Background and Objectives: Minimally invasive surgery (MIS) has become a cornerstone approach in cardiac surgery. A debate persists regarding the optimal aortic clamp occlusion strategy, with limited comparative data. The two principal strategies, which are transthoracic cross-clamping (TTCC) and endo-aortic balloon occlusion (EABO), offer distinct advantages, but comparative clinical data remain limited. This study compares the two techniques in terms of procedural safety and early outcome. Materials and Methods: This single-center retrospective study included consecutive adult patients undergoing elective MIS via video-assisted right mini-thoracotomy between 2012 and 2018 for mitral valve surgery. Tricuspid repair, atrial fibrillation and redo surgery were included in the final cohort. Aortic occlusion was performed with transthoracic cross-clamping (TTCC) or endo-aortic balloon occlusion (EABO). Primary endpoints were intra-operative complications and the rate of conversion to full sternotomy; secondary outcomes were overall mortality and Society of Thoracic Surgeons (STS)-defined comorbidities. Results: A total of 163 patients were analyzed (TTCC: n = 99, 60%; EABO: n = 64, 40%). While both techniques demonstrated equivalent safety profiles (overall mortality: 0%), EABO was associated with higher conversion to full sternotomy [(n = 7, 10.9%) vs. TTCC (n = 1, 1.3%), p = 0.016]. In a generalized estimation equations (GEE) model, no patient-level covariate predicted conversion, suggesting technical or procedural factors as the primary contributors. In addition, EABO was associated with longer cross-clamp time [median: 87 min (IQR: 73, 100) vs. TTCC median: 77 min (IQR: 65.5, 87.5), p = 0.03]. Stroke, acute kidney injury, respiratory failure, reoperation and wound infection did not differ significantly; also, hospital stay was similar between groups. Conclusions: In this single-center series, EABO showed longer operative times and a higher conversion rate to sternotomy, but without excess mortality or major complications. This may be correlated with the initial learning phase and redo cases; further comparison is needed to assess the benefits of EABO.

Sex Differences in Left Ventricular Size and Function Before and After Mitral Valve Repair.

Cardioembolic stroke remains one of the most severe manifestations of cardiovascular disease, with atrial fibrillation (AF) responsible for a large proportion of ischemic cerebrovascular events. Stroke prevention strategies are currently dominated by oral anticoagulation guided by CHA2DS2-VASc scores, which emphasize age and comorbidities and therefore have limited applicability in younger patients with low conventional risk profiles. Although bleeding risk is routinely assessed using tools such as HAS-BLED, lifelong anticoagulation may still confer a substantial cumulative hemorrhagic burden over decades of treatment. The left atrial appendage (LAA) represents the primary anatomical source of thromboembolism in AF, yet current guidelines largely restrict surgical or percutaneous LAA exclusion to patients with AF who have contraindications to anticoagulation, reflecting a predominantly reactive approach. This Perspective advocates reconsideration of prophylactic surgical LAA exclusion at the time of open mitral valve repair in younger patients. Although early mitral repair limits atrial remodeling, it does not abolish lifetime AF risk, and post-operative or late-onset AF remains frequent. Moreover, residual or recurrent mitral regurgitation promotes progressive atrial dilation and fibrosis, increasing long-term thromboembolic risk even in patients initially in sinus rhythm. By integrating atrial remodeling, LAA morphology and function, residual mitral pathology, and the limitations of lifelong anticoagulation, a selective preventive framework emerges. An anatomical brain-heart prevention strategy may reduce lifetime cerebrovascular risk and improve long-term outcomes. While prospective data are needed, existing evidence supports individualized discussion of prophylactic LAA exclusion during mitral valve repair in selected young patients with structural atrial disease.

