Robotic chordae shortening in mitral valve repair

Background: Cusp-level chordae shortening was largely abandoned after suboptimal durability in the sternotomy era. We postulated that the enhanced visualization and wristed instrumentation of totally endoscopic robotic mitral repair could enable precise shortening with durable hemodynamics and acceptable peri-operative risk. Methods: We retrospectively analyzed 523 consecutive degenerative mitral regurgitation (MR) repairs performed robotically at the National Taiwan University Hospital (January 2012–November 2024). Chordae shortening was used in 68 patients (13%; 46 primary, 22 adjunct) and compared with 455 contemporaneous repairs without shortening. Results: Baseline characteristics and operative times were similar [cross‑clamp 74±27 vs. 75±25 min; cardiopulmonary bypass (CPB) 120±30 vs. 120±25 min]. All shortening cases achieved successful repair without conversion or valve replacement. At discharge, none/trace MR was more frequent after shortening (95.6% vs. 93.4%); no patient in the shortening group had ≥ moderate MR. Early events were low: 30-day mortality 0% vs. 0.2%, stroke 0% vs. 0.2%, renal failure 1.5% vs. 1.8%, and reoperation for bleeding 1.5% vs. 0%. Reintubation (2.9% vs. 0%) and new-onset atrial fibrillation (33.8% vs. 13.6%) were more common with shortening, yet median ventilation time was comparable, and resource use favored shortening [intensive care unit (ICU) stay 19±28 vs. 27±25 h; hospital stay 7.0±2.9 vs. 9.5±2.7 days]. Follow-up echocardiography (median, 3.6 years) showed sustained competence: 92% of shortening patients remained MR-free. Ten-year freedom from ≥ moderate MR was 95.6% with shortening vs. 94.5% without (log-rank P=0.66). Conclusions: Robotic chordae shortening adds negligible operative time, shortens ICU and hospital stay, and delivers long-term valve competence equivalent to contemporary robotic repairs relying on chordal transfer or neochordae. Although new-onset atrial fibrillation was more frequent, other adverse events were rare. The robotic platform appears to overcome historical limitations of chordae shortening, restoring this tissue‑preserving option for anterior leaflet prolapse in degenerative mitral disease.