Background: Femoral cannulation is essential for minimally invasive mitral valve surgery (MIMVS). Our center transitioned from open femoral cut-down to ultrasound-guided percutaneous cannulation supported by smart venous cannulas, ThruPort arterial access, and the MANTA closure device. This study evaluates how this transition affects procedural efficiency, vascular safety, and postoperative outcomes. 

Methods: We retrospectively analyzed 575 consecutive MIMVS patients (2014–2025). Patients treated before 2021 formed the cut-down group, while those from 2021 onward underwent percutaneous cannulation. The outcomes included operative times, groin and lymphatic complications, MANTA performance, and 30-day mortality. Propensity score matching (PSM) was performed to adjust for baseline differences. 

Results: Of 575 patients, 393 (68.3%) underwent cut-down and 182 (31.7%) percutaneous access. Percutaneous access was associated with shorter cardiopulmonary bypass times (115 vs. 128 min, p < 0.0001), total operative times (210 vs. 242 min, p < 0.0001), ICU stays (2 vs. 3 days, p = 0.0267), and hospital stays (8 vs. 11 days, p < 0.0001). Lymph fistula occurred in 4.3% of cut-down cases and in 0% after the adoption of percutaneous access (p = 0.0004). Overall groin complication rates were comparable (2.8% vs. 4.9%, p = 0.51). MANTA closure had a 2.2% device-related complication rate (1.1% bleeding; 1.1% ischemia) with no documented long-term sequelae. Regarding 30-day mortality, this was 4.6% in the cut-down group and 1.6% in the percutaneous group (p = 0.096). In PSM (72 matched pairs), percutaneous access retained significantly shorter operative, bypass, and ICU times, with identical groin complication rates. 

Conclusions: Ultrasound-guided percutaneous femoral cannulation was associated with improved procedural efficiency and elimination of lymphatic morbidity, without increasing vascular risk or mortality. It represented a safe and effective standard strategy for contemporary MIMVS.