Beyond Technical Innovation: Organizational and Economic Evaluation of Minimally Invasive Cardiac Surgery – a Narrative Review and Hospital-Level Framework

Yerzhan Saparbay 1, Yerlan Orazymbetov 1 2 * , Argul Razbekova 3, Serik Aitaliyev 2, Margulan Uazhanov 4
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1 Department of Cardiac Surgery, JSC National Scientific Medical Research Centre, Astana, Kazakhstan
2 Department of Cardiac, Thoracic and Vascular Surgery, Hospital of Lithuanian University of Health Sciences Kauno Klinikos, Lithuanian University of Health Sciences, Kaunas, Lithuania
3 Administrative and Management Division, City Cardiology Centre, Almaty, Kazakhstan
4 Department of Public Health and Management, Astana Medical University, Astana, Kazakhstan
* Corresponding Author
J CLIN MED KAZ, Volume 23, Issue 4, pp. 103-112. https://doi.org/10.23950/jcmk/19045
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Author Contributions: Conceptualization, Y.S., Y.O., A.R., S.A., and M.U.; methodology, Y.S., Y.O., A.R., S.A., and M.U.; validation, Y.S., Y.O., A.R., S.A., and M.U.; formal analysis, Y.S., Y.O., A.R., S.A., and M.U.; investigation, Y.S. and Y.O.; resources, Y.S. and Y.O.; data curation, Y.S. and Y.O.; writing—original draft preparation, Y.S. and Y.O.; writing—review and editing, Y.O. and Y.S. All authors have read and approved the final version of the manuscript.

Data availability statement: All raw data underlying the findings of this study can be obtained from the corresponding author upon reasonable request.

Artificial Intelligence (AI) Disclosure Statement: During the preparation of this manuscript, the authors used InstaText and Grammarly, including their AI-assisted features, solely for English-language editing, text restructuring, and improving clarity and readability. These tools were not used to generate research data, perform statistical analyses, select or evaluate scientific evidence, or formulate the study conclusions. All scientific content, references, interpretations, and conclusions were critically reviewed and verified by the authors, who take full responsibility for the final content of the manuscript.

Ethics approval and consent to participate: Not applicable. This article is a narrative literature review and does not involve individual patient data.

ABSTRACT

Background: Minimally invasive cardiac surgery (MICS) is increasingly recognized as an integrated perioperative care model rather than simply a small-incision surgical technique. Its clinical and economic value depends on patient selection, team experience, recovery pathways, institutional resources, and local cost structures.
Objective: This narrative review summarizes the current evidence on the clinical, organizational, and economic value of MICS, and proposes a practical hospital-level framework for evaluating program performance and maturity.
Methods: A structured narrative search of PubMed/MEDLINE, Scopus, Web of Science, and Google Scholar was conducted between January 2010 and June 2026. The review focused on minimally invasive valve surgery, coronary revascularization, enhanced recovery pathways, programme learning curves, resource utilization, and hospital cost analyses. The conduct and reporting of the review were guided by the Scale for the Assessment of Narrative Review Articles (SANRA). Evidence was synthesized across four domains: clinical safety and effectiveness, programme maturity and learning curves, organizational performance, and economic performance. Since the review was interpretive rather than systematic, a formal duplicate-screening workflow, PRISMA flow diagram, or study-level risk-of-bias instrument was not utilized.
Results: MICS can provide outcomes comparable to conventional sternotomy, with shorter intensive care and hospital stays, lower transfusion requirements, fewer wound complications, and earlier mobilization. However, higher operative costs, specialized equipment, longer cardiopulmonary bypass and cross-clamp times, peripheral cannulation risks, conversion to sternotomy, and learning-curve effects may offset postoperative savings. Economic value therefore depends on whether reduced surgical trauma translates into fewer complications and lower overall resource use.
Conclusion: MICS should be evaluated as a value-based care model. Centres developing MICS programmes should monitor risk-adjusted outcomes, resource utilization, conversions, total costs and learning curve dynamics through a structured institutional registry.
Keywords: minimally invasive cardiac surgery, health economics, resource utilization, recovery, learning-curve, value-based healthcare

