Mitral valve repair (MVP) enables preservation of the entire native valve apparatus. Compared to a prosthetic replacement, repairs have been shown to improve postoperative left ventricular function and lower the risk of thromboembolic and bleeding events. Many studies have demonstrated a long-term survival benefit of MVP versus mitral valve replacement. Minimally invasive mitral valve repairs have been shown to be equal in quality and durability, compared to the open approach. Moreover, less invasive methods provide reduced blood loss, fewer transfusions; shorter mechanical ventilator times, and less intensive unit care stays. Also, patients benefit from less pain, better cosmesis, and a shorter overall recovery time. These benefits outweigh the moderate increase in risk afforded by longer cardiopulmonary perfusion and cardiac arrest times. It is probable that in the future, the sternotomy incision will be a used much less in primary mitral valve surgery. Nevertheless, mastering minimally invasive techniques requires a steep learning curve for both the surgeon and operating room staff. This chapter details the use of endoscopic assistance and endoballoon aortic occlusion for minimally invasive mitral valve repairs. These methods should be used in team and surgeon preparation to advance toward totally endoscopic robotic mitral valve surgery. We believe that new technology should be added serially to a mastered operation rather than relying on several complex advancements at once.
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