Minimally Invasive Aortic Valve Surgery: State-of-the-Art Review of Transaxillary, Thoracotomy, and Ministernotomy Approaches

Minimally invasive aortic valve replacement (MIAVR) via transaxillary access, right anterior thoracotomy (RAT), and ministernotomy has matured from niche innovation to guideline-endorsed standard, yet comparative data remain heterogeneous and fragmented. Objectives: This state-of-the-art review synthesizes contemporary evidence to define the role of each approach within modern valve care pathways. A PRISMA 2020 systematic review with PROSPERO registration identified studies reporting outcomes of isolated AVR performed through transaxillary, RAT, or ministernotomy access. Primary endpoints were 30-day mortality, operative times, and length of stay; secondary endpoints included complications, long-term survival, learning curves, and patient-reported outcomes. Forty-two studies encompassing 15,328 patients were included: transaxillary (n=2,156), RAT (n=4,892), and ministernotomy (n=8,280). All approaches achieved excellent perioperative safety (mortality 0.4–2.5%) and long-term survival comparable to full sternotomy, while consistently reducing blood loss, transfusion, ventilation time, and hospital stay. Ministernotomy offered broadest anatomical applicability and the shortest learning curve (20–30 cases). RAT combined complete sternal preservation, lowest bleeding rates, and superior cosmetic and functional recovery in anatomically suitable patients. Transaxillary access provided hidden scarring and attractive options in redo or sternum-avoidance scenarios, but higher reported stroke rates (2.0–6.3%) and greater technical demands limited its use to high-volume centres. MIAVR via ministernotomy, RAT, and transaxillary access now represents a mature, durable alternative to full sternotomy. A structured, anatomy- and centre experience–driven selection strategy is essential to fully realize its benefits across diverse patient populations.