CITATION

Saparbay Y, Orazymbetov Y, Razbekova A, Aitaliyev S, Uazhanov M. Beyond Technical Innovation: Organizational and Economic Evaluation of Minimally Invasive Cardiac Surgery – a Narrative Review and Hospital-Level Framework. J CLIN MED KAZ. 2026;23(4):103-12. https://doi.org/10.23950/jcmk/19045

REFERENCES

  • Coaston TN, Vadlakonda A, Tabibian K, Aguayo E, Sakowitz S, Mallick S. Shemin, Richard J. Benharash, Peyman. National trends in adult cardiac surgery inpatient costs: A decade in review. JTCVS Open. 2026 Feb 1. https://doi.org/10.1016/j.xjon.2025.101551
  • Poddi S, Rungatscher A. Minimally Invasive Cardiac Surgery: A State-of-the-Art Review. Journal of Clinical Medicine. Multidisciplinary Digital Publishing Institute (MDPI); 2026. https://doi.org/10.3390/jcm15010371
  • Schmitto JD, Mokashi SA, Cohn LH. Minimally-invasive valve surgery. Journal of the American College of Cardiology. Elsevier USA; 2010. p. 455–62. https://doi.org/10.1016/j.jacc.2010.03.053
  • Vignaroli W, Pala B, Nasso G, Sechi S, Campolongo G, Speziale G, Navarra EM. Mini- and Micro-Invasive Approaches in Cardiac Surgery: Current Techniques, Outcomes, and Future Perspectives. Medicina (B Aires). 2026 Jan 2;62(1):102. https://doi.org/10.3390/medicina62010102
  • Demirkıran T, Akyol FB, Özdem T, Hacızade E, Kubat E, Erol G. Kadan M., Karabacak K. Total coronary revascularization via left anterior thoracotomy: Comparison of early- and mid-term results with conventional surgery. Turkish Journal of Thoracic and Cardiovascular Surgery. 2024;32(4):402–11. https://doi.org/10.5606/tgkdc.dergisi.2024.26471
  • Dost B, Turunc E, Aydin ME, Kaya C, Aykut A, Demir ZA, Narayanan M, De Cassai A. Pain Management in Minimally Invasive Cardiac Surgery: A Review of Current Clinical Evidence. Pain and Therapy. Adis; 2025: 913–30. https://doi.org/10.1007/s40122-025-00739-1
  • Goecke S, Pitts L, Dini M, Montagner M, Wert L, Akansel S, Kofler M, Stoppe C, Ott S, Jacobs S, O’Brien B, Falk V, Hommel M, Kempfert J. Enhanced Recovery After Cardiac Surgery for Minimally Invasive Valve Surgery: A Systematic Review of Key Elements and Advancements. Medicina (Lithuania). Multidisciplinary Digital Publishing Institute (MDPI); 2025. https://doi.org/10.3390/medicina61030495
  • Sabatino ME, Okoh AK, Chao JC, Soto C, Baxi J, Salgueiro LA, Olds A, Ikegami H, Lemaire A, Russo MJ, Lee LY. Early Discharge After Minimally Invasive Aortic and Mitral Valve Surgery. In: Annals of Thoracic Surgery. Elsevier Inc. 2022, p. 91–97. https://doi.org/10.1016/j.athoracsur.2021.07.047
  • Alsheebani S, Goubran D, de Varennes B, Chan V. Contemporary Review of Minimally Invasive Mitral Valve Surgery: Current Considerations and Innovations. Journal of Cardiovascular Development and Disease. Multidisciplinary Digital Publishing Institute (MDPI). 2024. https://doi.org/10.3390/jcdd11120404
  • Shimokawa T, Kumamaru H, Motomura N, Nishi H, Nakajima H, Kamiya H, Okamoto K, Hosoba S, Saiki Y, Miura T, Tabata M, Shiose A, Sakaguchi T. Minimally invasive cardiac surgeries in 2022: annual report by Japanese Society of Minimally Invasive Cardiac Surgery. Gen Thorac Cardiovasc Surg. 2025 May 19. https://doi.org/10.1007/s11748-025-02225-z
  • Mourad N, Al-Hakim D, Groenewoud R, Al-Zeer B, Wu N, Myring A, Nakahara J, Wood D, Schisler T, Cook RC. Outcomes of Minimally Invasive Mitral Valve Surgery Using a Multidisciplinary Team Approach: A Single-Center Experience. J Pers Med. 2026 Jan 9;16(1):44. https://doi.org/10.3390/jpm16010044
