TAVR and SAVR have similar short and long-term all-cause mortality and risk of stroke among patients of moderate or high surgical risk. TAVR decreases the risk of major bleeding, acute kidney injury and improves haemodynamic performance compared with SAVR but increases the risk of vascular complications, the need for a pacemaker and residual aortic regurgitation.

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A 67-year-old man with severe mitral regurgitation and paroxysmal atrial fibrillation was admitted to our institution for surgical repair. The procedure was carried out off-pump. We first performed a totally thoracoscopic maze box lesion set with epicardial transmural radiofrequency, and clipped the left atrial appendage. The mitral valve prolapse was repaired by implanting three transapical neochordae. Six months later, the patient was in sinus rhythm with minimal residual mitral regurgitation on echocardiography. This novel approach is less invasive than the standard surgical correction and should ensure a faster recovery with similar safety and efficacy in selected cases.