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Minimally Invasive Mitral Valve Surgery

Mass General Brigham surgeons are among the few in the country that perform minimally invasive mitral valve repair—including robotic-assisted and catheter-based approaches—to treat leaking or damaged mitral valves.

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What is mitral valve surgery?

Mitral valve surgery is a treatment option for conditions affecting the mitral valve, such as mitral valve regurgitation and mitral valve stenosis. This procedure helps close the valve properly, so blood flows through your heart normally. If the valve can’t be repaired, it can be replaced using the same minimally invasive approach.

While some mitral valve conditions require open-heart surgery, many patients are candidates for a minimally invasive mitral valve repair or replacement, which can reduce recovery time and lower the risk of complications.

The Mass General Brigham Heart and Vascular team are experts at diagnosing and treating all types of heart valve conditions. Our Heart Valve Disease Program is one of the nation’s most comprehensive cardiac care programs, addressing all aspects of heart valve health.

 

What is the mitral valve?

The heart has four valves: the mitral, aortic, tricuspid, and pulmonary valves. These valves act like dams, making sure blood flows in one direction — through each of the heart's four chambers and out to the rest of the body.

The mitral valve controls blood flow between the heart’s upper (atrium) and lower (ventricle) chambers on its left side. It opens and closes with each heartbeat to keep blood moving forward.

When the mitral valve doesn’t close properly, blood flows backward through the valve toward the lungs. This condition is called mitral valve regurgitation, sometimes known as mitral insufficiency. It is one of the most common forms of heart valve disease.

Precision valve surgery: minimally invasive and robotic options

Minimally invasive mitral valve surgery (direct vision, endoscopic, or robotic assisted) and transcatheter procedures like TAVR are all advanced, less invasive techniques used to treat heart valve disease. Each is designed to improve recovery time and reduce surgical risk while delivering excellent outcomes.

A minimally invasive approach to mitral valve surgery uses small chest incisions and thin instruments to reach the heart. This approach allows the surgical team to access the valve between the ribs, without needing to open the breastbone, which often leads to a quicker and more comfortable recovery than in surgeries where the chest is opened.

In order to see the mitral valve clearly, your surgeon may look directly at the heart through the main incision, sometimes using magnifying glasses for precision. This is called direct vision valve surgery. Another common approach is to insert a tiny camera, or endoscope, through a small hole or incision called a port, allowing the surgeon to view the valve on a screen. This approach is called endoscopic valve surgery.

The choice between endoscopic and direct vision minimally invasive mitral valve surgery depends on your specific anatomy, the details of your heart condition, and the expertise of your surgical team. Both methods are minimally invasive and aim to reduce recovery time and improve outcomes, and your care team will recommend the safest and most effective option for you.

Some surgeons utilize robotic technology to assist with their mitral valve surgeries. As with all forms of minimally invasive mitral valve surgery, the procedure begins with small “keyhole” incisions in the chest. A camera (endoscope) and instruments attached to tiny robotic arms are inserted through these holes so that the surgeon can see and operate on the heart and its valves.

Your surgeon controls the robotic instruments from a console in the operating room. These instruments mimic the movement of the surgeon’s hands, but are much smaller and more precise. This robotic technology also provides a highly magnified, 3D view of the heart, ensuring accuracy with delicate surgical techniques.

TMVR is performed by guiding a thin, flexible tube called a catheter through a blood vessel in the groin (femoral artery) up to the heart. From there, the care team can access the mitral valve to perform either a repair or a replacement.

In transcatheter mitral valve repair (also called TEER, or transcatheter edge-to-edge repair), a small clip is placed on the valve to help it close more tightly and reduce leaking. In transcatheter mitral valve replacement, a new valve is delivered through the catheter and positioned inside the existing valve to restore proper function.

These procedures are typically performed by a team that includes structural heart specialists and cardiac surgeons, working together to determine the best approach for each patient.

Who is a candidate for minimally invasive mitral valve repair surgery?

Many people with mitral valve conditions, such as mitral valve regurgitation or mitral valve prolapse, may be good candidates for minimally invasive mitral valve repair.

Our expert heart team will carefully review your condition, imaging, and overall health to determine if this approach is right for you. We also work closely with referring cardiologists and primary care providers to coordinate your care every step of the way.

In some cases, a minimally invasive approach may not be recommended, such as when:

  • The valve has very complex disease, including severe calcification (MAC) or widespread infection (endocarditis)
  • There is a dilated aorta that also needs surgical repair, or you require bypass surgery (CABG)
  • You have certain anatomical factors, such as chest wall deformities or prior chest surgeries, that limit access

Even if minimally invasive surgery isn’t an option, we offer a full range of surgical and transcatheter treatments tailored to your needs.

