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. 2024 Jun 4;86(7):4005-4014.
doi: 10.1097/MS9.0000000000002204. eCollection 2024 Jul.

Minimally invasive approaches versus conventional sternotomy for aortic valve replacement in patients with aortic valve disease: a systematic review and meta-analysis of 17 269 patients

Saad Khalid  1 , Muhammad Hassan  1 , Abraish Ali  1 , Farah Anwar  1 , Mishal Shan Siddiqui  1 , Sunita Shrestha  2
Affiliations

Minimally invasive approaches versus conventional sternotomy for aortic valve replacement in patients with aortic valve disease: a systematic review and meta-analysis of 17 269 patients

Saad Khalid et al. Ann Med Surg (Lond). .

Abstract

Background: Aortic valve replacement (AVR) is a common procedure for aortic valve pathologies, particularly in the elderly. While traditional open AVR is established, minimally invasive techniques aim to reduce morbidity and enhance treatment outcomes. The authors' meta-analysis compares these approaches with conventional sternotomy, offering insights into short and long-term mortality and postoperative results. This study provides valuable evidence for informed decision-making between conventional and minimally invasive approaches for AVR.

Materials and methods: Till August 2023, PubMed, Embase, and MEDLINE databases were searched for randomized controlled trials (RCT) and propensity score matched (PSM) studies comparing minimally invasive approaches [mini-sternotomy (MS) and right mini-thoracotomy (RMT)] with full sternotomy (FS) for AVR. Various outcomes were analyzed, including mortality rates, bypass and clamp times, length of hospital stay, and complications. Risk ratios (RR) and the weighted mean differences (WMD) with corresponding 95% CIs were calculated using Review Manager.

Results: Forty-eight studies were included having 17 269 patients in total. When compared to FS, there was no statistically significant difference in in-hospital mortality in MS (RR:0.80; 95% CI:0.50-1.27; I2=1%; P=0.42) and RMT (RR:0.70; 95% CI:0.36-1.35; I2=0%; P=0.29). FS was also linked with considerably longer cardiopulmonary bypass duration than MS (MD:8.68; 95% CI:5.81-11.56; I2=92%; P=0.00001). The hospital length of stay was determined to be shorter in MS (MD:-0.58; 95% CI:-1.08 to -0.09; I2=89%; P=0.02) with no statistically significant difference in RMT (MD:-0.67; 95% CI:-1.42 to 0.08; I2=84%; P=0.08) when compared to FS.

Conclusions: While mortality rates were comparable in minimally invasive approaches and FS, analysis shows that MS, due to fewer respiratory and renal insufficiencies, as well as shorter hospital and ICU stay, may be a safer approach than both RMT and FS.

Keywords: aortic valve replacement; full sternotomy; mini-sternotomy; right mini-thoracotomy.

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Conflict of interest statement

The authors declare no conflicts of interest.Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article.

Figures

Figure 1
Figure 1
PRISMA flow diagram. PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analysis.
Figure 2
Figure 2
(A) 1-year mortality. (B) In-hospital mortality. (C) Operative mortality. (D) 30-day hospitality in patients undergoing mini-sternotomy versus full sternotomy. FS, full sternotomy; M-H, Mantel-Haenszel; MS, mini-sternotomy.
Figure 3
Figure 3
(A) 1-year mortality. (B) In-hospital mortality. (C) 30-day mortality in patients undergoing right mini-thoracotomy versus full sternotomy. M-H, Mantel-Haenszel.
Figure 4
Figure 4
Cross clamp time in patients undergoing mini-sternotomy versus full sternotomy. FS, full sternotomy; IV, inverse variance; MS, mini-sternotomy.
Figure 5
Figure 5
Cardiopulmonary bypass time in patients undergoing mini-sternotomy versus full sternotomy. FS, full sternotomy; IV, inverse variance; MS, mini-sternotomy.
Figure 6
Figure 6
Length of stay (days) in the hospital in patients undergoing mini-sternotomy versus full sternotomy. FS, full sternotomy; IV, inverse variance; MS, mini-sternotomy.
Figure 7
Figure 7
ICU in patients undergoing mini-sternotomy versus full sternotomy. FS, full sternotomy; IV, inverse variance; MS, mini-sternotomy.
Figure 8
Figure 8
Ventilation per 24 h in patients undergoing mini-sternotomy versus full sternotomy. FS, full sternotomy; IV, inverse variance; MS, mini-sternotomy.
See this image and copyright information in PMC

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