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OBJECTIVES  The full potential of robotics has not been achieved in terms of addressing the most challenging mitral valve (MV) cases. We outline our technique and report our early results with totally endoscopic robotic MV repair in a wide range of pathologies.    METHODS  From May 2011 to August 2017, a dedicated team attempted totally endoscopic robotic MV repair in 500 MV regurgitation patients. Repair complexity was scored in 3 categories. We analysed our sequential case experience by quartiles.    RESULTS  Patient mean age was 60.8 years (range 18–88). Aetiologies included: degenerative 382 (76.4%), functional 37 (7.4%), inflammatory 22 (4.4%) and others 59 (11.8%). Mitral annular calcification was present in 64 (12.8%) cases. Simple MV repair (annuloplasty alone or with 1 leaflet segment repair) was performed in 240 (48%) patients, complex (repair involving more than 1 segment on the same leaflet) in 140 (28%) patients and most complex (bileaflet repair or mitral annular calcification excision with atrioventricular groove repair) in 120 (24%) patients. Concomitant procedures included: left appendage closure (94.8%), patent foramen ovale/atrial septal defect (PFO/ASD) closure (19.6%), cryoablation (19.4%), tricuspid repair (6.2%) or hybrid percutaneous coronary revascularization (7.8%). The overall repair rate was 99.4%, with 0.6% early mortality and 1.2% stroke rate (0.2% permanent neurological deficit). Case complexity increased with our experience. Despite an increase in aortic occlusion and perfusion times (median 86.5 and 125 min) and a slight decrease in operating room extubation rate (overall 64%), length of hospital stay (median 4 days) and 30-day readmission rate (overall 3.6%) were not affected by the progressive inclusion of more complex cases.    CONCLUSIONS  Totally endoscopic robotic MV repair performed by a dedicated team allows one to address the entire spectrum of pathological complexity and provides consistent results.

Can complex mitral valve repair be performed with robotics? An institution’s experience utilizing a dedicated team approach in 500 patients†