Totally Endoscopic Approach for Aortic Valve Replacement: A Single-Arm Meta-Analysis

All articles of this category (opens in new window) Background: Totally endoscopic aortic valve replacement (TE-AVR) is a minimally invasive technique offering potential benefits of reduced surgical trauma and faster recovery compared with median sternotomy or other minimally invasive access. While isolated aortic valve replacement is well established through conventional and minimally invasive access, large-scale evidence for the totally endoscopic approach remains limited. This meta-analysis aimed to systematically assess the safety and feasibility of TE-AVR by aggregating perioperative outcomes, including mortality, stroke, conversion, bleeding, paravalvular leak (PVL), and atrial fibrillation (AF). Methods: A systematic search of PubMed, Embase, and the Cochrane Library was performed from December 1, 2024, to March 15, 2025, following PRISMA 2020 guidelines. Observational studies and randomized controlled trials reporting outcomes of totally endoscopic or thoracoscopic AVR were eligible. After independent screening and selection, data were analyzed using a single-arm proportion model, with proportions stabilized through the Freeman-Tukey or arcsine transformation. Pooled estimates were calculated using a DerSimonian–Laird random-effects model, with heterogeneity assessed by Cochran’s Q and the I 2 statistic. Leave-one-out sensitivity analyses were performed to evaluate the influence of individual studies. The protocol was registered in PROSPERO (CRD42024610128). Results: A total of 11 studies comprising 1,383 patients were included. The pooled perioperative mortality was 0.5% (95% CI: 0.1–0.8; I 2 = 0%), indicating highly consistent results across cohorts. The stroke incidence was 1.1% (95% CI: 0.6–1.7; I 2 = 0%), confirming the low cerebrovascular risk of this approach. Conversion to sternotomy occurred in 2.5% of cases (95% CI: 1.1–3.9; I 2 = 51%), with heterogeneity not attributable to a single study, suggesting variability in surgical expertise. Reintervention for bleeding occurred in 0.4% (95% CI: 0.0–0.7; I 2 = 20%), while PVL was reported in 0.7% (95% CI: 0.2–1.2; I 2 = 21.9%). AF incidence showed high heterogeneity, with subgroup analysis revealing clustering around 5% and 25%, likely due to differences in reporting methodology. Conclusion: TE-AVR is a safe and feasible technique associated with very low perioperative mortality, bleeding, and stroke rates, as well as low PVL incidence. Variability in AF reporting underscores the need for future randomized studies with harmonized definitions. Overall, TE-AVR offers a promising minimally invasive alternative for aortic valve replacement, with potential advantages in recovery, hospital stay, and aesthetic outcomes. Publication History Article published online: 17 February 2026 © 2026. Thieme. All rights reserved. Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany