Conventional Versus Minimally Invasive Mitral Valve Replacement: A Retrospective Comparison of Sternotomy, Mini-Thoracotomy, and Periareolar Approaches

Background/Objectives: Minimally invasive mitral valve replacement (MVR) is increasingly used as an alternative to median sternotomy, but comparisons of non-robotic, direct-visualization approaches (mini-thoracotomy and periareolar incision) with sternotomy remain sparse, and head-to-head comparisons between the two minimally invasive techniques are even more limited. This study compared early and 1-year outcomes of sternotomy with two direct-visualization minimally invasive approaches for MVR, and compared the two minimally invasive techniques with each other. Methods: In this retrospective, single-center study, 196 patients undergoing isolated MVR (tricuspid annuloplasty permitted as a concomitant procedure) between January 2018 and May 2025 were divided into a sternotomy group (n = 102) and a minimally invasive group (n = 94; periareolar, n = 39; mini-thoracotomy, n = 55). Perioperative outcomes, pain, cosmetic satisfaction, and 12-month echocardiographic follow-up were compared, with multivariable linear regression used to adjust for confounders. Results: Operative and bypass times were longer with the minimally invasive approach, but cross-clamp time was shorter (60.5 ± 13.6 vs. 67.8 ± 8.6 min, p < 0.001). The minimally invasive group had less drainage, fewer transfusions, and shorter intensive care unit (ICU) and hospital stays, with higher 30-day cosmetic satisfaction (all p < 0.001), confirmed on multivariable analysis. Pain was higher on day 1 but lower by day 7 with the minimally invasive approach (both p < 0.001). Complications, mortality, and 1-year valve function were similar between groups. Within the minimally invasive cohort, periareolar access gave higher cosmetic satisfaction, lower pain, and shorter ICU stay and cross-clamp time than mini-thoracotomy (p < 0.01 to p < 0.001). Conclusions: Direct-visualization minimally invasive MVR, performed without robotic assistance, was associated with less bleeding, fewer transfused blood units, and shorter ICU/hospital stay, together with greater cosmetic satisfaction, versus sternotomy; no statistically significant differences were observed in 1-year echocardiographic valve function between groups. Periareolar access may offer additional pain and cosmetic benefits over mini-thoracotomy in appropriately selected patients.