{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,16]],"date-time":"2026-09-16T17:03:59Z","timestamp":1789578239565,"version":"build-2803163510"},"reference-count":21,"publisher":"MDPI AG","issue":"18","license":[{"start":{"date-parts":[[2026,9,16]],"date-time":"2026-09-16T00:00:00Z","timestamp":1789516800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["J. Clin. Med.","JCM"],"abstract":"<jats:p>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 \u00b1 13.6 vs. 67.8 \u00b1 8.6 min, p &lt; 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 &lt; 0.001), confirmed on multivariable analysis. Pain was higher on day 1 but lower by day 7 with the minimally invasive approach (both p &lt; 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 &lt; 0.01 to p &lt; 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.<\/jats:p>","DOI":"10.3390\/jcm15187200","type":"journal-article","created":{"date-parts":[[2026,9,16]],"date-time":"2026-09-16T16:07:29Z","timestamp":1789574849000},"page":"7200","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Conventional Versus Minimally Invasive Mitral Valve Replacement: A Retrospective Comparison of Sternotomy, Mini-Thoracotomy, and Periareolar Approaches"],"prefix":"10.3390","volume":"15","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-2245-3775","authenticated-orcid":false,"given":"Alper Selim","family":"Kocao\u011flu","sequence":"first","affiliation":[{"name":"Department of Cardiovascular Surgery, Health Sciences University Eski\u015fehir City Health Practice and Research Hospital, 26080 Eski\u015fehir, Turkey"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"conceptualization","vocabulary":"credit"},{"role":"investigation","vocabulary":"credit"},{"role":"methodology","vocabulary":"credit"},{"role":"formal-analysis","vocabulary":"credit"},{"role":"data-curation","vocabulary":"credit"},{"role":"writing-original-draft","vocabulary":"credit"},{"role":"writing-review-editing","vocabulary":"credit"}]},{"given":"Beyza","family":"Ece Eral","sequence":"additional","affiliation":[{"name":"Department of Cardiovascular Surgery, Faculty of Medicine, Eski\u015fehir Osmangazi University, 26040 Eski\u015fehir, Turkey"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"conceptualization","vocabulary":"credit"},{"role":"methodology","vocabulary":"credit"},{"role":"writing-review-editing","vocabulary":"credit"}]},{"given":"Cengiz","family":"Oval\u0131","sequence":"additional","affiliation":[{"name":"Department of Cardiovascular Surgery, Faculty of Medicine, Eski\u015fehir Osmangazi University, 26040 Eski\u015fehir, Turkey"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"conceptualization","vocabulary":"credit"},{"role":"investigation","vocabulary":"credit"},{"role":"methodology","vocabulary":"credit"},{"role":"formal-analysis","vocabulary":"credit"},{"role":"data-curation","vocabulary":"credit"},{"role":"writing-original-draft","vocabulary":"credit"},{"role":"writing-review-editing","vocabulary":"credit"}]}],"member":"1968","published-online":{"date-parts":[[2026,9,16]]},"reference":[{"key":"ref_1","first-page":"14","article-title":"Minimally invasive surgical mitral valve repair: State-of-the-art review","volume":"13","author":"Stamm","year":"2018","journal-title":"Interv. Cardiol."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"181","DOI":"10.1186\/s13019-015-0390-y","article-title":"Early and long-term outcomes of minimally invasive mitral valve surgery through right minithoracotomy: A 10-year experience in 1,604 patients","volume":"10","author":"Glauber","year":"2015","journal-title":"J. Cardiothorac. Surg."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"760","DOI":"10.1016\/j.ejcts.2008.05.015","article-title":"Minimally invasive mitral valve repair for mitral regurgitation: Results of 1,339 consecutive patients","volume":"34","author":"Seeburger","year":"2008","journal-title":"Eur. J. Cardiothorac. Surg."},{"key":"ref_4","first-page":"7","article-title":"In-hospital outcomes of right minithoracotomy versus periareolar access for minimally invasive video-assisted mitral valve repair","volume":"37","author":"Oliveira","year":"2022","journal-title":"Braz. J. Cardiovasc. Surg."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"29","DOI":"10.1186\/s43057-022-00092-5","article-title":"A randomized controlled trial (PAMI trial) comparing our new trend periareolar minimally invasive (PAMI) technique with the inframammary approach for minimally invasive cardiac surgery","volume":"30","author":"Nady","year":"2022","journal-title":"J. Cardiothorac. Surg."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"783","DOI":"10.1136\/heartjnl-2018-314049","article-title":"Propensity-matched analysis of the minimally invasive approach versus sternotomy for mitral valve surgery","volume":"105","author":"Grant","year":"2019","journal-title":"Heart"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"228","DOI":"10.1186\/s13019-021-01578-9","article-title":"Minimally invasive or sternotomy approach in mitral valve surgery: A propensity-matched comparison","volume":"16","author":"Pojar","year":"2021","journal-title":"J. Cardiothorac. Surg."