September 10, 2025Open Access

Minimally Invasive or Conventional Sternotomy for Mitral Valve Surgery With Concomitant Surgical Ablation for Atrial Fibrillation: A Comparative Systematic Review

Key Points

Freedom from atrial arrhythmia was 94.52% for minimally invasive surgery versus 80.76% for sternotomy after one year.
Cardiopulmonary bypass time was significantly longer for minimally invasive techniques at 151.50 minutes compared to 120.01 minutes.
No significant differences in mortality rates were found between the minimally invasive and sternotomy approaches.
The rate of pacemaker implantation was notably higher in the sternotomy group at 5.20%, compared to 3.32% for minimally invasive surgery.

Abstract

Background: Presently, the availability of single-stage surgical correction of mitral valve disease combined with atrial fibrillation (AF) via a mini-access approach remains limited. Moreover, the comparative effectiveness of this procedure versus conventional sternotomy (CS) remains poorly understood. Thus, this study aimed to conduct a comparative assessment of the efficacy and safety of concomitant mitral valve surgery and AF ablation via a minimally invasive approach (minimally invasive cardiac surgery, MICS group) versus the standard sternotomy approach (CS group). Methods: An extensive literature search was performed to identify relevant studies. Additionally, for comparative analysis, we included isolated studies where the combined intervention was conducted exclusively via either minimally invasive or CS as the primary access. Results: Freedom from atrial arrhythmia (AA) for MICS and CS was 94.52% 95% CI 91.52, 96.50 vs. 80.76% 95% CI 67.19, 89.59 and 86.22% 95% CI 80.13, 90.66 vs. 86.33% 95% CI 79.39, 91.19 at 1 and 2 years, respectively, with no statistically significant differences. Meanwhile, cardiopulmonary bypass (CPB) and aortic cross-clamp (ACC) times were significantly longer in the MICS group compared to CS (CPB: 151.50 vs. 120.01 min; ACC: 112.36 vs. 101.43 min; p < 0.001). There were no differences in mortality between groups (p = 0.709). The rate of pacemaker implantation was significantly higher in the CS group (MICS: 3.32% 95% CI 1.58, 6.87 vs. CS: 5.20% 95% CI 2.80, 9.46; p < 0.001). Conclusion: This meta-analysis found that the minimally invasive approach was associated with longer CPB and ACC times but a lower rate of pacemaker implantation, with no significant differences observed in mortality and freedom from AA at 1 and 2 years. The PROSPERO registration: CRD42024570022, https://www.crd.york.ac.uk/PROSPERO/view/CRD42024570022.

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