: Certain clinical and anatomical conditions are absolute or relative contraindications for safe mitral valve surgery via the right mini-thoracotomy access. It is uncertain whether patients with these contraindications may benefit from the less invasive approach via upper hemi-sternotomy compared to standard full sternotomy. : Out of 2052 mitral valve surgery patients, operated from 6/04 through 2/19, 1535 were excluded due to the different criteria for eligibility to both approaches. Out of these, 350 received full sternotomy and 167 upper hemi-sternotomy. After propensity score matching, 164 pairs were analyzed for operative variables, postoperative complications and 30-day and one-year survival. : Upper hemi-sternotomy was associated with a survival benefit of 30 days (99.4% vs. 82.1%; < 0.001) and one-year (93.9% vs. 79.9% < 0.001, HR 0.26, 95% CI 0.14-0.49). Cardiopulmonary bypass and aortic cross-clamp times were comparable in both groups. Upper hemi-sternotomy resulted in less low cardiac output syndrome (18.9% vs. 31.1%; = 0.011); ventilation time (8 vs. 13 h; < 0.001), length of intensive care stay (1 vs. 2 days; < 0.001) and total hospital stay (8 vs. 9 days; < 0.001) were shorter in the upper hemi-sternotomy group. : In patients undergoing mitral valve surgery, upper hemi-sternotomy is associated with short- and mid-term survival benefits as well as lower postoperative complication rates compared to full sternotomy. Hence, the less invasive upper hemi-sternotomy can be a valid approach in patients with contraindications for right mini-thoracotomy.