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

Q: What are the key findings of this study?

Minimally invasive cardiac surgery for multivalve procedures did not prolong cardiopulmonary bypass time (adjusted difference -4.9 minutes) compared to full sternotomy and reduced hospital stays.

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: Aortic valve replacement-inclusive double or triple heart valve surgery (n=203). Intervention: Minimally invasive cardiac surgery (MICS) via right mini-thoracotomy vs. Conventional full sternotomy. Primary outcome: Cardiopulmonary bypass (CPB) time (adjusted difference -4.9 minutes, 95% CI -35.5 to 38.2, p=0.67).

Q: What does this research mean for the field?

Minimally invasive cardiac surgery via right mini-thoracotomy for multivalve procedures does not prolong cardiopulmonary bypass times compared to full sternotomy and is associated with reduced ICU and hospital stays. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Chansop Hwang; Hyung Gon Je; Min Ho Ju; Chee-Hoon Lee; Younju Rhee; Mi‐Hee Lim; Sang Yoon Kim; Joon Chul Jung; Hyoung Woo Chang; Jae Hang Lee; Sanghon Park; Jun Sung Kim; Kay‐Hyun Park

doi:10.21037/jtd-2026-1182

August 1, 2026Journal of Thoracic DiseaseOpen Access

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

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Key result

Minimally invasive multivalve surgery matches sternotomy bypass times and is linked to shorter hospital stays.

adjusted difference -4.9 minutes
95% CI -35.5 to 38.2
P=0.67
n=203

Why the study?

The role of minimally invasive cardiac surgery through right mini-thoracotomy for AVR-inclusive double or triple valve surgery is not well defined compared to conventional full sternotomy.

Does minimally invasive cardiac surgery (MICS) through a right mini-thoracotomy improve perioperative recovery and maintain equivalent mid-term outcomes compared to full sternotomy in adults undergoing AVR-inclusive double or triple valve surgery?

Key Points

To compare perioperative and mid-term outcomes of minimally invasive cardiac surgery via right mini-thoracotomy versus conventional full sternotomy in patients undergoing aortic valve replacement combined with mitral or tricuspid procedures.
Retrospective review of 203 adults (30 MICS, 173 full sternotomy) undergoing double or triple valve surgery between May 2015 and May 2025 across two tertiary centers.
Applied inverse probability of treatment weighting (IPTW) using a 10-covariate propensity score to balance baseline characteristics across a restricted common support pseudo-population.
Evaluated operative times, early morbidity and mortality, recovery metrics, and weighted Kaplan-Meier mid-term survival and freedom from significant valve regurgitation.
Operative times showed no significant difference between MICS and full sternotomy for cardiopulmonary bypass (163.6 vs. 168.5 minutes; adjusted difference -4.9 minutes, 95% CI -35.5 to +38.2, P=0.67) and aortic cross-clamp (127.7 vs. 126.5 minutes; adjusted difference +1.3 minutes, 95% CI -18.4 to +26.2, P=0.98).
MICS had 0.0% early mortality versus 4.1% in full sternotomy (adjusted risk difference -4.1%, 95% CI -8.3 to -0.8) with zero conversions to sternotomy.
MICS was associated with lower red blood cell transfusion (median 0.0 vs. 5.0 units, P<0.001), shorter mechanical ventilation (median 0 vs. 13 hours, P<0.001), shorter ICU stay (23 vs. 46 hours, P<0.001), and shorter hospital stay (5 vs. 9 days, P<0.001).

Study Design

Type

Cohort (n=203)

Multicenter

Yes

Structured PICO

Does minimally invasive cardiac surgery (MICS) through a right mini-thoracotomy improve perioperative recovery and maintain equivalent mid-term outcomes compared to full sternotomy in adults undergoing AVR-inclusive double or triple valve surgery?

P

Population

203 adults undergoing aortic valve replacement combined with mitral and/or tricuspid valve procedures followed for a median of 3.0 to 4.9 years.

E

Exposure

Minimally invasive cardiac surgery (MICS) through a right mini-thoracotomy (approximately 5-7 cm incision) under peripheral cannulation.

C

Comparator

Conventional full sternotomy (FS).

O

Outcome

Perioperative safety (early mortality, stroke, new-onset dialysis, mechanical circulatory support, reoperation for bleeding), postoperative recovery measures (mechanical ventilation duration, ICU stay, postoperative hospital stay, RBC transfusion), and mid-term survival and freedom from significant valvular regurgitation (analyzed in parallel, no single composite primary endpoint).hard clinical

Main Result

Mean Difference: -4.9 (95% CI -35.5–38.2)

Absolute Event Rate: 163.6% vs 168.5%

p-value: p=0.67

In experienced hands, minimally invasive cardiac surgery for AVR-inclusive double or triple valve surgery is technically feasible, avoids prolonged operative times, and may be associated with reduced transfusions and shorter recovery time compared to full sternotomy without compromising mid-term survival.

Limitations

Retrospective, non-randomized observational design with potential residual confounding
Valve-lesion severity variables remained imbalanced after inverse probability of treatment weighting
Small sample size underpowered for infrequent major safety outcomes and mid-term survival
Incomplete echocardiographic follow-up limiting the assessment of structural valve deterioration and patient-prosthesis mismatch
Most procedures were performed by a single highly experienced surgeon, limiting broader generalizability
Retrospective, non-randomized, two-center study
Residual confounding cannot be excluded (e.g., valve-lesion severity remained imbalanced after IPTW)
Underpowered for infrequent events
Constrained generalizability as procedures were primarily performed by a single experienced surgeon
Small MICS sample size (n=30)

Implication

MICS may shorten recovery without added bypass time in multivalve surgery; leaves open whether benefits hold in randomized or multicenter settings.

Abstract

Background: 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. Methods: 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. Results: 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. Conclusions: 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.

Discussion

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Cite This Study

Hwang et al. (2026) conducted a cohort in Aortic valve replacement-inclusive double or triple heart valve surgery (n=203). Minimally invasive cardiac surgery (MICS) via right mini-thoracotomy vs. Conventional full sternotomy was evaluated on Cardiopulmonary bypass (CPB) time (adjusted difference -4.9 minutes, 95% CI -35.5 to 38.2, p=0.67). Minimally invasive cardiac surgery for multivalve procedures did not prolong cardiopulmonary bypass time (adjusted difference -4.9 minutes) compared to full sternotomy and reduced hospital stays.

synapsesocial.com/papers/6ad0fce415427f6a840403f1 https://doi.org/10.21037/jtd-2026-1182

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

Key Points

Study Design

Structured PICO

Main Result

Limitations

Implication

Abstract

Discussion

Cite This Study

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

Key Points

Study Design

Structured PICO

Main Result

Limitations

Implication

Abstract

Discussion

Cite This Study

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