Technical feasibility and mid-term outcomes of right mini-thoracotomy for double or triple heart valve surgery: a...

Minimally invasive cardiac surgery (MICS) through a right mini-thoracotomy is well established for isolated valve procedures, but its role in aortic valve replacement (AVR)-inclusive double or triple valve surgery is not well defined. We compared perioperative and mid-term outcomes of MICS versus conventional full sternotomy (FS) for AVR combined with mitral and/or tricuspid valve procedures.

We retrospectively identified 203 adults (30 MICS, 173 FS) who underwent AVR-inclusive double or triple valve surgery at two tertiary centers between May 2015 and May 2025. Inverse probability of treatment weighting (IPTW) based on a 10-covariate propensity score was applied after restriction to the region of common support. Outcomes were compared on the weighted pseudo-population; adjusted differences were summarized with 95% confidence intervals (CIs), and mid-term survival and freedom from significant valvular regurgitation were assessed by weighted Kaplan-Meier analysis.

After IPTW, the 10 propensity-score covariates were better balanced (most standardized mean differences <0.15). Cardiopulmonary bypass (CPB) and aortic cross-clamp (ACC) times did not differ significantly between the MICS and FS groups (CPB 163.6 vs. 168.5 minutes; ACC 127.7 vs. 126.5 minutes). No early death occurred in the MICS group (0.0% vs. 4.1% in FS). Red blood cell (RBC) transfusion (median 0.0 vs. 5.0 units), duration of mechanical ventilation, intensive care unit (ICU) stay, and postoperative hospital stay were all lower in the MICS group (all P<0.001). Over a median follow-up of approximately 3.0 years in the MICS group and 4.9 years in the FS group, no statistically significant difference was observed in mid-term survival or in freedom from significant aortic or mitral regurgitation.

In this selected, non-randomized cohort, AVR-inclusive double or triple valve surgery was completed by MICS in all attempted cases, without a detectable increase in operative times and with shorter ventilation, ICU, and hospital stay. Mid-term survival and valve-related outcomes showed no statistically significant difference from FS.