Objectives
Femoral artery cannulation is traditionally performed via surgical cutdown to establish cardiopulmonary bypass during endoscopic mitral valve surgery (MVS). To avoid groin incision associated infection and lymphocele formation, percutaneous cannulation using a novel plug-based vascular closure device (Manta-device) emerged as an alternative but remains to be investigated.

Methods
Between 01/2020 and 06/2022 a total of 270 consecutive patients underwent fully endoscopic MVS at our institution. Cannulation of femoral vessels was either performed percutaneously using the Manta-device (Manta-group; n=139) or under direct vison via surgical cutdown using a limited groin incision (Control-group; n=131). Perioperative outcome was retrospectively analyzed.

Results
Patient characteristics including the prevalence of outcome-relevant comorbidities were similar within both groups. Of note, peripheral artery disease was prevalent in 2.2% of Manta-group patients vs. 3.8% of Control-group patients (p=0.49). All Manta-group patients underwent percutaneous femoral artery cannulation with catheters sized 17 (12.2%), 19 (60.4%) or 21 (27.3%) Fr. The rate of mitral valve repair was 90.6% within the Manta-group vs. 89.3% within the Control-group (p=0.71). Conversion rates to full sternotomy were favorably low within both groups (3.6% vs. 3.8%; p=0.92) and there were no differences regarding mean postoperative ventilation time (4.8 vs. 4.6h; p=0.66), intensive care unit (2.5 vs. 2.4days; p=91) and in-hospital stay (8.1 vs. 7.4days; p=0.19). Immediate hemostasis was achieved in all patients within both groups, nevertheless 1 (0.7%) patient within the Manta-group developed postoperative femoral artery bleeding requiring endovascular intervention. Furthermore, 3 (2.2%) Manta-group patients required surgical intervention due to pseudoaneurysm, arterio-venous fistula and device-related occlusion of the femoral artery. Within the Control-group 3 patients had to undergo surgical lymphocele excision and 2 patients required surgical debridement due to wound infection. Of note, 30-day mortality was 0% within the Manta-group vs. 0.8% within the Control-group (p=0.30).

Conclusion
Percutaneous femoral artery cannulation using a novel vascular closure device is safe and feasible during endoscopic MVS.  By avoiding groin incision, access site related infections and lymphocele formation can be eliminated. Nevertheless, the risk of minor vascular complications remains.