Aortic valve replacement using stented or sutureless/rapid deployment prosthesis via either full-sternotomy or a minimally invasive approach: a network meta-analysis

Kei Woldendorp^{1

2

3}, Mathew P Doyle^{2

3}, Paul G Bannon^{1

2

3

4}, Martin Misfeld^{3

4

5}, Tristan D Yan^{2

3

6}, Giuseppe Santarpino^{7

8

9}, Paolo Berretta¹⁰, Marco Di Eusanio¹⁰, Bart Meuris¹¹, Alfredo Giuseppe Cerillo¹², Pierluigi Stefàno^{12

13}, Niccolò Marchionni^{13

14}, Jacqueline K Olive¹⁵, Tom C Nguyen^{16

17}, Marco Solinas¹⁸, Giacomo Bianchi¹⁸

Affiliations

¹ Sydney Medical School, The University of Sydney, Sydney, Australia.
² The Baird Institute of Applied Heart and Lung Surgical Research, Sydney, Australia.
³ Cardiothoracic Surgical Unit, Royal Prince Alfred Hospital, Sydney, Australia.
⁴ Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, Australia.
⁵ University Department for Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany.
⁶ Sydney Adventist Hospital, Sydney, Australia.
⁷ Department of Cardiac Surgery, Anthea Hospital, GVM Care & Research, Bari, Italy.
⁸ Department of Cardiac Surgery, Paracelsus Medical University, Nuremberg, Germany.
⁹ Department of Clinical and Experimental Medicine, Magna Graecia University, Catanzaro, Italy.
¹⁰ Cardiac Surgery Unit, Lancisi Cardiovascular Center, Polytechnic University of Marche, Ancona, Italy.
¹¹ Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium.
¹² Unit of Cardiac Surgery, Careggi University Hospital, Florence, Italy.
¹³ University of Florence School of Medicine, Florence, Italy.
¹⁴ Unit of Cardiology, Careggi University Hospital, Florence, Italy.
¹⁵ Baylor College of Medicine, Houston, Texas, USA.
¹⁶ Department of Cardiothoracic and Vascular Surgery, University of Texas Health Science Center Houston, McGovern Medical School, Houston, Texas, USA.
¹⁷ Memorial Hermann Heart and Vascular Institute, Houston, Texas, USA.
¹⁸ Ospedale del Cuore Fondazione Toscana "G. Monasterio", Massa, Italy.

PMID: 33102174
PMCID: PMC7548209
DOI: 10.21037/acs-2020-surd-17

Aortic valve replacement using stented or sutureless/rapid deployment prosthesis via either full-sternotomy or a minimally invasive approach: a network meta-analysis

Kei Woldendorp et al. Ann Cardiothorac Surg. 2020 Sep.

. 2020 Sep;9(5):347-363.

doi: 10.21037/acs-2020-surd-17.

Authors

Affiliations

¹ Sydney Medical School, The University of Sydney, Sydney, Australia.
² The Baird Institute of Applied Heart and Lung Surgical Research, Sydney, Australia.
³ Cardiothoracic Surgical Unit, Royal Prince Alfred Hospital, Sydney, Australia.
⁴ Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, Australia.
⁵ University Department for Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany.
⁶ Sydney Adventist Hospital, Sydney, Australia.
⁷ Department of Cardiac Surgery, Anthea Hospital, GVM Care & Research, Bari, Italy.
⁸ Department of Cardiac Surgery, Paracelsus Medical University, Nuremberg, Germany.
⁹ Department of Clinical and Experimental Medicine, Magna Graecia University, Catanzaro, Italy.
¹⁰ Cardiac Surgery Unit, Lancisi Cardiovascular Center, Polytechnic University of Marche, Ancona, Italy.
¹¹ Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium.
¹² Unit of Cardiac Surgery, Careggi University Hospital, Florence, Italy.
¹³ University of Florence School of Medicine, Florence, Italy.
¹⁴ Unit of Cardiology, Careggi University Hospital, Florence, Italy.
¹⁵ Baylor College of Medicine, Houston, Texas, USA.
¹⁶ Department of Cardiothoracic and Vascular Surgery, University of Texas Health Science Center Houston, McGovern Medical School, Houston, Texas, USA.
¹⁷ Memorial Hermann Heart and Vascular Institute, Houston, Texas, USA.
¹⁸ Ospedale del Cuore Fondazione Toscana "G. Monasterio", Massa, Italy.

PMID: 33102174
PMCID: PMC7548209
DOI: 10.21037/acs-2020-surd-17

Abstract

Background: New technologies such as sutureless or rapid deployment prosthetic valves and access via minimally invasive incisions offer alternatives to traditional full-sternotomy aortic valve replacement (SAVR). However, a comprehensive comparison of these surgical techniques along with alternative valve prosthesis has not been completed.

