Abstract: Introduction: When implementing a minimally invasive cardiac surgery program, increased surgical times may serve as a deterrent. Results demonstrating parity in operative times between minimally invasive (MIMVR) and conventional mitral valve replacement/repair (CMVR) have been limited to high-volume centers. The purpose of this study was to examine operative efficiency for MIMVR in a low-volume center. Methods: All patients having undergone non-emergent, isolated MIMVR or CMVR at the New Brunswick Heart Centre from 2011-2017 were considered. Detailed peri-operative data, including cross clamp (XC), cardiopulmonary bypass (CPB), skin-to-skin (SS) and total operative (TO) times, were collected. Patients were assigned to one of 3 eras: 2011-2013, 2014-2015, 2016-2017. Unadjusted comparisons were made between MIMVR and CMVR over the entire study period and within each era. Results: A total of 168 patients were included (MIMVR: 64; CMVR: 104). There was an increase in the number of MIMVR cases over time (2011-2013:19; 2014-2015:17; 2016-2017: 28). Patients undergoing MIMVR were less likely to be >= 70years (29.7% vs. 47.1%, p=0.04) and to have had NYHA-IV symptoms (17.2% vs. 41.3%, p=0.002), previous cardiac surgery (4.7% vs. 23.1%, p=0.003) or urgent presentation (12.5% vs. 35.6%, p=0.002). Intra-operatively, MIMVR patients were more likely to have undergone a mitral valve repair (65.1% vs. 29.1%, p<0.0001). No differences were noted in rates of in-hospital mortality (0.0% vs. 5.1%, p=0.29). Median operative times were uniformly longer among MIMVR patients between 2011-2013. However, in 2014-2015 and 2016-2017, these times improved to the point where no significant differences in operative efficiency were noted. Conclusions: Improved operative efficiency may be safely achieved for MIMVR in a low-volume center. It is evident that conventional bypass surgery when compared with minimally invasive cardiac surgery (MIS), has shorter CPB/XC. However, evidence suggests that equality between the two types of techniques can be achieved through experiences gained in high volume centers and even can see decreases in operation times. Surgical experience of the different surgeons involved in introducing a minimally invasive cardiac surgery into a heart program, combined with the experiences of the surgical team, are two important factors that influence the outcome and effective implementation of any program. Beyond that it has been identified that even when there are comparable learning opportunities between centres, the concept of "organizational learning effects" are considered important factors which affect the learning curve.An organization with a strong "learning culture" and "learning effectiveness", whereby education and training, having a dedicated team to begin with, are all necessary factors, which will influence the learning curve. The results of this study should encourage low-volume centers to adopt a minimally invasive approach to isolated mitral valve surgery.
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