Automated Versus Conventional Annular Suturing in Totally Endoscopic Aortic Valve and Ascending Aorta Replacement: A Prospective Randomized Trial

Background Totally endoscopic aortic valve replacement (AVR) combined with ascending aorta replacement (AAR) remains technically demanding, with prolonged CPB and ischemic times. Annular suturing is a principal technical limitation; automated devices aim to simplify this step and improve efficiency. This study compared early clinical outcomes between automated and conventional annular suturing in totally endoscopic AVR with concomitant AAR. Methods Between August 2023 and February 2026, 86 patients undergoing totally endoscopic AVR with concomitant AAR via right anterior minithoracotomy (RAMT) were randomized 1:1 to automated annular (RAM group; n=43) or conventional suturing (conventional group; n=43) in this single-center trial. Primary endpoints were technical success and procedural times; secondary endpoints included complications and 30-day mortality. Results Baseline characteristics were comparable, bicuspid aortic valve morphology was more frequent in the RAM group (74.4% vs. 53.5%; P = 0.043). Automated suturing was associated with shorter median procedure (120.8 vs. 144.0 minutes; P = 0.004), CPB (90.0 vs. 105.0 minutes; P = 0.005), and aortic cross-clamp times (62.0 vs. 74.0 minutes; P = 0.003), respectively. No stroke, conversion to sternotomy, paravalvular leakage, or 30-day mortality occurred in either group. Hospital stay was shorter with automated suturing (6.0 vs. 7.0 days; P = 0.037), while total treatment cost, accounting for incremental device cost, did not differ significantly (P = 0.421). Conclusions Automated annular suturing appears to be a safe, efficient alternative to conventional suturing in totally endoscopic AVR with AAR, associated with reduced operative and ischemic times and shorter hospital stay without compromising early outcomes.