts","sideBox":"Learn more about [Journal of Cardiothoracic Surgery](http://cardiothoracicsurgery.biomedcentral.com)","snPcode":"13019","submissionUrl":"https://submission.nature.com/new-submission/13019/3","title":"Journal of Cardiothoracic Surgery","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-8929107/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8929107/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eTotally video-guided thoracoscopic surgery (TVTS) has emerged as a minimally invasive alternative to conventional surgery with full sternotomy for mitral valve surgery. Evaluation of clinical outcomes of TVTS mitral valve surgery is essential for guiding patient selection and surgical planning.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe conducted a retrospective study of 368 consecutive patients who underwent TVTS for mitral valve repair at a tertiary academic center to evaluate the safety and efficacy of this minimally invasive approach.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eMitral valve repair was accomplished using the respect technique in 96.4% %, using two PTFE artificial-cordae on the posterior leaflet in 61.7% of patients. In-hospital mortality was 0.8%, stroke 1.2% and ECMO support was required for 1.4% of patients. The median follow-up was 2.5 years (q1; q3 1.18;4.15) and it was complete in 98.6% of patients. At 7-year, all-cause mortality was 3.3% and the rate of major cardiac and cerebrovascular events and reoperations were respectively 1.9% and 1.7%.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eProvided adequate surgical expertise, TVTS mitral valve surgery can be performed with excellent early and late clinical outcomes.\u003c/p\u003e","manuscriptTitle":"Mid-term Outcomes after Totally Video Guided Thoracoscopic Mitral Valve Surgery","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-23 10:17:55","doi":"10.21203/rs.3.rs-8929107/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-03T12:06:23+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-29T18:59:26+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-25T06:34:32+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"67163136348445629786169527695193062608","date":"2026-03-24T06:57:06+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"139314617751263008088642138610046508318","date":"2026-03-21T17:29:22+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"267061035620694001871902617446152423268","date":"2026-03-21T06:48:35+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-20T11:28:40+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"64611306191953925679200524454255136764","date":"2026-03-20T07:34:02+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"282812440802746032761338141947043209293","date":"2026-03-19T07:54:57+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"254883934211741753084347332061978287097","date":"2026-03-19T05:54:02+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-03-19T05:42:41+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-03T04:17:45+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-03T04:16:30+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Cardiothoracic Surgery","date":"2026-02-20T20:56:33+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-cardiothoracic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jcts","sideBox":"Learn more about [Journal of Cardiothoracic Surgery](http://cardiothoracicsurgery.biomedcentral.com)","snPcode":"13019","submissionUrl":"https://submission.nature.com/new-submission/13019/3","title":"Journal of Cardiothoracic Surgery","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"51324a23-7b71-4d39-8601-c36f1a2b81df","owner":[],"postedDate":"March 23rd, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-05-04T16:06:32+00:00","versionOfRecord":{"articleIdentity":"rs-8929107","link":"https://doi.org/10.1186/s13019-026-04234-2","journal":{"identity":"journal-of-cardiothoracic-surgery","isVorOnly":false,"title":"Journal of Cardiothoracic Surgery"},"publishedOn":"2026-04-28 15:57:30","publishedOnDateReadable":"April 28th, 2026"},"versionCreatedAt":"2026-03-23 10:17:55","video":"","vorDoi":"10.1186/s13019-026-04234-2","vorDoiUrl":"https://doi.org/10.1186/s13019-026-04234-2","workflowStages":[]},"version":"v1","identity":"rs-8929107","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8929107","identity":"rs-8929107","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}