  • Kirmani BH, Jones SG, Muir A, Malaisrie SC, Chung DA, Williams RJNN, Akowuah E. Limited versus full sternotomy for aortic valve replacement. Cochrane Database of Systematic Reviews. 2023. https://doi.org/10.1002/14651858.CD011793.pub3
  • Piekarski F, Rohner M, Monsefi N, Bakhtiary F, Velten M. Anesthesia for Minimal Invasive Cardiac Surgery: The Bonn Heart Center Protocol. Journal of Clinical Medicine. 2024. https://doi.org/10.3390/jcm13133939
  • Servito M, Ramsay H, Mann S, Ramelli L, Fernandez AL, Diasty M El. Surgical Outcomes After Minimally Invasive Versus Full Sternotomy Aortic Valve Replacement: Meta-Analysis of 75 Comparative Studies. Innovations: Technology and Techniques in Cardiothoracic and Vascular Surgery. 2025. https://doi.org/10.1177/15569845251335969
  • El-Sayed Ahmad A, Salamate S, Bakhtiary F. Lessons learned from 10 years of experience with minimally invasive cardiac surgery. Front Cardiovasc Med. 2023;9. https://doi.org/10.3389/fcvm.2022.1053572
  • Elsebaie A, Boutros CS, Awad AK, Sanad M, Pelletier M, Abu-Omar Y, El-Diasty M. Defining the Learning Curve in Minimally Invasive Cardiac Surgery: A Systematic Review and Meta-Analysis. Annals of Thoracic Surgery. 2026. https://doi.org/10.1016/j.athoracsur.2025.08.013
  • Jovanovic M, Zivkovic I, Jovanovic M, Bilbija I, Petrovic M, Markovic J, Radovic I, Dimitrijevic A, Soldatovic I. Economic Justification Analysis of Minimally Invasive versus Conventional Aortic Valve Replacement. Int J Environ Res Public Health. 2023;20(3). https://doi.org/10.3390/ijerph20032553
  • Gianoli M, de Jong AR, van der Harst P, van der Kaaij NP, Jacob KA, Suyker WJL. Cost Analysis of Robot-Assisted Versus On-Pump and Off-Pump Coronary Artery Bypass Grafting: A Single-Center Surgical and 30-Day Outcomes Comparison. Innovations: Technology and Techniques in Cardiothoracic and Vascular Surgery. 2024;19(4). https://doi.org/10.1177/15569845241269312
  • Sembo TWS, Fatehi Hassanabad A, Stevens K, Brown AN, Parhar K, Adams C, Kent WDT. Cost Analysis for Minimally Invasive Mitral Valve Surgery: A Single-Centre Canadian Study. CJC Open. 2025;7(7). https://doi.org/10.1016/j.cjco.2025.04.072
  • Hawkins RB, Mehaffey JH, Kessel SM, Dahl JJ, Kron IL, Kern JA, Yarboro LT, Ailawadi G. Minimally invasive mitral valve surgery is associated with excellent resource utilization, cost, and outcomes. Journal of Thoracic and Cardiovascular Surgery. 2018;156(2). https://doi.org/10.1016/j.jtcvs.2018.03.108
  • Baethge C, Goldbeck-Wood S, Mertens S. SANRA—a scale for the quality assessment of narrative review articles. Res Integr Peer Rev. 2019;4(1). https://doi.org/10.1186/s41073-019-0064-8
  • Engelman DT, Ben Ali W, Williams JB, Perrault LP, Reddy VS, Arora RC, Arora R, Roselli E, Khoynezhad A, Gerdisch M, Levy J, Lobdell K, Fletcher N, Kirsch M, Nelson G, Engelman R, Gregory A, Boyle E. Guidelines for Perioperative Care in Cardiac Surgery: Enhanced Recovery after Surgery Society Recommendations. JAMA Surgery. 2019. https://doi.org/10.1001/jamasurg.2019.1153
  • Berretta P, De Angelis V, Alfonsi J, Pierri MD, Malvindi PG, Zahedi HM, Munch C, Di Eusanio M. Enhanced recovery after minimally invasive heart valve surgery: Early and midterm outcomes. Int J Cardiol. 2023;370. https://doi.org/10.1016/j.ijcard.2022.11.016
