Endoscopic mitral valve repair-one hundred and one ways to use neochords: a narrative review.

Background and Objective: Mitral valve repair for mitral regurgitation remains technically demanding due to the complex anatomy of the mitral apparatus, including the annulus, left ventricle, papillary muscles, and chordae. Although Alain Carpentier's "French Correction" laid foundational principles, repair remains challenging, particularly for junior or low-volume surgeons. Neochordal implantation is a critical tool in mitral repair but lacks standardized technique selection, leading to variability in outcomes and surgical training. This narrative review aims to provide a comprehensive classification of neochordal repair techniques and a structured framework to guide clinical application. Methods: A narrative review of published literature on neochordal implantation was conducted, emphasizing technique evolution, anatomical considerations, imaging guidance, and minimally invasive approaches. Over 100 techniques were identified and categorized by anchoring strategy, leaflet involvement, and integration with advanced technologies, including robotic and artificial intelligence (AI)-assisted planning. The review also considers educational tools, simulation methods, and credentialing practices relevant to neochordal repair. Key Content and Findings: Endoscopic mitral valve repair offers patient benefits by avoiding sternotomy but increases technical complexity. Current surgical strategies largely depend on institutional habits, with limited structured guidance. Innovations highlighted include single- and multi-point anchoring, Y-shaped configurations, and techniques optimized using advanced imaging and simulation. These methods allow precise tension distribution, minimize leaflet manipulation, and enhance reproducibility. Despite these advancements, most techniques lack high-level evidence, with data primarily from single-center or retrospective studies. Emerging approaches show promise for biomechanically optimized repairs that simplify complex procedures, potentially reducing mid-term reoperation rates. Training limitations, absence of standardized checklists, and variability in credentialing remain barriers to widespread adoption. Conclusions: Neochordal implantation represents a versatile and evolving component of mitral valve repair. While numerous innovative techniques exist, reproducible outcomes require multicenter validation, long-term follow-up, and standardized training frameworks. This review provides a structured classification of neochordal techniques, identifies emerging trends, and underscores the need for future research and educational standardization to improve surgical consistency and patient outcomes.