Additional exploration is required to determine how to treat patients with moderate aortic regurgitation (AR) in rheumatic mitral valve (MV) surgery. This study compared clinical outcomes in patients undergoing non-surgical treatment (NT) of aortic valve (AV), aortic valvuloplasty (AVP), and aortic valve replacement (AVR). This multicenter, retrospective observational cohort study included 338 moderate AR patients undergoing rheumatic MV surgery from January 2015 to January 2024. We followed up with patients for a median of 43.4 months. Furthermore, more-than-mild aortic valve dysfunction (AVD) in the follow-up period was our primary outcome. Our secondary outcomes were all-cause mortality and cardiac valve reoperation before discharge and during follow-up. We classified patients into three groups, namely, NT (n = 128), AVP (n = 91), and AVR (n = 119) groups, respectively. Moreover, 33.0%, 30.1%, and 3.9% of patients achieved our primary outcome, while 4.2%, 5.6%, and 9.6% of them attained our secondary outcomes in the three groups, respectively. We observed that fewer patients from the AVR group had achieved the primary outcome than those in the NT [adjusted relative risk (RR), 0.41; 95% confidence interval (CI), 0.21-0.68; p = 0.002] and AVP groups (adjusted RR, 0.14; 95% CI, 0.04-0.43; p = 0.002), respectively. The secondary outcomes did not significantly differ among the three groups. Without increasing surgical risks, the concurrent AVR significantly improves AV status in moderate AR patients undergoing rheumatic MV surgery throughout follow-up. None or mild AVD was observed in many patients from the NT group during the follow-up, thereby warranting the delay of surgery for AV.

Abstract Background Multiple valvular heart disease (MVD) is defined as the presence of stenotic and/or regurgitant lesions occurring in at least two cardiac valves. Among the possible combinations, the combination of significant aortic regurgitation (AR) and mitral regurgitation (MR) is not uncommon. Current guidelines recommend intervention when one of the two lesions progresses to a severe stage in the presence of symptoms, left ventricular (LV) dysfunction, or LV dilation. However, these recommendations are based on evidence from isolated AR or MR, while limited data is available on the outcomes of patients presenting with both lesions. Purpose To evaluate the clinical and echocardiographic characteristics of patients with combined significant AR and MR (≥ moderate AR and ≥ moderate MR) and their outcome in a multicenter setting. Methods A total of 156 patients (age 65 ± 13 years, 72% male) with significant AR and MR were included. Patients were categorized into four groups based on the regurgitation severity: (1) Moderate AR and Moderate MR (n=69); (2) Moderate AR/Severe MR (n=37); (3) Severe AR/Moderate MR (n=30); and (4) Severe AR and Severe MR (n=20)(Figure 1A). Regurgitation severity was determined using a multiparametric approach, in accordance with current ESC/EACVI guidelines. The study endpoint was all-cause mortality, with valve intervention accounted for during follow-up as a time-dependent covariate. Results Over a median follow-up of 6 years (IQR 2-10), 56 (36%) patients died. A total of 90 (58%) patients underwent aortic valve surgery (AVS), 94 (60%) underwent mitral valve surgery (MVS), and 101 (65%) underwent either procedure. Patients with Moderate AR and MR were older and more often female (Table 1). Severe AR was more frequently associated with bicuspid aortic valve, and Severe MR was more often associated with organic etiology. Atrial fibrillation was more prevalent among patients with Severe MR. The presence of Severe AR was associated with greater LV dilation compared to the other groups, while patients with Severe MR showed larger left atrial volume. After adjustment for age, New York Heart Association (NYHA) class, renal function, AR etiology, systolic pulmonary arterial pressure (SPAP) and valve intervention (AVS and/or MVS) as a time-dependent covariate, patients with combined Severe AR and MR showed the worst adjusted 10-year survival (HR 4.16; 95% CI 1.24-13.92; p=0.021) (Figure 1B). This was followed by patients with Severe AR/Moderate MR (HR 3.66; 95% CI 1.50-8.93; p=0.004) and those with Moderate AR/Severe MR (HR 2.50; 95% CI 1.06-5.91; p=0.037). Patients with concomitant Moderate AR and MR showed the best adjusted 10-year survival. Conclusion In patients with combined significant AR and MR, increasing regurgitation severity was associated with poorer survival. Notably, Severe AR was associated with significantly worse outcomes regardless of MR severity.