  • Poddi S, Rungatscher A. Beyond Surgical Access: Evidence Supporting a Multidimensional Concept of Surgical Invasiveness in Contemporary Cardiac Surgery. J Cardiovasc Dev Dis. 2026 Jul 8;13(7):315. https://doi.org/10.3390/jcdd13070315
  • Akowuah EF, Maier RH, Hancock HC, Kharatikoopaei E, Vale L, Fernandez-Garcia C, Ogundimu E, Wagnild J, Mathias A, Walmsley Z, Howe N, Kasim A, Graham R, Murphy G, Zacharias J. Minithoracotomy vs Conventional Sternotomy for Mitral Valve Repair: A Randomized Clinical Trial. JAMA. 2023;329(22). https://doi.org/10.1001/jama.2023.7800
  • Amin A, Kumar R, Mokhtassi SS, Alassiri AK, Odaman A, Khan MAR, Lakshmana S, Din Z, Acharya P, Cheema H, Nashwan A, Khan A, Hussain A, Bhudia S, Vincent R. Minimally invasive vs. conventional mitral valve surgery: a meta-analysis of randomised controlled trials. Frontiers in Cardiovascular Medicine. 2024. https://doi.org/10.3389/fcvm.2024.1437524
  • Leusder M, Porte P, Ahaus K, Van Elten H. Cost measurement in value-based healthcare: A systematic review. BMJ Open. 2022;12(12). https://doi.org/10.1136/bmjopen-2022-066568
  • Porter ME. What Is Value in Health Care? New England Journal of Medicine. 2010;363(26). https://doi.org/10.1056/NEJMp1011024
  • Olsthoorn JR, Heuts S, Houterman S, Maessen JG, Sardari Nia P, Bramer S, Van Boven W, Vonk A, Koene B, Bekkers J, Hoohenkerk G, Markou A, Weger A, Segers P, Porta F, Speekenbrink R, Stooker W, Li W, Daeter E, Van Der Kaaij N, Vigano G. Effect of minimally invasive mitral valve surgery compared to sternotomy on short- and long-term outcomes: a retrospective multicentre interventional cohort study based on Netherlands Heart Registration. European Journal of Cardio-thoracic Surgery. 2022;61(5). https://doi.org/10.1093/ejcts/ezab507
  • Cheng DCH, Martin J, Lal A, Diegeler A, Folliguet TA, Nifong LW, Perier P, Raanani E, Smith J, Seeburger J, Falk V. Minimally invasive versus conventional open mitral valve surgery: A meta-analysis and systematic review. Innovations: Technology and Techniques in Cardiothoracic and Vascular Surgery. 2011;6(2). https://doi.org/10.1097/imi.0b013e3182167feb
  • Généreux P, Piazza N, Alu MC, Nazif T, Hahn RT, Pibarot P, Bax J, Leipsic J, Blanke P, Blackstone E, Finn M, Kapadia S, Linke A, Mack M, Makkar R, Mehran R, Popma J, Reardon M, Rodes-Cabau J, Van Mieghem N, Webb J, Cohen D, Leon MB. Valve Academic Research Consortium 3: Updated Endpoint Definitions for Aortic Valve Clinical Research. J Am Coll Cardiol. 2021;77(21). https://doi.org/10.1016/j.jacc.2021.02.038
  • Stone GW, Vahanian AS, Adams DH, Abraham WT, Borer JS, Bax JJ, Schofer J, Cutlip D, Krucoff M, Blackstone E, Signreux P, Mack M, Siegel R, Grayburn P, Enriquez-Sarano M, Lancellotti P, Filippatos G, Kappetein A. Clinical trial design principles and endpoint definitions for transcatheter mitral valve repair and replacement: Part 1: Clinical trial design principles. European Heart Journal. 2015. https://doi.org/10.1093/eurheartj/ehv281
  • Bowdish ME, D’Agostino RS, Thourani VH, Schwann TA, Krohn C, Desai N, Shahian DM, Fernandez FG, Badhwar V. STS Adult Cardiac Surgery Database: 2021 Update on Outcomes, Quality, and Research. Annals of Thoracic Surgery. 2021;111(6). https://doi.org/10.1016/j.athoracsur.2021.03.043