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

Introduction

Double or triple valve surgery is among the most demanding procedures in adult cardiac surgery and has traditionally required a full sternotomy (FS) to expose multiple, geometrically distinct cardiac structures. FS provides versatile and unrestricted access, but it involves substantial surgical trauma and carries a risk of sternal-related complications (1-3).

Over the past two decades, minimally invasive cardiac surgery (MICS) through a right mini-thoracotomy has become an established alternative for isolated mitral or aortic valve procedures (4-6). Accumulating evidence suggests that MICS can be associated with reduced bleeding and shorter hospital stay without compromising surgical safety (2,3,7,8).

The extension of MICS to aortic valve replacement (AVR)-inclusive multivalve procedures is less well established. The principal technical challenge is the need to expose anatomically distinct planes—the aortic and atrioventricular valves lie in near-perpendicular orientations—through a single, restricted intercostal incision. This has raised concern that cardiopulmonary bypass (CPB) and aortic cross-clamp (ACC) times might be prolonged, potentially offsetting the benefits of a smaller incision. Multicenter data comparing MICS and FS specifically for AVR-inclusive multivalve configurations remain limited; prior large series have predominantly addressed mitral or mitral-tricuspid configurations that do not require sequential aortic exposure (9), and much of the remaining literature consists of single-center experiences or pooled analyses of heterogeneous populations (10).

We report a comparison of MICS versus FS in patients undergoing double or triple valve surgery mandatorily including AVR at two tertiary centers with established minimally invasive valve programs. We evaluated perioperative safety and recovery measures and mid-term valve-related outcomes. We present this article in accordance with the STROBE reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-1182/rc).

Methods

We conducted a multicenter retrospective cohort study of adult patients who underwent AVR with concomitant mitral and/or tricuspid valve surgery between May 2015 and May 2025 at two tertiary centers, Seoul National University Bundang Hospital and Pusan National University Yangsan Hospital. This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the institutional review boards of both centers (Seoul National University Bundang Hospital, IRB No. B-2511-1008-115; Pusan National University Yangsan Hospital, IRB No. 55-2026-091). The requirement for individual informed consent was waived by both institutional review boards owing to the retrospective design and the use of de-identified data.

Patients were included if they underwent double or triple valve surgery involving AVR. Exclusion criteria were (I) emergent operations, (II) active infective endocarditis, (III) cardiac reoperations, (IV) partial sternotomy, (V) concomitant coronary artery bypass grafting (CABG) or ascending aortic surgery, and (VI) complex congenital heart disease. Eligible patients were classified by the surgical approach performed into the MICS and FS groups (Figure 1).

Figure 1 Study flow diagram. Of 497 patients screened for aortic valve replacement with concomitant mitral and/or tricuspid valve surgery at 2 tertiary centers, 294 were excluded, leaving 203 eligible patients (30 MICS, 173 FS). IPTW was then applied, yielding a weighted pseudo-population of 146.0 MICS and 144.4 FS patients in whom major morbidity, recovery outcomes, and valve function were compared. AVR, aortic valve replacement; CABG, coronary artery bypass grafting; FS, full sternotomy; IPTW, inverse probability of treatment weighting; MICS, minimally invasive cardiac surgery.

In this study, MICS was defined not by an absolute incision length but as valve surgery performed under CPB through a small chest-wall incision without a FS. Specifically, MICS here denotes AVR-inclusive valve surgery performed through a right mini-thoracotomy under peripheral cannulation. Skin-incision length was not used as a defining criterion; it was generally approximately 5–7 cm, individualized to thoracic anatomy and surgeon judgment.

No prespecified protocol, scoring system, or numerical threshold was used to assign patients to MICS or FS, and eligibility for MICS was not restricted by the type or severity of the valve lesion, functional status, or comorbidity. The choice of approach therefore rested primarily on the judgment of the operating surgeon rather than on prespecified criteria.