ObjectivesOlder patients are more prone to postoperative morbidity and mortality after mitral valve (MV) surgery. Minimally invasive MV surgery (MIMVS) is increasingly adopted worldwide, with a potential benefit in the elderly. This study compares short-term and mid-term outcomes in patients above 70 years, undergoing MIMVS versus median sternotomy (MST), in a nationwide registry.MethodsAll patients above 70 years undergoing primary elective MV surgery (±tricuspid valve [TV] surgery, atrial septal defect closure, rhythm surgery) between 2013 and 2021 were included. All data were extracted from the Netherlands Heart Registration. Primary outcomes were short-term morbidity, mortality, and 5-year survival.ResultsIn total, 1418 patients were included (MST n = 797, MIMVS n = 621). No statistically significant differences in baseline characteristics were found. Median Logistic EuroSCORE I was 6.3 [4.7–8.5] vs 6.0 [4.6–8.5], P = .27 for MST and MIMVS, respectively. Mitral valve repair (77.7% vs 64.7% P < .001) and concomitant TV surgery (43.9% vs 18.2%, P < .001) was more frequently performed in MST. Lower 30-day mortality was observed in MIMVS (0.6% [n = 4] vs 2.5% [n = 21], P = .01). Furthermore, the incidence of pneumonia, prolonged intubation, readmission to intensive care unit, kidney failure, and new-onset arrhythmia were lower for MIMVS. No difference in 5-year survival was found (MST: 89.1 ± 4.6% vs MIMVS: 91.6 ± 4.7% Log-Rank P = .51).ConclusionsMinimally invasive MV surgery in patients above 70 years may be associated with lower 30-day mortality and incidence of postoperative complications compared with sternotomy.

Minimally invasive cardiac surgery for mitral valve (MV) disease is a rising strategy. Axillary access is linked to reduced pain and faster recovery, but its efficacy and safety compared with median sternotomy for MV surgery (MVS) remain unclear. We conducted a meta-analysis comparing the clinical outcomes of MVS via axillary access and median sternotomy. Four databases were analyzed. The primary endpoint was perioperative mortality. Secondary endpoints included cardiopulmonary bypass (CPB) and cross-clamp times, rethoracotomy, wound complications, mechanical ventilation duration, stroke, hospital and intensive care unit (ICU) stay, and residual moderate mitral regurgitation. A random-effects model was used. We included 2,129 patients from 4 studies, with 1,135 (53.3%) undergoing axillary access. Perioperative mortality was comparable between approaches (odds ratio [OR] = 0.34, 95% confidence interval [CI]: 0.09 to 1.23, P = 0.10). Axillary access was associated with longer CPB times (mean difference [MD] = 16.38, 95% CI: 6.42 to 26.34, P = 0.001), fewer wound complications (OR = 0.41, 95% CI: 0.21 to 0.80, P = 0.009), shorter ventilation time (MD = -4.93, 95% CI: -8.79 to -1.08, P < 0.01), and shorter hospital (MD = -0.78, 95% CI: -1.41 to -0.14, P = 0.02) and ICU stays (MD = -10.84, 95% CI: -19.54 to -2.14, P = 0.01). No difference was found in cross-clamp time, rethoracotomy, stroke, or residual mitral regurgitation. Axillary access for MVS shows comparable mortality to median sternotomy, with benefits in wound complications, ventilation, and recovery but longer CPB times. Further research is needed to confirm long-term safety and efficacy.

Monitoring cardiac output (CO) is helpful in the perioperative management of the patient with severe mitral regurgitation (MR). We assessed the accuracy and precision of the Cheetah CO monitor in patients with moderate or severe MR undergoing right and left heart catheterization as part of their pre-operative evaluation for mitral valve surgery. Cheetah CO was obtained concurrently with thermodilution CO (TD CO). Bias data was non-normally distributed; therefore, a non-parametric equivalent to Bland and Altman limits of agreement was used. Additionally, the proportions of differences between the experimental and reference method that were ≤ 0.5 L/min, ≤ 1 L/min, and >1 L/min were calculated. Twenty-seven subjects were enrolled and completed the study. The median difference between Cheetah and TD CO measurements was − 0.82 L/min, and the 5th and 95th centiles were − 6.05 L/min and 3.25 L/min, respectively. Of all differences, 25.9%, 51.9%, and 48.1% were ≤ 0.5 L/min, ≤ 1 L/min, and > 1 L/min. No proportional bias was present. We conclude that the Cheetah CO measurements in patients with moderate to severe MR cannot be used interchangeably with TD CO due to a large bias and imprecision.