What to expect

Understanding what to expect before, during, and after minimally invasive mitral valve surgery can help you and your family feel more prepared and confident. This section walks you through each stage of the process—from your initial evaluation to the procedure itself and your recovery at home—so you know what’s ahead every step of the way.

Prior to your procedure, your care team will order imaging to better understand your heart and how blood flows through the coronary arteries. This assessment can be done either by a minimally invasive procedure using a thin tube (coronary catheterization) or a special type of CT scan.

Like with any surgery, you may need to:

  • Change or stop taking certain medications
  • Fast (not eat or drink) prior to surgery
  • Get blood tests, heart tests, and urine tests
  • Plan for at-home support 
  • Stop using tobacco products

Most minimally invasive mitral valve surgeries take about four hours, though the exact time depends on your specific condition.

Factors that can affect the length of the procedure include:

  • The complexity of your valve repair or replacement
  • Your overall health and heart anatomy
  • The type of surgical approach used (robotic-assisted, camera-guided, or small-incision/open)
  • Whether other treatments are performed during the same operation (such as treating atrial fibrillation)

Including preparation before the procedure and initial recovery afterward, you can expect to spend about five to six hours total in the operating room.

When possible, your surgeon will aim to repair your mitral valve rather than replace it. There are several proven techniques they may use to help your mitral valve close properly again:

  • Removing damaged tissue (resection technique)
    If part of the valve is thickened or floppy, the surgeon may remove the affected tissue and stitch the remaining healthy parts together. This helps restore the valve’s ability to close tightly.
  • Supporting the valve with new cords (neochordal technique)
    If the natural cords that hold the valve in place are damaged or stretched, the surgeon can replace them with durable artificial cords. These help realign the valve and create a tight seal to prevent leaking.
  • Repairing with a patch
    In rare cases where infection or other damage has caused a hole or missing tissue in the valve, the surgeon may use a patch made from your own heart lining (called the pericardium) to rebuild the valve.
  • Reshaping the valve with a ring (annuloplasty)
    No matter which technique is used, most repairs also include placing a flexible ring or band around the valve opening. This helps restore the valve’s natural shape and ensures a long-lasting seal between the valve’s two flaps (called leaflets).

Minimally invasive mitral valve surgery typically requires 2 to 4 small incisions on the right side of the chest. One of these is a slightly larger main incision—usually about 2 to 3 inches long—that allows your surgeon to access the heart valve between the ribs. The other incisions are much smaller and are used for a camera or specialized surgical tools. Depending on your needs, additional small access points may be made in the groin or chest area to support the heart-lung machine during surgery.

The surgeon usually operates through small incisions on the right side of your chest, even though the heart sits slightly to the left, because the mitral valve is positioned in a way that makes it easier to reach from the right.

Recovery after minimally invasive mitral valve repair and replacement is generally shorter than with traditional open-heart surgery—but healing still takes time and care.

After surgery, you generally stay one to two days in the intensive care unit, followed by two to four days on a regular hospital floor. Before you leave, you are given clear instructions to help you recover safely at home. Your care team will also schedule your follow-up appointments with your surgeon and cardiologist.

Many patients start to feel better within four to six weeks, while others may need up to three months.

This procedure is considered open-heart surgery because it involves stopping the heart and using a heart-lung machine to temporarily take over its function. This allows the surgeon to operate on the heart valves with the accuracy and precision provided by a bloodless heart, giving them clear visual access to the chambers and valves, whether with an endoscope or through direct vision. 

Benefits of minimally invasive mitral valve surgery

Compared with traditional open-heart surgery (sternotomy) to repair or replace your mitral valve, minimally invasive procedures tend to result in:

  • Less blood loss and tissue trauma
  • Less pain and bruising
  • Shorter hospital stays
  • Lower risk of infection
  • Faster recovery 
  • Quicker return to work/leisure activities
  • Smaller scars

Whenever possible, we aim to repair the mitral valve rather than replace it. Repair prevents the need for lifelong use of blood-thinning medications and preserves the heart’s natural structure.

Risks of minimally invasive mitral valve surgery

Both minimally invasive mitral valve repair and replacement are generally safe and effective, with a low risk of complications. At Mass General, more than 95% of patients who undergo minimally invasive mitral valve surgery have a successful valve repair, reflecting our team’s expertise and commitment to excellent outcomes. By comparison, the national average repair rate ranges from 90% to 96%, according to data from the Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database.
 

Dolly's Story: Getting Back on Her Feet

When mitral valve disease started to affect the quality of Dolly Lakkis' life, she turned to a team of Mass General specialists. Dolly’s doctors repaired her damaged heart valve with minimally invasive surgery, that got her back on her feet—and back on the dance floor—as quickly as possible.

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