Endoscopic techniques in redo mitral and tricuspid valve surgery

Redo mitral and tricuspid valve surgery presents considerable technical challenges due to dense adhesions, previous surgical alterations, and distortion of normal anatomical landmarks. Traditionally, these complex reoperative procedures have been approached through repeat median sternotomy, a strategy that, while familiar, carries heightened risks of cardiac or great vessel injury during re-entry, increased bleeding, longer operative times, and prolonged recovery. As minimally invasive cardiac surgery has evolved, endoscopic techniques have emerged as a viable and increasingly attractive alternative, offering surgeons enhanced visualization and patients a less traumatic operative experience. In this technical paper, we outline our institutional approach with endoscopic redo mitral and tricuspid valve surgery, emphasizing comprehensive preoperative planning, thoughtful patient selection, and meticulous intraoperative strategy. Critical components of preparation include detailed imaging assessment, analysis of previous operative notes, and formulation of a cannulation strategy tailored to each patient's anatomy and prior interventions. Myocardial protection remains a fundamental priority, and we describe the methods we have found most effective in achieving consistent and safe cardiac preservation in a reoperative setting. Our stepwise operative approach focuses on minimizing dissection, utilizing enhanced visualization, and employing targeted techniques to navigate scar tissue and restored anatomy while preserving procedural safety. In the experience of expert surgeons and teams, endoscopic access has translated into meaningful clinical benefits, including reduced transfusion requirements, shorter intensive care and hospital stays, and excellent early postoperative outcomes compared with traditional redo sternotomy as previously published. With proper preparation, a multidisciplinary team, and intraoperative vigilance, endoscopic redo mitral and tricuspid valve surgery represents a reliable, reproducible, and patient-centered option for complex valve reoperations.