All patients underwent preoperative chest computed tomography (CT) to assess the position of the aortic root and aortic valve relative to the chest wall, the ease of right-sided access, and the suitability of the iliofemoral vessels for peripheral cannulation. The position of the aortic valve therefore governed the choice of intercostal space rather than whether MICS was performed. Valve morphology and calcification were not assessed for the purpose of approach selection. Patients were positioned with the right chest slightly elevated. Procedures were performed predominantly under direct vision; video assistance was used in a small number of early cases only, and no procedure was performed fully endoscopically. When exposure through a right mini-thoracotomy was limited, a partial resection of the adjacent costal cartilage or rib was performed to widen the operative field, and the resected segment was reapproximated with sutures at the completion of the procedure. A small port was used only for ancillary purposes; introduction of the transthoracic aortic clamp, carbon dioxide insufflation, and camera assistance where used. All three valves were addressed through the single right mini-thoracotomy, and no additional thoracotomy was made for any individual valve.

CPB was established by peripheral cannulation under ultrasound and transesophageal echocardiographic guidance. When right atrial exposure was required, superior vena caval drainage was added, either by a percutaneous right internal jugular cannula or by direct superior vena caval cannulation through the same atriotomy already made for the tricuspid procedure, so that no atriotomy was made solely to permit cannulation. In most cases not requiring right atrial exposure, no additional venous access or atriotomy was needed. Myocardial protection used antegrade cardioplegia delivered through an aortic root cannula; when significant aortic regurgitation compromised antegrade root delivery, direct ostial delivery after aortotomy was used selectively. Retrograde coronary sinus cardioplegia was not used in this MICS cohort.

The core technical task, which is sequential exposure of valves lying in different anatomical planes through a single incision, was addressed with pericardial stay sutures, a dedicated atrial retractor, and left-right table tilt, rather than by adding a separate thoracotomy for each valve. The sequence of valve procedures was standardized: when a concomitant Maze procedure for atrial fibrillation was indicated, it was performed first, followed by the mitral procedure through the left atrium, then the tricuspid procedure, and finally AVR. After completion of the valve procedures, de-airing, cross-clamp removal, weaning from CPB, decannulation, hemostasis, and wound closure were performed.

Perioperative safety and postoperative recovery outcomes were analyzed in parallel rather than as a single composite primary endpoint. Early mortality was defined as all-cause death within 30 days of surgery or during the same hospitalization. The major-morbidity components were stroke, new-onset renal failure requiring dialysis, need for mechanical circulatory support, and reoperation for bleeding, each defined and reported individually.

Recovery measures were duration of mechanical ventilation (hours), intensive care unit (ICU) stay (hours), postoperative hospital stay (days), and red blood cell (RBC) transfusion (units), analyzed as continuous variables. Regurgitation severity was graded qualitatively as none/trace, mild, moderate, or severe using an integrative echocardiographic approach consistent with contemporary American Society of Echocardiography reporting recommendations; “significant” regurgitation was defined as moderate or greater.

Statistical analysis

To address confounding by indication, we used inverse probability of treatment weighting (IPTW) based on a propensity score. The propensity score was estimated by logistic regression on 10 prespecified preoperative clinical covariates: sex, age, body surface area, hypertension, diabetes, cerebrovascular disease, chronic kidney disease, New York Heart Association class III/IV, atrial fibrillation, and rheumatic etiology. There were no missing values in any of these covariates, so the propensity model was fitted on complete data. These were selected based on two-stage univariate logistic screening as predictors of the MICS approach and of the major outcomes.

To restrict the analysis to the region of common support and to prevent extreme weights, patients whose predicted propensity score fell outside 0.05–0.95 were excluded. Stabilized weights targeting the average treatment effect were then applied to the restricted cohort. Covariate balance was assessed by standardized mean differences (SMDs) before and after weighting and displayed in a Love plot. The discrimination of the propensity model was assessed by the c-statistic.

On the weighted pseudo-population, continuous variables are summarized as weighted mean ± standard deviation or median [interquartile range (IQR)] and categorical variables as weighted frequency (%). Normally distributed continuous variables were compared by weighted t-test, right-skewed continuous variables by a weighted nonparametric test, and categorical variables by design-based weighted comparison with robust standard errors. For the main intraoperative characteristics and safety outcomes, adjusted differences are reported with 95% confidence intervals (CIs) obtained by bootstrap resampling with 1,000 replicates. Survival and freedom-from-event analyses used weighted Kaplan-Meier estimation with the weighted log-rank test; numbers at risk and 95% confidence bands are shown. A two-sided P value below 0.05 was considered statistically significant. Analyses were performed in R (version 4.4.2; R Foundation for Statistical Computing, Vienna, Austria).

