# Single-Center Experience With Minimally Invasive Approaches From Sternotomy to Thoracoscopy: Assessing the Learning Curve and Benefits

## TL;DR

This study shows that minimally invasive heart surgery, despite a learning curve and longer operation times, offers faster recovery and fewer complications compared to traditional methods.

## Contribution

The study provides empirical evidence on the safety and benefits of establishing a minimally invasive cardiac surgery program during its early phase.

## Key findings

- Minimally invasive surgery resulted in less blood loss, lower transfusion needs, and faster recovery times compared to traditional sternotomy.
- Despite longer operative times and higher phrenic nerve palsy rates, minimally invasive surgery was found to be safe with no significant differences in mortality or stroke.
- The study highlights the importance of patient selection and team training in successfully implementing minimally invasive cardiac surgery.

## Abstract

Background

Cardiac surgery is increasingly shifting from traditional full sternotomy (FS) towards minimally invasive cardiac surgery (MICS), driven by evidence of benefits like reduced trauma, faster recovery, and shorter hospital stays. However, the adoption of MICS is hindered by a significant learning curve, technical complexity, and the need for specialized team training and equipment. This study aimed to evaluate the initial outcomes and safety of a newly established MICS program by comparing its first cases with concurrent FS procedures.

Results

A single-center prospective cohort study was conducted from November 2024 to April 2025, including 98 patients undergoing primary, elective single-valve surgery. Patients were allocated to either the MICS group (n=30), representing the program's initial experience, or the FS group (n=68). The FS group, which had a higher preoperative risk profile and more complex procedures, served as the control. The MICS group demonstrated significantly longer operative and cardiopulmonary bypass times (6.56 vs. 4.87 hours; 122.93 vs. 92.66 minutes, p<0.001). However, MICS patients experienced substantially less blood loss (288.3 vs. 592.7 mL, p<0.001) and lower transfusion requirements. Postoperatively, the MICS group had lower pain scores, faster mobilization (1.23 vs. 2.31 days, p<0.001), shorter hospital stays (6.20 vs. 7.74 days, p=0.004), and a markedly quicker return to normal activity (2.50 vs. 10.49 weeks, p<0.001). A significant increase in phrenic nerve palsy was observed in the MICS group (16.7% vs. 0%, p=0.001). Crucially, there were no significant differences in mortality, stroke, or reoperation for bleeding.

Conclusion

Despite a clear learning curve, as evidenced by longer procedure times and a higher rate of procedure-specific complications such as phrenic nerve palsy, the initial implementation of a minimally invasive program was safe and conferred significant patient benefits, including enhanced recovery and superior patient-reported outcomes. Prudent patient selection and a structured team-based approach are essential for navigating the learning phase successfully. These findings support the feasibility of establishing such a program without compromising fundamental patient safety.