C URRENT O PINION Mitral repair and the robot: a revolutionary tool or marketing ploy? Aly Ghoneim  , Ismail Bouhout  , Fahd Makhdom, and Michael W.A. Chu Purpose of review In this review, we discuss the current evidence supporting each minimally invasive mitral repair approach and their associated controversies. Recent findings Current evidence demonstrates that minimally invasive mitral repair techniques yield similar mitral repair results to conventional sternotomy with the benefits of shorter hospital stay, quicker recovery, better cosmesis and improved patient satisfaction. Despite this, broad adoption of minimally invasive mitral repair is still not achieved. Two main approaches of minimally invasive mitral repair exist: endoscopic mini- thoracotomy and robotic-assisted approaches. Summary Both minimally invasive approaches share many commonalities; however, most centres are strongly polarized to one approach over another creating controversy and debate about the most effective minimally invasive approach. Keywords endoscopic, minimally invasive, mitral valve surgery, robotic INTRODUCTION The mitral valve remains the most posteriorly located valve within the heart and often requires extensive manoeuvres (‘twisting’) to expose it adequately through a sternotomy. This manoeuvring can result in distortion of the leaflets, annulus and subvalvar apparatus, often requiring annular sutures to provide adequate exposure for repair. It has been well recog- nized since the early days of cardiac surgery, that the mitral valve can be beautifully exposed with an ‘en face’ view from a right chest approach. Initial oper- ations were performed via large right thoracotomy incisions; however, the large thoracotomy was revis- ited and modernized in the early 1990s, using a much smaller mini-thoracotomy access port and endo- scopic or robot-assisted visualization to facilitate mitral repair [1,2]. Since this time, continued refine- ment in minimally invasive techniques, improved instrumentation and robotics, optimized team dynamics and accrued experience have allowed many centres to develop mastery in minimally invasive mitral repair, which has led to similarly excellent mitral repair outcomes to conventional sternotomy mitral repair [3–6] with shorter hospitalization, faster recovery, better cosmesis and overall improved patient satisfaction. Despite these results, broad adoption of such minimally invasive mitral techni- ques has yet to be achieved. Barriers include the need for dedicated surgeon and team training, overcoming the learning curve, prolonged surgical time, the need for specialized equipment and in some cases, the costs of robotic technology. In addition, controversies between endoscopic and robotic-assisted approaches fuel confusion about the optimal minimally invasive approach to mitral repair. The aim of this review is to discuss the current evidence surrounding both approaches of minimally invasive mitral valve sur- gery (MIMVS) in light of their outcomes, benefits and drawbacks. Division of Cardiac Surgery, Department of Surgery,Western University, Lawson Health Research Institute, London Health Sciences Centre, London, Ontario, Canada Correspondence to Michael W.A. Chu, MD, FRCSC, Associate Profes- sor of Surgery, Division of Cardiac Surgery, Department of Surgery, Western University, Lawson Health Research Institute, London Health Sciences Centre, B6–106 University Campus, 339 Windermere Road, Lo. ndon, ON N6A 5A5, Canada. Tel: +1 519 663 3593; fax: +1 519 663 3595; e-mail: Michael.Chu@lhsc.on.ca  Aly Ghoneim and Ismail Bouhout contributed equally to this work. Curr Opin Cardiol 2018, 32:000–000 DOI:10.1097/HCO.0000000000000499 0268-4705 Copyright ß 2018 Wolters Kluwer Health, Inc. All rights reserved. www.co-cardiology.com REVIEW Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.