Over the past 20 years, there has been a rise in interest in minimally invasive techniques for heart surgery. Numerous factors, including improved patient satisfaction and cosmetic appearance, a decrease in surgical trauma, and the development of specialized equipment that makes these procedures safe to perform, have contributed to this. Performing minimally invasive cardiac surgical procedures presents unique challenges and considerations, in contrast to other surgical specialties, particularly in relation to cardiopulmonary bypass (CPB) and myocardial protection. Numerous cardiac lesions have been addressed with great success, and mitral valve pathologies have been treated to a large extent. Since the early days of Heart Port technology [1], right mini thoracotomy-based minimally invasive mitral valve surgery (MIMVS) has become a well-recognized and extensively used procedure worldwide. The origins of MIMVS can be traced back to separate teams led by Delos Cosgrove and Lawrence Cohn in the 1990s, who investigated minimally invasive procedures like the mini-thoracotomy, hemisternal incision, and parasternal incision. The first video-directed repair [2] and replacement [3], carried out via a mini-thoracotomy, and the first application of aortic endoballoon clamping are examples of later advancements. The introduction of robotic surgery and stereoscopic three-dimensional video-endoscopy are examples of more recent advancements. Expert proponents report comparable outcomes, including quicker patient recovery, lower morbidity, and higher patient satisfaction, as with most novel procedures. Though there are certain technical difficulties with the procedure, most mitral valve procedures still require a complete median sternotomy. Alternative minimally invasive techniques for the mitral valve have been reported, in addition to the mini-thoracotomy. A parasternal approach has been reported, involving the excision of the third and fourth costal cartilages through a right parasternal incision of 10 cm [4]. Despite offering excellent access, patients occasionally experienced instability in their chest walls. Moreover, the internal mammary artery on the right was sacrificed [5]. Some have reported undergoing mini sternotomy mitral valve surgery, which has the benefit of being easily converted to a full sternotomy if necessary.

Table 1: Association between Transfusion requirement: Type of surgery

Table 2: Association between Inotropes: Type of surgery

Table 3: Association between Analgesia (Usual= IV PCM & IV Fentanyl): Type of surgery

Table 4: Association between Wound on POD 7: Type of surgery

Table 5: Distribution of mean CPB time (Min): Type of surgery

Table 6: Distribution of mean Cross clamp time (Min): Type of surgery

Table 7: Distribution of mean Chest drain (ml/24 hrs.): Type of surgery

Table 8: Distribution of mean Ventilator estuation time (hrs.): Type of surgery

Table 9: Distribution of mean Incision length cm: Type of surgery

In MICS surgery, 7 (23.3%) patients had 1 PRBC and 10 (33.3%) patients had 2 PRBC in Transfusion requirement.

In Sternotomy surgery, 9 (30.0%) patients had 1 PRBC, 14 (46.7%) patients had 2 PRBC and

2 (6.7%) patients had 3 PRBC in Transfusion requirement.

Association of Transfusion requirement with Type of surgery was not statistically significant (p=0.0908).

In MICS surgery, 11 (36.7%) patients had Minimum Inotropes.

In Sternotomy surgery, 10 (33.3%) patients had Minimum Inotropes

Association of Inotropes with Type of surgery was not statistically significant (p=0.7866).

In MICS surgery, 30 (100.0%) patients Healthy Wound on POD 7.

In Sternotomy surgery, 29 (96.7%) patients had Healthy Wound on POD 7 and 1 (3.3%) patients had Sternal wound infection on lower side Wound on POD 7.

Association of Wound on POD 7 with Type of surgery was not statistically significant (p=0.3132).

In MICS surgery, the mean CPB time (mean± s.d.) of patients was 127.5333± 8.9548 (Min).

In Sternotomy surgery, the mean CPB time (mean± s.d.) of patients was 80.7333± 6.9029 (Min).

Distribution of mean CPB time (Min) with Type of surgery was statistically significant (p<0.0001).

In MICS surgery, the mean Cross clamp time (mean± s.d.) of patients was 78.5000± 8.9549 (Min).

In Sternotomy surgery, the mean Cross clamp time (mean± s.d.) of patients was 57.6000± 7.0349 (Min).

Distribution of mean Cross clamp time (Min) with Type of surgery was statistically significant (p<0.0001)

In MICS surgery, the mean Chest drain (mean± s.d.) of patients was 312.0000± 82.6459 (ml/24 hrs).

In Sternotomy surgery, the mean Chest drain (mean± s.d.) of patients was 438.0000± 92.4904 (ml/24 hrs).

Distribution of mean Chest drain (ml/24 hrs) with Type of surgery was statistically significant (p<0.0001).

In MICS surgery, the mean Ventilator extubation time (mean± s.d.) of patients was 6.4000± 3.7287 (Hrs).

In Sternotomy surgery, the mean Ventilator extubation time (mean± s.d.) of patients was 10.1333± 3.4415 (Hrs).