Results

Of 497 patients screened, 203 met the inclusion criteria; 30 (14.8%) underwent MICS and 173 (85.2%) underwent FS (Figure 1). The IPTW analysis cohort comprised 145 patients (29 MICS, 116 FS), corresponding to a weighted pseudo-population of 146.0 MICS and 144.4 FS. Before weighting, the groups differed on several covariates (Table 1). After IPTW, the 10 propensity-score covariates were better balanced, with most SMDs below 0.15 (Figure S1); male sex retained an SMD of 0.172. Valve-lesion severity variables remained imbalanced after weighting (Table 1). The c-statistic of the propensity model was 0.79.

All patients underwent AVR as the index component of a multivalve procedure, and the planned MICS approach was completed in all 30 patients. On the weighted pseudo-population (Table 2), the proportions of mitral and tricuspid procedures and of concomitant Maze procedures did not differ significantly between groups, and the aortic valve prosthesis size showed no statistically significant difference (21.9±1.5 mm in MICS vs. 22.3±1.8 mm in FS, P=0.16). CPB time was 163.6±62.4 minutes in MICS and 168.5±46.4 minutes in FS (P=0.75), and ACC time was 127.7±36.6 versus 126.5±34.4 minutes (P=0.89). The corresponding IPTW-adjusted differences were −4.9 minutes (95% CI −35.5 to +38.2, P=0.67) for CPB time and +1.3 minutes (95% CI −18.4 to +26.2, P=0.98) for ACC time (Table S1).

No early death occurred in the MICS group, versus 4.1% in the FS group (Table 3). Individual major-morbidity events—new-onset dialysis, mechanical circulatory support, stroke, and reoperation for bleeding—were all recorded as zero in the MICS group and at low frequencies in the FS group. None of these differences reached statistical significance in the unweighted cohort (Table 3). After weighting, the corresponding IPTW-adjusted risk differences were −4.1% (95% CI −8.3 to −0.8) for early mortality, −6.4% (−13.8 to −1.1) for new-onset dialysis, −6.2% (−11.2 to −1.6) for reoperation for bleeding, and −3.4% (−7.2 to 0.0) for stroke (Table S1). There was no conversion to sternotomy in the MICS cohort.

The MICS group was associated with lower RBC transfusion [median 0.0 (IQR, 0.0–0.4) vs. 5.0 (IQR, 3.0–10.0) units], shorter mechanical ventilation [0 (IQR, 0–6) vs. 13 (IQR, 4–25) hours], and shorter ICU stay [23 (IQR, 21–27) vs. 46 (IQR, 25–72) hours) (all P<0.001] (Table 3). Postoperative hospital stay was also shorter in the MICS group [5 (IQR, 4–7) vs. 9 (IQR, 7–13) days, P<0.001].

Valve-regurgitation assessment on the last available echocardiogram was documented in 96.7% of MICS patients (29/30) and 97.1% of FS patients (168/173), which formed the basis of the freedom-from-regurgitation analyses. Follow-up was shorter in the MICS group, reflecting concentration of MICS adoption in the later study years: median follow-up was approximately 3.0 years (IQR, 1.2–4.7 years) in the MICS group and 4.9 years (IQR, 2.3–8.0 years) in the FS group. On weighted Kaplan-Meier analysis, no statistically significant difference in overall survival was observed between groups (unweighted P=0.17; weighted P=0.08; Figure 2A,2B). The corresponding 5-year estimates were 96.6% in the MICS group and 79.9% in the FS group.

Figure 2 Kaplan-Meier estimates of overall survival. (A) Unweighted estimate in the full cohort. (B) IPTW-weighted estimate. Shaded areas denote 95% confidence bands and numbers at risk are shown beneath the X-axis. Five-year survival was 91.2% for MICS versus 79.0% for FS in the unweighted analysis (P=0.17) and 96.6% versus 79.9% after weighting (P=0.08). FS, full sternotomy; IPTW, inverse probability of treatment weighting; MICS, minimally invasive cardiac surgery.

