Minimally invasive or conventional sternotomy for concomitant mitral valve surgery and surgical ablation for atrial fibrillation: propensity score study

Background Surgical ablation for atrial fibrillation (AF) during mitral valve surgery is performed via minimally invasive (MICS) or conventional sternotomy (CS) approaches, with a paucity of comparative data. Objective This study compared the efficacy and safety of MICS vs. CS for concomitant mitral valve surgery and AF ablation. Methods From January 2012 to December 2024, 496 combined procedures were performed. After exclusions, 457 patients were analyzed (73 MICS, 384 CS). Propensity score matching (PSM) was used to create balanced groups for comparison. Results After PSM (61 MICS, 191 CS). cardiopulmonary bypass time, aortic cross-clamp time, and total operative duration were longer in the MICS group ( p < 0.001). The MICS group also had a longer ICU stay [2 (1–3) vs. 1 (1–2), p < 0.001] and greater postoperative drainage (MICS—IQR 350–750 mL vs. CS—IQR 250–500 mL, p < 0.001). No significant differences were observed in the incidence of major adverse cardiac and cerebrovascular events (MACE) or mortality. At discharge, more MICS patients were in sinus rhythm (95% vs. 70%, p = 0.003). During long-term follow-up (mean 3.15 years), there were no significant differences in overall survival (HR = 0.69, 95% CI: 0.22–2.21, p = 0.53), freedom from atrial tachyarrhythmias (HR = 0.51, 95% CI: 0.25–1.05, p = 0.068), or freedom from permanent pacemaker implantation [HR = 1.13 (0.20–6.49), p = 0.89]. Conclusion Despite longer perfusion times and certain early recovery metrics, the MICS for combined mitral valve and AF surgery offers comparable long-term safety, efficacy, and rhythm control outcomes to CS. MICS should be considered a viable alternative, contingent upon surgical expertise and individualized patient assessment.