Distribution of mean Ventilator extubation time (Hrs) with Type of surgery was statistically significant (p=0.0002)

In MICS surgery, the mean Incision length (mean± s.d.) of patients was 11.7333± 1.5742 cm.

In Sternotomy surgery, the mean Incision length (mean± s.d.) of patients was 24.4333± 1.6333 cm.

Distribution of mean Incision length cm with Type of surgery was statistically significant (p<0.0001).

From March 2020 to November 2021, a prospective, non-randomized study was carried out at the Cardiothoracic OT and Post Cardiac Surgery Recovery Unit, I.P.G.M.E & R, and SSKM Hospital, a tertiary care hospital and teaching institution affiliated with a university. Patients undergoing general anesthesia for Mitral Valve (MV) replacement, patients undergoing right thoracotomy for Minimally Invasive Mitral Valve Surgery (MIMVS), and patients undergoing traditional sternotomy for Mitral Valve surgery comprised the control group.

We discovered that 25(83.4%) of the patients undergoing minimally invasive cardiac surgery were between the ages of 31 and 50. and the majority of sternotomy patients [19(63.3%)] were between the ages of 41 and 60.

In this study, the proportion of men [42(70.0%)] exceeded that of women [18(30.0%)].

We found that both types of minimally invasive cardiac surgery had a higher prevalence of RHD with severe multiple sclerosis [11 (36.7%)]. Sternotomy [11(36.7%)] as well. Additionally, 2 (6.7%) patients in Minimally Invasive Cardiac Surgery had Moderate MR. 4(13.3%) patients had severe MS with moderate MR and 3 (10.0%) had RHD, severe MS with mild MR, 3 (10.0%) had severe MR, and three (10.0%) had RHD, severe MS with moderate MR in primary disease. In the sternotomy surgery, there were 4(13.3%) patients with moderate MR, 3 (10.0%) with RHD, moderate MS, and moderate MR, 2 (6.7%) with RHD, severe MS, and mild MR, 3 (10.0%) with RHD, severe MS, and moderate MR in primary disease, and none of these findings were statistically significant (p=0.7983). It has been discovered by Mariscalco et al. [6] that endoscopic MV surgery is a common procedure. According to the current study, fewer ECHO LAA clots were seen in patients undergoing minimally invasive cardiac surgery [3 (10.0%)] than in those undergoing sternotomy surgery [8 (26.7%)]. however (p=0.0952), this was not statistically significant. According to Wang et al. [7], MIMVS is linked to lower blood loss and fewer postoperative blood transfusion needs when compared to sternotomy incisions, which result in less tissue destruction and, as a result, less blood loss. According to our research, the amount of chest drain during minimally invasive cardiac surgery (312.0000± 82.6459 ml/24 hours) was much lower than during sternotomy surgery (438.000+ 92.4904 ml/24 hours). (p<0.0001). Additionally, we discovered that patients undergoing sternotomy surgery required more 1 PRBC, 2 PRBC, and 3 PRBC transfusions [9 (30.0%), 14 (46.7%), and 2 (6.7%), respectively], in comparison to patients undergoing minimally invasive cardiac surgery [7 (23.3%), 10 (33.3%), and 0 (0.0%), respectively]. However, these

differences were not statistically significant (p=0.0908). Our research revealed that patients undergoing minimally invasive cardiac surgery [11 (36.7%)] observed slightly more minimum inotropes (not exceeding the patient's "X" dose) than patients undergoing sternotomy surgery [10 (33.3%)]. This difference was not statistically significant (p=0.7866). We found that patients undergoing Minimally Invasive Cardiac Surgery [22 (73.3%)] used Usual Analgesia (Usual= IV PCM & IV Fentanyl) significantly more frequently than patients undergoing Sternotomy surgery [8 (26.7%)]. (p = 0.0006).

According to Dokhan AL et al.'s 8(2018) research, three patients in the sternotomy group and zero patients in the minimally invasive group experienced superficial wound infections during the study. At POD 7, all 30 (100.0%) patients in our study who had undergone minimally invasive cardiac surgery were found to be healthy; however, only 1 (3.3%) patient who had undergone a sternotomy had a lower side sternal wound infection, which was not statistically significant (p=0.3132). The learning curve effect can be attributed to the fact that our study's results represent the very early series of MIMVS cases at our center. In earlier studies by Modi et al. [9] and Moscarelli et al. [10], there was no significant difference between the two groups' cross-clamp times and TBT. This is one of the drawbacks of MIMVS, as the surgeon and team must master the technique before performing it through a smaller incision.

In comparison to sternotomy surgery, which took 80.7333± 6.9029 minutes and 57.6000± 7.0349 minutes, respectively, we discovered that the CPB and cross clamp times in minimally invasive cardiac surgery were significantly higher—127.5333± 8.9548 minutes and 78.5000± 8.9549 minutes, respectively. (p<0.0001).

