Combined aortic and mitral valve surgery remains one of the most demanding scenarios in valve surgery. Surgical trauma, prolonged cardiopulmonary bypass times, and the frequently complex clinical profile of these patients account for historically high mortality rates that may reach double digits.
Whereas minimally invasive techniques have become well established for isolated valve procedures, their systematic use in multivalve surgery remains limited. At the same time, the expansion of structural interventions has shifted part of the surgical volume, particularly in aortic valve disease. However, when significant mitral pathology coexists, surgery continues to represent the standard treatment.
In this setting, the possibility of performing a fully endoscopic mitral-aortic procedure that is reproducible and yields outcomes comparable to those of conventional sternotomy represents a meaningful conceptual shift.
The authors report a single-center retrospective study including 111 patients who underwent combined endoscopic aortic and mitral valve surgery at a high-volume institution between 2016 and 2025. All procedures were performed through a right mini-thoracotomy with endoscopic assistance and peripheral cannulation. In-hospital mortality was 3.6%, with a low incidence of stroke (3.6%), reoperation for bleeding (8.1%), and dialysis requirement (5.4%). Median cardiopulmonary bypass time was 198 minutes, and median aortic crossclamp time was 139 minutes.
Over a median follow-up of 46 months, overall survival was 87%, whereas freedom from reintervention and major adverse cardiovascular events reached 97.8%. On univariable analysis, renal dysfunction (reduced eGFR; p = .017), coronary artery disease (p = .016), chronic lung disease (p = .022), and peripheral arterial disease (p = .050) were associated with a higher risk of early complications.
The authors conclude that combined endoscopic aortic and mitral valve surgery is feasible and safe in experienced centers, with acceptable perioperative and mid-term outcomes, thus supporting broader adoption of this technique in specialized settings.
COMMENTARY:
This study adds one of the largest published series to date on totally endoscopic mitral-aortic surgery. Beyond the sample size, the most relevant aspect is its technical consistency: all procedures were performed using a standardized approach, which gives the reported outcomes substantial internal coherence.
The in-hospital mortality rate of 3.6% lies at the lower end of the range historically reported for combined surgery through sternotomy and appears consistent with the risk profile of the cohort, whose median EuroSCORE II was 3.3%. This is particularly noteworthy given that more than half of the patients were in functional class III-IV and had substantial comorbidity, suggesting that the endoscopic approach did not increase the expected risk in this population.
Although cardiopulmonary bypass and crossclamp times were prolonged, they remain acceptable for mitral-aortic surgery, especially considering that additional concomitant procedures were performed in nearly 40% of cases, including tricuspid repair, atrial fibrillation surgery, or left atrial appendage closure. The fact that only 1 conversion to sternotomy occurred reflects the technical maturity of the surgical team.
At follow-up, an 87% survival rate at nearly 4 years and 97.8% freedom from reintervention suggest that the minimally invasive approach does not compromise either procedural durability or quality.
One particularly interesting finding is that the predictors of complications were not technical variables but baseline clinical factors: renal function, coronary artery disease, pulmonary disease, and peripheral arterial disease. This suggests that risk is driven more by patient characteristics than by the surgical approach itself. It is noteworthy that neither EuroSCORE II nor cardiopulmonary bypass duration reached statistical significance. This may be interpreted as indicating that, in expert hands, the endoscopic technique does not add independent risk in this setting.
From a strategic standpoint, this study should be interpreted in the context of TAVI expansion. In patients with aortic valve disease associated with significant mitral pathology requiring surgical treatment, an isolated transcatheter option does not solve the full problem, and surgery therefore remains the treatment of choice. In this setting, the debate is no longer whether surgery should be performed, but rather how invasive it should be. An endoscopic approach makes it possible to preserve the radical nature of multivalve surgical treatment while reducing access-related trauma, which may at least partially offset the perceived advantage of isolated structural intervention.
These findings must necessarily be interpreted in light of the environment in which they were generated. The series comes from S. Bortolo Hospital in Vicenza, where the endoscopic surgery program began in 2009 and accumulated more than 1000 isolated mitral procedures before systematically incorporating double-valve surgery. Four fully trained surgeons work within a structured, high-volume organizational model. This accumulated experience and a learning curve that had already been overcome likely explain the low conversion rate, the stability of surgical times, and the favorable outcomes observed. Therefore, the study demonstrates less the easy generalizability of the technique than its feasibility when volume, standardization, and a consolidated team are in place; outside such an environment, results may not be equivalent.
As always, the limitations of the study must not be overlooked. This is a retrospective, single-center study without a comparator group. There is no parallel cohort treated through sternotomy during the same period, which precludes any formal assessment of superiority or noninferiority. Predictive analysis was limited to univariable assessment, restricting interpretation of the factors associated with events. In addition, functional outcomes, quality of life, and detailed longitudinal echocardiographic parameters were not evaluated. The generalizability of these findings to centers with lower volume or without a structured endoscopic surgery program remains questionable.
Overall, the study does not establish superiority over conventional sternotomy, but it does confirm that combined endoscopic surgery is a feasible, safe, and consistent option in settings with consolidated experience.
From a practical standpoint, the message is clear: multivalve surgery should not be displaced by structural intervention. The logical evolution of surgery is to reduce invasiveness without sacrificing radicality or durability. Adoption of this technique requires a structured program, adequate volume, and progressive training. This is not a technique for starting out, but rather one for consolidating pre-existing expertise in isolated endoscopic valve surgery.
Ultimately, rather than representing an immediate paradigm shift, this study provides a clear signal of where complex valve surgery can (and probably should) evolve over the coming years.
REFERENCE:
Cresce GD, Zoni D, Grazioli V, Tropea I, De Luca A, Sanesi V, et al. Endoscopic Combined Aortic and Mitral Valve Surgery: Feasibility and Mid-term Outcomes. Eur J Cardiothorac Surg. 2026 Feb 5;68(2):ezag091. doi: 10.1093/ejcts/ezag091.