Aim . To identify the main differences in patients undergoing surgical treatment of acquired mitral valve (MV) disease depending on the preoperative type of pulmonary hypertension (PH), as well as to identify factors associated with PH persistence and its type one year after surgical treatment of MV disease. Material and methods . This open-label, single-­center prospective study included 40 patients with valvular heart disease (VHD) undergoing MV surgery. These patients had verified PH according to the right heart catheterization (RHC) as follows: 15 patients with isolated post-capillary PH and 25 patients with a combined post-/precapillary PH. Intraoperatively, 26 patients with PH underwent a right lung tissue biopsy with subsequent histological examination. One year after surgery, RHC was performed to assess PH dynamics. The significance ranks of the predictors were used to assess the contribution of factors to PH dynamics after surgery. Results . Patients with VHD and combined post/precapillary PH were characte­rized by more impaired right ventricle-­pulmonary artery coupling, increased le­vels of myocardial strain markers, severe changes in pulmonary circulation hemodynamics, arteriolization of venules, and a higher frequency of pandemic arterial thrombosis (53,3%) compared to patients with isolated postcapillary PH (9%). According to RHC data one year after surgery (n=21), PH regression was observed in 28,5%, while isolated postcapillary PH persisted in 42,85%, and combined post/precapillary PH — in 28,5%. The factors, that made the most significant contribution to PH regression one year after surgery included mitral valve stenosis (100 units), atrial fibrillation (73 units), type 2 diabetes (72 units), combined intervention on the mitral valve and aortic valve (61 units), obesity class (56 units), male sex (48 units). The character of morphological lung changes did not significantly contribute to perioperative dynamics of PH. Conclusion . Patients with VHD and combined post/precapillary PH are characterized by more impaired right ventricle-­pulmonary artery coupling, elevated levels of myocardial strain markers, severe changes in pulmonary circulation hemodynamics with arteriolization of venules and a higher prevalence of pandemic arterial thrombosis. For the first time, potentially modifiable factors have been identified as making the greatest impact on the PH dynamics one year after surgery.

The aim of this study is to gain insight into mortality rates and causes of death after major cardiac interventions, using nationwide real-world data from the Netherlands. For this retrospective observational study, data from Statistics Netherlands and the Dutch all-payer claims database in the period 2016-2019 were used to select the intervention groups: coronary artery bypass grafting (CABG), percutaneous coronary intervention, surgical aortic valve replacement (SAVR), SAVR + CABG, mitral valve surgery, transcatheter heart valve intervention, pulmonary vein isolation and minimally-invasive maze surgery. For all interventions, survival status, date, and cause of death were retrieved. Causes of death were clustered for cardiovascular (CV) and non-CV causes by their corresponding ICD-10 code at different time intervals up to 5years after the intervention. Atotal of 203,001 interventions were included, and 13.7% (27,832) of the patients died during the 5‑year follow-up. Of these, 45.1% (12,560) were CV, and 54.9% (15,272) were non-CV deaths. After coronary revascularization, valve intervention, and aortic valve intervention and coronary revascularization combined, respectively, non-CV mortality increased from 14.2%, 12.9% and 20.7% at 30days to 44.5%, 47.0% and 44.5% after 2years. Of all deaths up to 5years, 54.7%, 54.3% and 55.3% were non-CV. Initially main cause of death after cardiac intervention is CV-related. The proportion of non-CV deaths increases during follow-up, impacting survival for all patients up to 5years after intervention. (Fig.1).

To explore the feasibility and effect of video-assisted minimally invasive surgery for combined heart valvular diseases through an intercostal incision. From July 2022 to April 2025, a total of 50 video-assisted minimally invasive combined heart valve surgeries were performed in the Department of Cardiovascular Surgery of the First Affiliated Hospital of Anhui Medical University. Combined heart valve procedures include mitral and tricuspid valve surgery and mitral and aortic valve surgery, as well as large atrial septal defect repair combined with mitral and tricuspid valve surgery. The 4th right intercostal incision along the anterior axillary line was set as the primary access for the surgical procedure of combined mitral and tricuspid valves. The 3rd intercostal incision next to the sternum was set as the primary access for the surgical procedure of combined aortic and mitral valves. The 4th right intercostal incision along the midclavicular line was set as the primary access for the surgical procedure of combined mitral and tricuspid valves concomitant with a large defect of the atrial septal. The perioperative data of patients was collected. All patients underwent the video-assisted minimally invasive surgery completely. A total of 49 patients were discharged as expected except for only 1 older patient who was transferred into a local medical institution for extended rehabilitation due to delayed postoperative awakening. Postoperatively, excellent function of replaced prosthetic valves without paravalvular leaking has been confirmed. Moreover, there was no or less than mild regurgitation for repaired mitral and tricuspid valves. Also, postoperative complications, including III atrioventricular block, renal failure, and severe hypoxaemia, have not been found. Video-assisted minimally invasive surgery for combined heart valves is safe and effective with a short-term satisfactory outcome.