Dokhan AL et al. 8(2018) discovered that attempts were made to extubate patients in the operating room, which was already done for six patients in the minimally invasive group, in order to reap the benefits of the small incision, which was predicted to cause less pain and improve respiratory mechanics. Furthermore, compared to the sternotomy group, the minimally invasive group had a substantially shorter total ICU stay and postoperative ventilation time. According to Shah et al. [11], patients receiving MIMVS have much shorter ICU stays and postoperative mechanical ventilation.

The current study found that, in comparison to minimally invasive cardiac surgery, patients who underwent sternotomy surgery had longer ventilator extubation times [10.1333± 3.4415 hours].

Dokhan AL et al.'s 8(2018) study demonstrated that the visual analog pain scale evaluation of pain in the minimally invasive group showed a high statistically significant change with low pain perception, which was similar to the findings of Santana et al.[12], who reported less pain during hospital stays, after discharge, less use of analgesics, higher patient satisfaction, and an early return to normal activity.

Every single result points to the same conclusion—namely, that the sternotomy incision has a significant impact on the patient's quality of life following surgery and that there is a constant need to look for better options.

Using the Wong-Baker scale, we discovered that patients undergoing minimally invasive cardiac surgery [2.4667± 8604] had significantly less pain than patients undergoing sternotomy surgery [3.5333±.8604]. (p<0.0001).

Dokhan AL et al.'s 8(2018) study demonstrated that the visual analog pain scale evaluation of pain in the minimally invasive group showed a high statistically significant change with low pain perception, which was similar to the findings of Santana et al. [12], who reported less pain during hospital stays, after discharge, less use of analgesics, higher patient satisfaction, and an early return to normal activity. Every single result points to the same conclusion—namely, that the sternotomy incision has a significant impact on the patient's quality of life following surgery and that there is a constant need to look for better options.

Using the Wong-Baker scale, we discovered that patients undergoing minimally invasive cardiac surgery [2.4667± 8604] had significantly less pain than patients undergoing sternotomy surgery [3.5333±.8604]. (p<0.0001). Many patients search for incisions that are always shorter because they are concerned about the length and shape of the scar that will form after surgery. This choice is always available in MIMVS; however, a statistically significant difference in incision length was observed, with smaller incisions in the MIMVS group, according to Gao et al. [13].

Additionally, we discovered that patients undergoing sternotomy surgery had noticeably longer incisions. Patients undergoing Minimally Invasive Cardiac Surgery [11.7333± 1.5742 cm] compared to [24.4333± 1.6333 cm] patients. (p<0.0001).

We concluded that the statistically significant conclusion that most patients undergoing minimally invasive cardiac surgery were between the ages of 31 and 50, while most patients undergoing sternotomy were between the ages of 41 and 60. There was a statistically significant difference in the mean age of patients undergoing sternotomy surgery (51.2333 years) and those undergoing minimally invasive cardiac surgery (39.2000 years). Male population was higher in our study than female population. We found that, although not statistically significant, RHD with severe multiple sclerosis was more common in both minimally invasive cardiac surgery and conventional sternotomy, depending on the primary disease. The current study demonstrated that, although not statistically significant, ECHO LAA clots were less common in patients undergoing minimally invasive cardiac surgery than in those undergoing sternotomy surgery. Additionally, we discovered that patients undergoing sternotomy surgery required more PRBC transfusions than patients undergoing minimally invasive cardiac surgery. According to our research, there was a marginally significant increase in minimum inotropes among patients undergoing minimally invasive cardiac surgery when compared to those undergoing sternotomy surgery. It was observed that patients undergoing Minimally Invasive Cardiac Surgery utilized Usual Analgesics (Usual IV PCM & IV Fentanyl) considerably more frequently than patients undergoing Sternotomy surgery. All of the patients in our study who underwent minimally invasive cardiac surgery were found to be healthy at POD 7, but only one (3.3%) patient who had a lower-side sternotomy had a statistically non-significant sternal wound infection at that point. In comparison to sternotomy surgery, we discovered that the CPB and cross clamp times were noticeably longer in minimally invasive cardiac surgery. In comparison to sternotomy surgery, our study demonstrated a significant reduction in chest drain with minimally invasive cardiac surgery. The current study demonstrated a statistically significant difference in post-operative ventilator support time between patients undergoing sternotomy surgery and those undergoing minimally invasive cardiac surgery. We discovered that, at 12 hours and during the post-operative period, patients undergoing minimally invasive cardiac surgery had significantly lower visual pain scores on the Wong-Baker scale than patients undergoing sternotomy surgery. When comparing patients undergoing minimally invasive cardiac surgery to those undergoing sternotomy surgery, we found that the former had a much shorter post-operative hospital stay. Furthermore, we discovered that, in contrast to patients undergoing minimally invasive cardiac surgery, incision length was notably longer in patients undergoing sternotomy surgery

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