Background and Aim of the Study Whether minimally invasive mitral valve surgery (MMVS) leads to better outcomes remains unclear. We conducted a systematic review and meta‐analysis comparing various MMVS approaches with conventional sternotomy. Methods We searched Cochrane CENTRAL, MEDLINE, EMBASE, ClinicalTrials. gov, and the ISRCTN Register for studies comparing minimally invasive approach (thoracotomy, port access, partial sternotomy, or robotic) with median sternotomy for mitral valve surgery. We performed title and abstract, full‐text screening, and data extraction independently and in duplicate. We pooled data using random effect models. Quality assessment was performed using validated tools. Certainty of evidence was established using the GRADE framework. Results One hundred and nineteen studies (n = 38,106) met eligibility criteria: eight randomized controlled trials (RCTs) and 111 observational studies. MMVS was associated with fewer days in hospital (RCT: MD: −2.2 days, 95% CI, [−3.7 to −0.8]; observational: MD: −2.4 days, 95% CI, [−2.7 to −2.1]). Observational studies suggested that MMVS reduced transfusion requirements with fewer units transfused per patient (MD: −1.2; 95% CI, [−1.6 to −0.9]) and fewer patients transfused (RR, 0.7; 95% CI, [0.6−0.7]). Observational data also suggested lower mortality with MMVS (RR, 0.6; 95% CI, [0.5−0.7], p < .001, I2 = 0%), but this was not corroborated by RCT data. The risk of postoperative mitral regurgitation (≥2+ or requiring re‐intervention) did not differ between the two groups. Conclusions MMVS may be associated with shorter length of hospital stay with no significant difference in short‐term morbidity and mortality. There is a paucity of high‐quality data on the long‐term outcomes of MMVS when compared with conventional sternotomy.

No abstract

OBJECTIVES Guidelines recommend retrograde autologous priming (RAP) of the cardiopulmonary bypass circuit. However, the efficacy and safety of RAP is not well-established. We performed a systematic review and meta-analysis to determine the effects of RAP on transfusion requirements, morbidity and mortality. METHODS We searched Cochrane Central Register of Controlled Trials, Medline, ScienceDirect, Cumulative Index to Nursing and Allied Health Literature and Embase for randomized controlled trials (RCTs) and observational studies comparing RAP to no-RAP. We performed title and abstract review, full-text screening, data extraction and risk of bias assessment independently and in duplicate. We pooled data using a random effects model. RESULTS Twelve RCTs (n = 1206) and 17 observational studies (n = 3565) were included. Fewer patients required blood transfusions with RAP [RCTs; risk ratio 0.58 [95% confidence interval (CI): 0.51, 0.65], P &lt; 0.001, and observational studies; risk ratio 0.65 [95% CI: 0.53, 0.80], P &lt; 0.001]. The number of units transfused per patient was also lower among patients who underwent RAP (RCTs; mean difference −0.38 unit [95% CI: −0.72, −0.04], P = 0.03, and observational studies; mean difference −1.03 unit [95% CI: −1.76, −0.29], P &lt; 0.006). CONCLUSIONS This meta-analysis supports the use of RAP as a blood conservation strategy since its use during cardiopulmonary bypass appears to reduce transfusion requirements.

Background Guidelines recommend both acetylsalicylic acid and ticagrelor following acute coronary syndrome (ACS), but appropriate prescription practices lag. We analyzed the impact of government medication approval, national guideline updates, and publicly funded drug coverage plans on P2Y12 inhibitor utilization. Methods Accessing provincial databases, we obtained data for elderly ACS patients in Ontario, Canada, between 2008 and 2018. Using interrupted-time series with descriptive statistics and segmented regression analysis, we evaluated types of P2Y12 inhibitors prescribed at discharge and changes to their utilization in patients managed with percutaneous intervention (PCI), coronary artery bypass grafting (CABG) or medically, following national antiplatelet therapy guidelines (by the Canadian Cardiovascular Society), ticagrelor’s national approval by Health Canada, and ticagrelor’s coverage by a publicly funded medication plan. Results We included 114,142 patients (49.4%-PCI; mean age 75.71±6.94 and 62.3% male and 7.7%-CABG; mean age 74.11±5.63 and 73.5% male). Among PCI patients, clopidogrel utilization declined monthly after 2010 national guidelines were published (p<0.0001) and within the first month after ticagrelor’s national approval by Health Canada (p=0.03). Among PCI patients, ticagrelor utilization increased within the first month (p<0.0001) and continued increasing monthly (p<0.0001) after its coverage by a publicly funded medication plan. Among PCI patients, clopidogrel utilization declined within the first month (p=0.003) and ticagrelor utilization increased monthly (p=0.05) after 2012 CCS guidelines. Among CABG patients, ticagrelor’s coverage was associated with a monthly increase in its utilization (p<0.0001). Conclusion National guideline updates and drug coverage by a publicly funded medication plan significantly improved P2Y12 inhibitor utilization. Barriers to appropriate antiplatelet therapy in the surgical population must be explored.

No abstract