Background: Rheumatic heart disease (RHD) remains highly prevalent in Yemen, often presenting with advanced mitral valve lesions and pulmonary hypertension (PH). However, prospective data on early postoperative outcomes, including 3-month mortality, are limited. Therefore, this study aimed to evaluate the association between preoperative PH severity and 3-month outcomes following mitral valve surgery for RHD in Yemen. Methods: A prospective observational study was performed on 134 adult patients with RHD who were undergoing mitral valve surgery at the Cardiovascular and Kidney Transplantation Center, Taiz, Yemen (January 2022–August 2024). Patients were stratified according to preoperative systolic pulmonary artery pressure (sPAP) into Group I (&lt;60 mmHg) and Group II (≥60 mmHg). All-cause 3-month mortality, readmissions, and major postoperative complications were recorded. Results: The 30-day mortality was low and did not differ significantly between groups (3.9% vs. 3.5%; p = 0.907). The overall 3-month all-cause mortality rate was 10.4%, with no significant difference in mortality within the two groups (12.3% vs. 9.1%; p = 0.551). The early complication rates and hospital readmissions were comparable between groups. Conclusions: Early mitral valve surgery before the development of severe PH and right ventricular dysfunction was shown to improve survival outcomes. Surgery is safe and feasible for RHD patients with severe PH, with low early mortality and an 89.6% 3-month survival rate.

Background: The advantage of employing multidisciplinary heart teams (MDHT) for the selection process of minimally invasive (MIS) mitral valve repair (MVr) and mitral valve replacement (MVR) has been previously substantiated. Here, we outline the contributions each member of the MDHT at our institution made during the intra-operative and peri-operative periods and describe their impacts on short-term outcomes. Patients and Methods: This is a single-center retrospective review of all 278 adult patients who underwent MIS MVR or MVr by a single surgeon at our institution between 2006 and 2023. The repair’s efficacy was assessed intraoperatively and at 1 year post-operation. The surgical technique involved a mini-thoracotomy and valve repair or replacement. Outcomes included post-operative mortality, complications, operative time, repair success rate, hospital length of stay (LOS), and post-operative ejection fraction. There was no control group, as all patients undergoing MIS MVR/MVr were treated within an MDHT model. Results: Delivery of regional anesthesia via paravertebral catheter (PVC) was associated with a statistically significant shorter hospital LOS (6.52 vs. 7.81 days, p = 0.028). Enhanced Recovery After Surgery (ERAS) implementation by nurses was associated with a potentially clinically important, although not statistically significant, reduction in LOS (6.7 vs. 10.1 days, p = 0.168). Introduction of the COR-KNOT® DEVICE for securing annuloplasty sutures was associated with a statistically significant reduction in operative time (288 vs. 326 min, p < 0.001). Percutaneous cannulation, proctored by interventional cardiology in 2019, was associated with a decrease in lymphocele rate from 6.2% before 2019 to 0% after 2019. Conclusions: Initiatives implemented by our MDHT were associated with reduced post-operative LOS, shorter operative times, and lower incidence of post-operative complications.

This study aimed to assess long-term outcomes of automated titanium fasteners versus hand-tied knots in mitral valve surgery. In this retrospective, single-centre analysis, 2678 adult patients who underwent mitral valve repair or replacement between November 2008 and November 2024 at the Medical University of Vienna were included. Patients were grouped according to the suture-securing technique used: automated titanium fasteners versus hand-tied knots. The primary endpoint was prosthetic dehiscence (either mitral annuloplasty ring or valve replacement prosthesis) requiring reintervention. Secondary endpoints comprised ischaemic stroke, intracranial bleeding, and all-cause mortality during the follow-up period. Among the study population, 1072 (40%) underwent mitral valve surgery using an automated titanium fastener device, and 1606 (60%) with conventional hand-tied sutures. A total of 31 patients (1.2%) had prosthetic dehiscence during the follow-up period. The risk of prosthetic dehiscence was significantly lower in the automated titanium fastener group in both univariable (crude sub-hazard ratio [sHR] 0.32; 95% confidence interval [CI], 0.12-0.86, P = .023) and multivariable competing risk regression analysis (adjusted sHR 0.34; 95% CI, 0.12-0.91, P = .033). Automated titanium fastener group was not associated with an increased risk of ischaemic stroke (adjusted sHR 0.92; 95% CI, 0.67-1.27, P = .600), intracranial bleeding (adjusted sHR 0.89; 95% CI, 0.52-1.52, P = .675), or all-cause mortality (adjusted hazard ratio 0.93; 95% CI, 0.74-1.18, P = .559). The use of an automated titanium fastener device seems to be associated with a lower risk of prosthetic dehiscence in mitral valve surgery. Due to the limited number of prosthetic dehiscence events and the potential for residual confounding, the results should be interpreted with caution.

