Background: Femoral cannulation is essential for minimally invasive mitral valve surgery (MIMVS). Our center transitioned from open femoral cut-down to ultrasound-guided percutaneous cannulation supported by smart venous cannulas, ThruPort arterial access, and the MANTA closure device. This study evaluates how this transition affects procedural efficiency, vascular safety, and postoperative outcomes. Methods: We retrospectively analyzed 575 consecutive MIMVS patients (2014–2025). Patients treated before 2021 formed the cut-down group, while those from 2021 onward underwent percutaneous cannulation. The outcomes included operative times, groin and lymphatic complications, MANTA performance, and 30-day mortality. Propensity score matching (PSM) was performed to adjust for baseline differences. Results: Of 575 patients, 393 (68.3%) underwent cut-down and 182 (31.7%) percutaneous access. Percutaneous access was associated with shorter cardiopulmonary bypass times (115 vs. 128 min, p < 0.0001), total operative times (210 vs. 242 min, p < 0.0001), ICU stays (2 vs. 3 days, p = 0.0267), and hospital stays (8 vs. 11 days, p < 0.0001). Lymph fistula occurred in 4.3% of cut-down cases and in 0% after the adoption of percutaneous access (p = 0.0004). Overall groin complication rates were comparable (2.8% vs. 4.9%, p = 0.51). MANTA closure had a 2.2% device-related complication rate (1.1% bleeding; 1.1% ischemia) with no documented long-term sequelae. Regarding 30-day mortality, this was 4.6% in the cut-down group and 1.6% in the percutaneous group (p = 0.096). In PSM (72 matched pairs), percutaneous access retained significantly shorter operative, bypass, and ICU times, with identical groin complication rates. Conclusions: Ultrasound-guided percutaneous femoral cannulation was associated with improved procedural efficiency and elimination of lymphatic morbidity, without increasing vascular risk or mortality. It represented a safe and effective standard strategy for contemporary MIMVS.

Background: Minimally invasive and endoscopic techniques have expanded the surgical options for tricuspid valve repair. Conventional approaches often require manual snaring of the venae cavae, which can increase procedural complexity and invasiveness, especially in redo or advanced heart failure settings. This study describes a snare-free totally endoscopic approach to tricuspid valve repair utilizing percutaneous venous selfexpanding cannulation. Methods: Between 2020 and 2025, 32 consecutive patients with severe tricuspid regurgitation (TR) underwent totally endoscopic tricuspid valve repair using a standardized snare-free technique. Venous drainage was achieved via percutaneous femoral cannulation with a self-expanding venous cannula, providing optimal central venous decompression without external tourniquets or loops. All clinical, intraoperative, and early postoperative parameters were systematically collected and analyzed using descriptive statistical methodology. Results: Endoscopic tricuspid valve repair was successfully completed in all 32 patients. The mean total cardiopulmonary bypass (CPB) time was 145.9 ± 35.8 minutes, and the mean aortic cross-clamp duration was 92.4 ± 24.5 minutes. The early postoperative safety profile was characterized by an all-cause 30-day mortality rate of 3.1% (n = 1) and zero cases of clinically relevant hemolysis (0.0%)The mean intensive care unit stay was 6.0 ± 4.9 days, and the mean total hospital length of stay was 15.4 ± 9.7 days. Conclusion: Snare-free totally endoscopic tricuspid valve repair using a percutaneous self-expanding venous cannulation is a safe, technically feasible, and reproducible technique. This structural approach simplifies right atrial endoscopic visualization, eliminates the complications associated with deep caval-dissection, and demonstrates highly stable early clinical and electrophysiological outcomes.

Background: Minimally invasive cardiac valve surgery (MIVS) provides distinct clinical advantages, yet annular suturing remains a technically demanding step. Automated annular suturing devices (RAM^®) have been developed to standardize suture placement during valve replacement. This study evaluates the initial clinical feasibility, technical safety, and operational integration of automated suturing during its institutional adoption phase. Methods: We retrospectively evaluated 43 consecutive patients undergoing MIVS supported by the RAM^® system (2021–2025), stratified into mitral valve replacements (RAM-MVR, n = 26) and aortic valve replacements (RAM-AVR, n = 17). Technical parameters, procedural safety metrics, and perioperative outcomes were descriptively analyzed and contextualized against our broader institutional MIVS platform using percutaneous femoral cannulation (n = 182). Results: Automated annular suturing achieved a 100% technical feasibility rate (43/43, 95% CI: 91.8–100.0%) with zero mechanical device failures or intraoperative suture-line disruptions (0%, 95% CI: 0.0–8.2%). In the RAM-MVR cohort, median cross-clamp and cardiopulmonary bypass (CPB) times were 73.0 min (IQR 64.0–91.0) and 114.5 min (IQR 94.8–129.5), respectively. In RAM-AVR, median cross-clamp time was 75.0 min (IQR 71.0–83.0). Thirty-day mortality was 4.7% (2/43, 95% CI: 0.6–15.8%), secondary to non-device-related medical complications in high-risk baseline patients. Postoperative echocardiography demonstrated no paravalvular regurgitation (0%, 95% CI: 0.0–8.2%). Conclusions: Initial institutional experience demonstrates that automated annular suturing is technically feasible and safe in minimally invasive mitral and aortic valve replacement. The system enables consistent procedural execution across valve positions. These observational data support automated suturing as a feasible alternative to manual suturing in MIVS workflows.

Background: Minimally invasive cardiac valve surgery (MIVS) is established as a safe alternative to conventional sternotomy, yet the technical complexity of annular suturing remains a significant barrier to procedural efficiency. Automated annular suturing devices (RAM®) have been introduced to mechanize and standardize suture placement specifically during valve replacements. This study evaluates the clinical feasibility, safety, and device usability of automated suturing during its institutional introductory phase. Methods: We retrospectively reviewed 43 consecutive patients undergoing MIVS supported by the RAM® system between 2021 and 2025. The cohort was stratified into RAM-supported Mitral Valve Replacements (RAM-MVR, n=26) and Aortic Valve Replacements (RAM-AVR, n=17). Technical parameters, device configurations, and perioperative outcomes were descriptively analyzed and contextualized within our mature institutional percutaneous MIVS benchmark platform (n=182). Results: Automated annular suturing achieved 100% technical feasibility with zero mechanical malfunctions or suture-line failures. In the RAM-MVR group, the median aortic cross-clamp and cardiopulmonary bypass (CPB) times were 73.0 minutes (IQR 64.0–91.0) and 114.5 minutes (IQR 94.8–129.5), respectively. RAM-AVR cases demonstrated a median cross-clamp time of 58.0 minutes (IQR 50.0–63.0). Conclusion: Automated annular suturing represents a robust and predictable technology that integrates seamlessly into a mature percutaneous MIVS environment. The system provides reliable standardization of valve anchoring across varying positions, yielding stable procedural times and excellent hemodynamic performance without introducing device-specific morbidity.