Minimally Invasive Mitral Valve Surgery in Patients Aged ≥75 Years: An Expanding Standard of Care

<b>Background:</b> Right anterior mini-thoracotomy has gained increasing popularity as a preferred approach for mitral valve surgery due to its numerous advantages. This study aims to evaluate the safety and efficacy of this technique in elderly patients. <b>Methods</b>: Between January 2010 and November 2024, a total of 4092 adult patients underwent mitral valve repair or replacement at our institution. Of these, 1687 patients were treated using a minimally invasive approach. This analysis focuses on elderly patients aged 75 years and older (<i>n</i> = 402), further subdivided into two groups: 75-79 years (<i>n</i> = 253) and 80 years and older (<i>n</i> = 149). <b>Results</b>: The study population comprised 49.8% male patients. A small percentage (1.7%) had a history of endocarditis, and 6.5% had undergone prior cardiac surgery. The median logistic EuroSCORE was 7.68 (IQR 5.83-11.00), and the median EuroSCORE II was 2.75 (1.71, 4.40). Alternative cannulation strategies, guided by AngioCT scans, can expand the applicability of this technique to patients unsuitable for femoral cannulation. Median durations for cardiopulmonary bypass (CPB) and aortic cross-clamping were 99.5 and 80.0 min, respectively. Median ventilation time was 7 h, and the median ICU stay was 2 days. Atrial fibrillation was the most common postoperative complication (20.9%). A significant proportion of patients (47.8%) required blood transfusions, and 3.0% needed re-exploration for bleeding. The in-hospital mortality rate was 3.7%, with 7 (1.7%) patients requiring postoperative dialysis and 5 (1.2%) experiencing sepsis and multiple organ failure. Patients aged 80 years and older exhibited worse renal function and higher EuroSCOREs compared to the younger group (<i>p</i> < 0.001). However, they had shorter CPB (<i>p</i> = 0.004) and cross-clamp times (<i>p</i> = 0.001) and underwent a higher proportion of valve replacements (<i>p</i> = 0.003). Rates of major complications and in-hospital mortality were comparable between the two age groups. Logistic regression analysis identified the logistic EuroSCORE as the only significant preoperative risk factor (<i>p</i> = 0.001). <b>Conclusions</b>: Right anterior minithoracotomy is a safe and reproducible surgical approach, even in elderly patients, promoting faster recovery with a lower risk of complications. Among patients aged >80 years, despite higher comorbidities and elevated EuroSCORE II, in-hospital outcomes are comparable to those aged 75-79 years.