Methods: Electronic databases were searched for studies comparing outcomes for SAVR, minimally invasive AVR (MiAVR), sutureless/rapid-deployment AVR (SuAVR) via full-sternotomy, or minimally invasive SuAVR (MiSuAVR) from their inception until September 2018. Early postoperative outcomes and follow-up data were included in a Bayesian network meta-analysis.

Results: Twenty-three studies with 8,718 patients were identified. Compared with standard SAVR, SuAVR had significantly lower incidence of postoperative AF [odds ratio (OR) 0.33, 95% confidence interval (CI): 0.14-0.79, P=0.013] and MiSuAVR greater requirement for postoperative permanent pacemaker (OR 2.27, 95% CI: 1.25-4.14, P=0.008). All sutureless/rapid-deployment procedures had reduced cardiopulmonary bypass and cross-clamp times, by a mean of 25.9 and 25.0 min, respectively. Hospital length of stay (LOS), but not intensive care LOS, was reduced for all groups (MiAVR -1.53 days, MiSuAVR -2.79 days, and SuAVR 3.37 days). A signal towards reduced early mortality, wound infections, and acute kidney injury was noted in both sutureless/rapid-deployment and minimally invasive techniques but did not achieve significance. Sutureless/rapid-deployment procedures had favourable survival and freedom from valve related reoperation, however follow-up times were short and demonstrated significant heterogeneity between intervention groups.

Conclusions: Minimally invasive and sutureless techniques demonstrate equivalent early postoperative outcomes to SAVR and may reduce ventilation time, hospital LOS and postoperative atrial fibrillation (POAF) burden.

Keywords: Aortic valve replacement; aortic stenosis (AS); hemisternotomy; minimally invasive; rapid deployment; right anterior thoracotomy; sutureless.

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Conflict of interest statement

Conflicts of Interest: The authors have no conflicts of interest to declare.

Figures

**Figure 1**
Network map for AVR by surgical approach and prosthesis examining postoperative outcomes. AVR, full sternotomy aortic valve replacement; MiAVR, minimally invasive AVR; SuAVR, sutureless AVR; MiSuAVR, minimally invasive sutureless AVR.

**Figure 2**
Forest plots for AVR by surgical approach and prosthesis examining postoperative outcomes. AVR, full sternotomy aortic valve replacement; MiAVR, minimally invasive AVR; SuAVR, sutureless AVR; MiSuAVR, minimally invasive sutureless AVR.

**Figure 3**
Rankograms for AVR by surgical approach and prosthesis examining postoperative outcomes. For example, if suAVR accounts for 40% of the rankogram, then it has a 40% probability of being the best-ranked treatment option for that particular outcome. AVR, full sternotomy aortic valve replacement; MiAVR, minimally invasive AVR; SuAVR, sutureless AVR; MiSuAVR, minimally invasive sutureless AVR.

**Figure 4**
Network map, forest plot and rankogram for AVR by surgical approach and prosthesis examining late postoperative outcomes. For example, if suAVR accounts for 40% of the rankogram, then it has a 40% probability of being the best-ranked treatment option for that particular outcome. AVR, full sternotomy aortic valve replacement; MiAVR, minimally invasive AVR; SuAVR, sutureless AVR; MiSuAVR, minimally invasive sutureless AVR.

**Figure S1**
Forest plots for AVR by surgical approach and prosthesis examining perioperative outcomes. AVR, full sternotomy aortic valve replacement; MiAVR, minimally invasive AVR; SuAVR, sutureless AVR; MiSuAVR, minimally invasive sutureless AVR.

**Figure S2**
Rankograms for AVR by surgical approach and prosthesis examining perioperative outcomes. For example, if suAVR accounts for 40% of the rankogram, then it has a 40% probability of being the best-ranked treatment option for that particular outcome. AVR, full sternotomy aortic valve replacement; MiAVR, minimally invasive AVR; SuAVR, sutureless AVR; MiSuAVR, minimally invasive sutureless AVR.

See this image and copyright information in PMC

References

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Aortic valve replacement using stented or sutureless/rapid deployment prosthesis via either full-sternotomy or a minimally invasive approach: a network meta-analysis

Affiliations

Aortic valve replacement using stented or sutureless/rapid deployment prosthesis via either full-sternotomy or a minimally invasive approach: a network meta-analysis

Authors

Affiliations

Abstract

Conflict of interest statement

Figures

References

LinkOut - more resources

Full Text Sources

Research Materials