Prof. Cătălin Constantin Badiu,
MD, PhD, Head of the Department of
Cardiovascular Surgery at the Bucharest
University Emergency Hospital
I.Introduction and Institutional Context
Scientific research in the field of cardiac surgery is primarily focused on significantly reducing surgical trauma while simultaneously improving postoperative outcomes and minimizing Within this continuously evolving landscape, endoscopic cardiac surgery represents a major advancement in the treatment of various heart conditions. This minimally invasive approach contributes substantially to reducing overall hospitalization time and significantly accelerates patients’ postoperative recovery, thereby becoming a fundamental pillar of modern therapeutic strategies. At its core, endoscopic cardiac surgery is a constantly evolving medical field, strongly driven by rapid technological progress and, above all, by the medical community’s ongoing commitment to improving surgical outcomes and providing patients with a safe and effective alternative.The Minimally Invasive Cardiac Surgery Program was launched in 2015, followed in 2019 by the official inauguration of the fully endoscopic cardiac surgery program. Today, the Department of Cardiovascular Surgery at the Bucharest University Emergency Hospital successfully treats a broad spectrum of pathologies, including complex mitral valve repairs, mitral valve replacement, aortic valve replacement, tricuspid valve repair and replacement, explantation of atrial septal defect closure devices, and excision of benign cardiac tumors. Of particular significance is the fact that this department, led by Professor Dr. Cătălin Constantin Badiu, is the only center in Romania and one of the few specialized departments in Europe where aortic valve replacement is performed using a fully endoscopic technique.
Complementing this program, Professor Badiu’s department offers minimally invasive aortic valve replacement through all currently available minimally invasive approaches, including upper mini-sternotomy and the transaxillary approach. This newer technique, involving a right mini- thoracotomy through the anterior axillary line, was introduced into the clinic in 2025.
II. Definition, Techniques, and Major Advantages
Endoscopic cardiac surgery involves the use of advanced visualization technologies to perform complex cardiac procedures exclusively through small incisions made between the ribs, thereby completely avoiding adjacent bony structures, unlike conventional surgery.
The procedure is continuously guided by miniature video cameras and highly precise surgical instruments, enabling exceptionally detailed visualization of both the external and internal cardiac anatomy and producing clear three-dimensional images. In recent years, medicine has witnessed the development of new fully endoscopic techniques, including aortic valve replacement, mitral valve surgery, and coronary artery bypass procedures.
The advantages of endoscopic cardiac surgery are various:
- Minimized surgical trauma, resulting directly from the small incisions used and significantly reducing the invasiveness of the procedure.
- Accelerated postoperative recovery, associated with a lower complication rate and shorter hospital
- Reduced risk of hospital-acquired
- Superior cosmetic outcomes, achieved through substantially smaller incisions and less traumatic techniques for surrounding tissues. This contributes positively to patients’ psychological and social well- being and enhances overall quality of life.
III. Challenges and Limitations of the Endoscopic Approach
Despite its undeniable benefits, endoscopic cardiac surgery presents several anatomical and technical limitations. Certain patient-specific anatomical characteristics may create genuine challenges when performing endoscopic procedures, occasionally requiring procedural adaptations or alternative surgical approaches. Patient selection must therefore be rigorous, as not all individuals are ideal candidates for this type of intervention. Factors such as previous surgeries, individual anatomical variations, or complex cardiac pathologies may significantly complicate these procedures, requiring careful evaluation of each case.
Another challenge is represented by costs and limited accessibility, as not all cardiovascular centers currently possess the financial resources and specialized personnel required to implement these techniques. Furthermore, the technical expertise required is highly demanding, necessitating advanced skills and specialized training in operating through small incisions using precise movements under video guidance. The learning curve can be steep. Limitations also exist regarding the specialized instruments employed. Although designed for minimally invasive surgery, these instruments may offer a more restricted range of motion and reduced maneuverability compared with traditional surgical tools. All of these technical requirements frequently result in longer operative times compared with conventional open-heart surgery.