},{"key":"ref_8","doi-asserted-by":"crossref","unstructured":"Cetinkaya, A., Geier, A., Bramlage, K., Hein, S., Bramlage, P., Sch\u00f6nburg, M., Choi, Y.-H., and Richter, M. (2021). Long-term results after mitral valve surgery using a minimally invasive versus sternotomy approach: A propensity-matched comparison of a large single-center series. BMC Cardiovasc. Disord., 21.","DOI":"10.1186\/s12872-021-02121-3"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"1319","DOI":"10.1111\/jocs.16314","article-title":"Minimally invasive mitral valve surgery versus conventional sternotomy mitral valve surgery: A systematic review and meta-analysis of 119 studies","volume":"37","author":"Eqbal","year":"2022","journal-title":"J. Card. Surg."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"180","DOI":"10.5761\/atcs.oa.21-00131","article-title":"Comprehensive pain control strategy in minimally invasive mitral valve repair","volume":"28","author":"Hosono","year":"2022","journal-title":"Ann. Thorac. Cardiovasc. Surg."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"2307","DOI":"10.1111\/jocs.14799","article-title":"Mitral valve repair with minimally invasive approaches versus sternotomy: A meta-analysis of early and late results in randomized and matched observational studies","volume":"35","author":"Cavalcanti","year":"2020","journal-title":"J. Card. Surg."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"477","DOI":"10.1186\/s13019-024-02948-9","article-title":"Periareolar minimally invasive approach for cardiac surgery: A case series and description of technique with a review of the literature","volume":"19","author":"Mortada","year":"2024","journal-title":"J. Cardiothorac. Surg."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"125","DOI":"10.1007\/s11748-025-02187-2","article-title":"Robotic versus sternotomy mitral valve replacement in rheumatic disease: A comparison of early postoperative outcomes","volume":"74","author":"Duman","year":"2026","journal-title":"Gen. Thorac. Cardiovasc. Surg."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"490","DOI":"10.21037\/acs-2022-rmvs-21","article-title":"Robotic versus conventional sternotomy mitral valve surgery: A systematic review and meta-analysis","volume":"11","author":"Williams","year":"2022","journal-title":"Ann. Cardiothorac. Surg."},{"key":"ref_15","first-page":"9","article-title":"A systematic review and meta-analysis of robot-assisted mitral valve repair","volume":"18","author":"Nagase","year":"2023","journal-title":"Innovations"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"1970","DOI":"10.1136\/heartjnl-2018-313129","article-title":"A propensity-matched analysis of robotic, minimally invasive, and conventional mitral valve surgery","volume":"104","author":"Hawkins","year":"2018","journal-title":"Heart"},{"key":"ref_17","first-page":"ivag002","article-title":"Initial experience with robotic mitral valve replacement: Results from a single center","volume":"41","author":"Duman","year":"2026","journal-title":"Interdiscip. Cardiovasc. Thorac. Surg."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"ezad090","DOI":"10.1093\/ejcts\/ezad090","article-title":"Risk-related clinical outcomes after minimally invasive mitral valve surgery: Insights from the Mini-Mitral International Registry","volume":"63","author":"Berretta","year":"2023","journal-title":"Eur. J. Cardiothorac. Surg."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"189","DOI":"10.1093\/ejcts\/ezab364","article-title":"Minimally invasive surgery versus sternotomy in native mitral valve endocarditis: A matched comparison","volume":"61","author":"Kofler","year":"2021","journal-title":"Eur. J. Cardiothorac. Surg."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"716","DOI":"10.1016\/j.athoracsur.2018.03.086","article-title":"Isolated mitral valve surgery: An analysis of the Society of Thoracic Surgeons Adult Cardiac Surgery Database","volume":"106","author":"Gammie","year":"2018","journal-title":"Ann. Thorac. Surg."},{"key":"ref_21","doi-asserted-by":"crossref","unstructured":"Russo, G., Maisano, F., Massaro, G., Terlizzese, G., Mariano, E., Bonanni, M., Matteucci, A., Bezzeccheri, A., Benedetto, D., and Chiricolo, G. (2022). Challenges and Open Issues in Transcatheter Mitral Valve Implantation: Smooth Seas Do Not Make Skillful Sailors. Front. Cardiovasc. Med., 8.","DOI":"10.3389\/fcvm.2021.738756"}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/15\/18\/7200\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,9,16]],"date-time":"2026-09-16T16:30:07Z","timestamp":1789576207000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/15\/18\/7200"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,9,16]]},"references-count":21,"journal-issue":{"issue":"18","published-online":{"date-parts":[[2026,9]]}},"alternative-id":["jcm15187200"],"URL":"https:\/\/doi.org\/10.3390\/jcm15187200","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,9,16]]}}}