Severe mitral annular calcification (MAC) carries an increased risk of perioperative complications in patients undergoing mitral valve surgery and may be considered a prohibitive surgical risk. Cavitron ultrasonic surgical aspiration (CUSA) has been reported as a method for controlled debridement of severe MAC during mitral valve surgery; however, experience in the literature is limited. We assessed 30-day and intermediate-term outcomes in 67 consecutive patients (mean age: 72 [SD 9] years; female sex: 65.7% [44/67]) with severe MAC who underwent mitral valve repair or replacement for mitral stenosis and/or regurgitation using CUSA from March 2021 through December 2024. Operations included isolated mitral valve replacement (41.8% [28/67]), isolated mitral valve repair (4.5% [3/67]), mitral and aortic valve replacement (37.3% [25/67]), mitral valve replacement with coronary bypass (6.0% [4/67]), and mitral and aortic valve replacement with coronary bypass (10.4% [7/67]). Intermediate survival was estimated using the Kaplan-Meier method. Mortality rate was 6.0% (4/67), stroke was 3.0% (2/67), and new postoperative atrial fibrillation was 29.0% (20/67). There were no atrioventricular groove ruptures. At a median echocardiographic follow-up time of 361 days (interquartile range [IQR] 112, 671), moderate paravalvular leak occurred in 3.0% (1/67). Mid-term all-cause mortality was 9.0% at a mean follow-up time of 42.5 (95% CI, 39.0, 46.0) months. The use of CUSA to debride severe mitral annular calcification in patients undergoing mitral valve surgery is associated with acceptable short-term morbidity and mortality and durable intermediate-term results. This technique allows surgical intervention in patients who may otherwise be deemed prohibitive surgical risk.

Worsening tricuspid regurgitation after mitral valve surgery: a meta-analysis and meta-regression.

Right Ventricular Function After Mitral Valve Surgery: Insights From the United Kingdom Mini Mitral Study.

Tips and tricks in addressing mitral annular calcification in mitral valve surgery.

The benefits of minimally invasive mitral valve surgery (MIMVS) compared with conventional approaches (CMVS, conventional mitral valve surgery) remain controversial. We conducted a systematic review and meta-analysis to evaluate the short-term benefits between these approaches. To evaluate the short-term benefits of MIMVS versus CMVS in adults. We searched PubMed/MEDLINE, EMBASE, Cochrane Library, LILACS, SciELO, clinical trial registries and grey literature using MeSH terms, without date or language restrictions. Randomised clinical trials (RCTs) comparing MIMVS and CMVS in adults (≥18 years) were included. Robotic, endovascular and redo procedures were excluded. Two reviewers independently extracted data following Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. Risk of bias was assessed with the Cochrane tool, and certainty of evidence with Grading of Recommendations, Assessment, Development and Evaluation. Meta-analyses used random-effects models. Primary outcomes were mortality, acute kidney injury (AKI) and wound infection. Nine studies (1248 patients) from eight RCTs were included (686 CMVS, 562 MIMVS). MIMVS showed no significant difference in mortality or AKI compared with CMVS. There was a trend towards fewer wound infections (risk ratio=0.47; 95% CI=0.22 to 1.00) and shorter intensive care unit (ICU) stay (mean difference=-0.71 days; 95% CI=-1.47 to 0.04). MIMVS reduced reoperation for bleeding (RR=0.24; 95% CI=0.06 to 0.92) and hospital stay (mean difference=-1.83 days; 95% CI=-3.03 to -0.64). Operative times were longer with MIMVS, but without clinical impact. Stroke, myocardial infarction, mechanical ventilation time and transfusion rates were similar. Most studies had low risk of bias, with moderate to high certainty of evidence. No heterogeneity was detected for primary outcomes. MIMVS enhances postoperative recovery through shorter hospital stays, fewer reoperations for bleeding and a trend towards fewer wound infections and shorter ICU stays compared with CMVS. Despite longer operative times, key safety is comparable between techniques. The overall certainty of evidence is high for most outcomes, supporting strong clinical recommendations in favour of MIMVS. CRD42022321939.

A Practical Technique for Antegrade Myocardial Protection in Combined Aortic and Mitral Valve Surgery