IV. Particular Considerations in Valvular Disease
Aortic Valve Disease: Endoscopic Surgery versus TAVI The scope of minimally invasive techniques continues to expand. Modern options for aortic valve replacement include mini-sternotomy, transaxillary access, endoscopic surgery, robot-assisted surgery, and transcatheter aortic valve implantation (TAVI). The use of endoscopic surgery for aortic valve disease is steadily increasing, supported by the introduction of new technologies such as automated suturing devices, suture-fastening systems, high-definition 3D 4K cameras, automated endoscopic arms, and next- generation prosthetic valves, including sutureless valves that significantly reduce operative times.
The learning curve depends largely on the surgeon’s experience but does not require substantial additional investment, as endoscopic surgical towers are already available in tertiary-care hospitals. Studies reported in the literature, such as the analysis of 715 patients conducted by Yilmaz et al., demonstrate a clear reduction in bleeding with endoscopic surgery while maintaining survival rates identical to those of conventional open surgery, confirming that the technique is both safe and feasible.
In treatment decision-making, TAVI is generally preferred for high-risk surgical patients. However, evaluating intermediate-risk patients requires detailed assessment by the “Heart Team”, consisting of a cardiac surgeon, cardiologist, and anesthesiologist.
Younger patients with a long life expectancy, complex anatomies, or calcified bicuspid valves under the age of 70 benefit primarily from fully endoscopic surgery.
Major advantages include direct visualization of the valve, complete removal of calcifications, very low risk of paravalvular leakage, reduced incidence of atrioventricular block requiring pacemaker implantation, lower risk of embolic events and neurological injury. This approach also allows implantation of mechanical prosthetic valves, which are recommended in patients under 60 years of age according to the European Association for Cardio- Thoracic Surger, reducing degeneration and the need for reintervention.
Mitral and Tricuspid Valve Pathology
Fully endoscopic mitral valve surgery, performed through a right mini-thoracotomy measuring only 1–2 cm without sternotomy, is regarded as the most advanced and least invasive approach currently available. Using a high- definition 3D 4K endoscope, the technique provides superior visualization of the subvalvular apparatus and delivers exceptional cosmetic results. Survival rates remain excellent, while bleeding and intensive care stays are reduced. However, longer cardiopulmonary bypass times and an extensive learning curve are notable considerations. According to the International Mini-Mitral Registry, which analyzed more than 6,500 patients, the overall mortality rate associated with the fully endoscopic approach was only 1.7%. Observational cohort studies have also demonstrated repair success rates of up to 99%.
The same fully endoscopic approach is successfully applicable to tricuspid valve surgery, particularly for secondary tricuspid regurgitation, a condition becoming increasingly prevalent as the population ages. Published studies report reduced blood transfusion requirements, less postoperative pain, and a lower incidence of acute kidney injury.
V. Revascularization Through Coronary Artery Bypass Surgery
Totally endoscopic coronary artery bypass surgery maximizes the advantages of robot-assisted minimally invasive technology (RA-MIDCAB), enabling complete revascularization of the left anterior descending artery using the internal mammary artery. By avoiding median sternotomy, this approach significantly limits the harmful inflammatory response associated with cardiopulmonary bypass. Whether performed off-pump with robot-assisted anastomoses under direct visualization or entirely endoscopically using a surgical robot, these procedures offer the prospect of extremely rapid recovery while presenting the logistical challenges inherent to cutting- edge technology.
VI. Conclusions and Future Perspectives
The findings of comprehensive meta-analyses and large retrospective studies confirm that endoscopic cardiac surgery has evolved from a theoretical concept into a genuine first-line therapeutic alternative. Thanks to its minimal surgical trauma and outstanding cosmetic outcomes, patients benefit from faster recovery and a significantly improved quality of life. Given the growing body of evidence demonstrating mortality, morbidity, and reintervention rates that are equal to—or even lower than— those associated with conventional cardiac surgery, a fundamental question is gradually finding a clear answer within the modern medical community:
Can endoscopic cardiac surgery become the new definitive standard in cardiac surgery?