On the immediate postoperative echocardiogram, the aortic mean pressure gradient was low in both groups (12.7 vs. 12.5 mmHg), and no statistically significant difference was observed in regurgitation grades or left ventricular ejection fraction (Table 4). On weighted Kaplan-Meier analysis, no statistically significant difference in freedom from significant regurgitation was observed for either valve (aortic, unweighted P=0.13; weighted P=0.10, Figure 3A,3B; mitral, unweighted P=0.60; weighted P=0.35, Figure 4A,4B).

Figure 3 Kaplan-Meier estimates of freedom from significant aortic regurgitation. (A) Unweighted estimate in the full cohort. (B) IPTW-weighted estimate. Significant regurgitation was defined as moderate or greater. Shaded areas denote 95% confidence bands and numbers at risk are shown beneath the X-axis. Five-year freedom from significant aortic regurgitation was 100.0% for MICS versus 91.1% for FS in the unweighted analysis (P=0.13) and 100.0% versus 92.9% after weighting (P=0.10). AR, aortic regurgitation; FS, full sternotomy; IPTW, inverse probability of treatment weighting; MICS, minimally invasive cardiac surgery.

Figure 4 Kaplan-Meier estimates of freedom from significant mitral regurgitation. (A) Unweighted estimate in the full cohort. (B) IPTW-weighted estimate. Significant regurgitation was defined as moderate or greater. Shaded areas denote 95% confidence bands and numbers at risk are shown beneath the X-axis. Five-year freedom from significant mitral regurgitation was 96.4% for MICS versus 91.9% for FS in the unweighted analysis (P=0.60) and 96.9% versus 90.8% after weighting (P=0.35). FS, full sternotomy; IPTW, inverse probability of treatment weighting; MICS, minimally invasive cardiac surgery; MR, mitral regurgitation.

Discussion

In this two-center, IPTW-adjusted analysis of AVR-inclusive double or triple valve surgery, the planned MICS approach was completed in every attempted case, no statistically significant difference from FS was observed in CPB or ACC times or in mid-term valve-related outcomes, and the approach was associated with more favorable early recovery measures. These observations describe what was achievable in a selected cohort under an experienced operator.

The most persistent barrier to MICS for complex multivalve surgery has been the expectation of prolonged CPB and ACC times arising from restricted access, and previous series have frequently reported longer operative times for MICS (11). In the present cohort, operative times did not differ significantly between groups; however, the 95% CIs for the adjusted differences were wide and included clinically relevant values, so these results indicate an absence of a detectable difference under limited precision rather than proof that no time penalty exists. The MICS procedures in this cohort were performed, in effect, by a single experienced surgeon who had already performed more than 500 minimally invasive valve procedures before undertaking multivalve MICS. The observed operative times may not generalize to lower-volume or early-adoption settings.

The MICS group was associated with lower transfusion requirements and shorter ventilation, ICU, and hospital stay. These recovery measures are among the outcomes most susceptible to selection bias, and we therefore frame these findings as associations rather than treatment effects. The transfusion difference is mechanistically consistent with a smaller incision and reduced tissue trauma. Valve-lesion severity also remained imbalanced after weighting, so residual and unmeasured confounding cannot be excluded. The differences were consistent in direction and substantial in magnitude across recovery measures; the association should therefore not be dismissed, although whether it reflects the approach itself requires prospective evaluation.

Reports of minimally invasive multivalve surgery have accumulated steadily. Right-sided minimally invasive approaches to double and triple valve disease have been described in single-center series (4,12), and a dedicated series of right mini-thoracotomy for aortic plus mitral surgery with or without a tricuspid procedure has reported that the combination is technically achievable (11). Mid-term series of minimally invasive mitral surgery through a right mini-thoracotomy (13) and multicenter registry data for mini-mitral surgery (9) provide the broader denominator against which multivalve extensions should be judged. Reported operative times in these series have generally been longer than for sternotomy, which is the principal point of contrast with the present cohort and the reason the operative-time findings here should be regarded as an observation requiring replication rather than a resolved question. Techniques have also diverged: fully endoscopic and robotic programs differ substantially from the direct-vision approach used here in visualization, instrumentation, and learning requirements, so results are not directly transferable between them.

Contemporary experience with minimally invasive and endoscopic multivalve surgery is expanding. A recent two-center propensity-matched analysis of endoscopic minimally invasive multiple-valve surgery versus median sternotomy reported feasibility with acceptable early outcomes, providing a directly relevant contemporary benchmark for the present AVR-inclusive cohort (14). Set against such contemporary endoscopic and robotic programs, our right mini-thoracotomy, direct-vision experience should be viewed as one point on a spectrum of minimally invasive strategies rather than as a uniquely early demonstration (14).

