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

Background and Objectives: 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 (AVR) 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). Materials and Methods: A systematic search of PubMed, Embase, and the Cochrane Library was performed, 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. 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 1135 patients were included. The pooled perioperative mortality was 0.00% (95% CI 0.00-0.23; I² = 0.0%), indicating highly consistent results across cohorts. The stroke incidence was 0.69% (95% CI 0.00-2.07; I² = 42.7%), confirming the low cerebrovascular risk of this approach. Conversion to sternotomy occurred in 0.00% of cases (95% CI 0.00-0.17; I² = 0.0%), with no statistical heterogeneity observed. Reintervention for bleeding occurred in 1.75% (95% CI 0.34-3.85; I² = 43.4%), while PVL was reported in 1.24% (95% CI 0.00-4.22; I² = 64.0%). AF incidence was 10.54% (95% CI 3.79-19.70; I² = 90.5%), with substantial between-study heterogeneity, likely related to non-standardized definitions of new-onset AF and variability in postoperative rhythm monitoring and reporting across studies. Conclusions: TE-AVR is a safe and feasible technique associated with very low perioperative mortality, bleeding, and stroke rates, as well as low PVL incidence. The absent conversion rate in our pooled analysis highlights the technical reliability of the procedure. 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 (pooled ICU stay 1.86 days), hospital stay (pooled 7.98 days), and aesthetic outcomes.