This retrospective single-center study compared automated titanium fasteners to hand-tied knots in 2,678 patients undergoing mitral valve surgery between 2008 and 2024, with the primary endpoint being prosthetic dehiscence requiring reintervention. Among participants, 1,072 (40 percent) received automated titanium fasteners, while 1,606 (60 percent) received hand-tied sutures. Over a median follow-up of 5.3 years, automated fasteners demonstrated a significantly lower risk of prosthetic dehiscence in both univariable (sub-hazard ratio 0.32, 95 percent confidence interval (CI) 0.12-0.86, p=0.023) and multivariable analysis (adjusted sub-hazard ratio 0.34, 95 percent CI 0.12-0.91, p=0.033), with no increased risk of stroke, intracranial bleeding, or mortality. The authors conclude that automated titanium fasteners may reduce prosthetic dehiscence through consistent suture tension; however, they emphasize cautious interpretation given the limited dehiscence events and the potential for residual confounding, recommending randomized trials for a more robust assessment.