A practical concern specific to MICS-AVR is that restricted annular visualization might lead to implantation of smaller prostheses and predispose to patient-prosthesis mismatch (15,16). In the present cohort, no statistically significant difference in aortic prosthesis size was observed between groups, and immediate postoperative mean gradients, regurgitation grades, and ventricular function likewise showed no statistically significant difference (17). These observations are consistent with implantation of prostheses of similar nominal size with MICS. Because patient-prosthesis mismatch is defined by indexed effective orifice area (iEOA) rather than by nominal size, and iEOA was not routinely measured, these findings speak to prosthesis sizing rather than to mismatch itself.

The overall mitral repair rate in this cohort was low, which might be read as a limitation of the approach. Stratification by etiology indicates otherwise (Table S2). Rheumatic disease predominated in both groups and was almost always treated by replacement: none of the 19 rheumatic MICS patients and only 4 of 104 rheumatic FS patients underwent repair. Among non-rheumatic disease, repair was performed in 7 of 8 MICS patients (87.5%) and in 30 of 57 FS patients (52.6%). The low overall repair rate therefore reflects the etiologic composition of an AVR-inclusive multivalve cohort rather than avoidance of repair with MICS.

This pattern is consistent with the published experience in rheumatic mitral disease, in which repair remains contested. Repair can achieve durability approaching that of mechanical replacement when performed in carefully selected valves (18), but pooled analyses report a higher rate of subsequent mitral reoperation after repair than after replacement in rheumatic disease (19). In a cohort in which rheumatic etiology accounted for approximately 60% of patients in both groups, a replacement-predominant strategy is therefore an expected consequence of pathology rather than of surgical access. The repairs performed with MICS included annuloplasty with artificial chordal reconstruction, limited leaflet resection, commissural repair, and direct closure of leaflet perforation, indicating that the approach did not restrict the technical repertoire available for reconstruction. The repair-amenable MICS subgroup was small (n=8), so these proportions are descriptive and were not formally compared.

This study has several limitations. First, this was a retrospective, non-randomized, two-center study, and residual confounding cannot be excluded. Valve-lesion severity variables were deliberately excluded from the propensity model because they are the surgical targets of the procedures compared, and they remained imbalanced after weighting. IPTW balances only the covariates entered the model, so the groups may still have differed in ways that were not captured. All comparisons reported here are therefore associations rather than causal treatment effects. Second, the study is underpowered and its generalizability is constrained. The treated group comprised 30 patients and the effective sample size after weighting was smaller still, so the unweighted comparisons of individual safety outcomes were not statistically significant and the weighted estimates rest on few observed events; neither the presence nor the absence of a statistically significant difference in these outcomes should be read as evidence of superiority or of equivalence. The findings are therefore exploratory and hypothesis-generating and require confirmation in adequately powered prospective studies. Third, echocardiographic follow-up was incomplete for the assessment of prosthetic valve performance. As a tertiary referral practice, patients who returned to their referring institution after the early postoperative period contributed no later study. Measurement of iEOA, core-laboratory adjudication, and a prespecified echocardiographic follow-up schedule were all lacking, so structural valve deterioration and patient-prosthesis mismatch could not be assessed by standardized criteria, and the mechanism of individual regurgitation events was not adjudicated in every case.

Conclusions

In this 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. Given the small, treated group and the limitations outlined above, these observations are exploratory and hypothesis-generating. Adequately powered prospective multicenter studies are needed before broader adoption can be recommended.

Acknowledgments

The authors thank the surgical and nursing teams at Seoul National University Bundang Hospital and Pusan National University Yangsan Hospital for their contributions to patient care.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-1182/rc

Data Sharing Statement: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-1182/dss

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-1182/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-1182/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Institutional Review Board of Seoul National University Bundang Hospital (IRB No. B-2511-1008-115, approved on 2025-11-01) and Pusan National University Yangsan Hospital (IRB No. 55-2026-091, approved on 2026-04-23). The requirement for individual informed consent was waived by both institutional review boards owing to the retrospective design and the use of de-identified data.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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