Limited versus full sternotomy for aortic valve replacement

Abstract

The evidence in this review was assessed as generally low to moderate quality. The study sample sizes were small and underpowered to demonstrate differences in outcomes with low event rates. Clinical heterogeneity both between and within studies is a relatively fixed feature of surgical trials, and this also contributed to the need for caution in interpreting results.Considering these limitations, there was uncertainty of the effect on mortality or extracorporeal support times with upper hemi-sternotomy for aortic valve replacement compared to full median sternotomy. The evidence to support a reduction in total hospital length of stay or intensive care stay was low in quality. There was also uncertainty of any difference in the rates of other, secondary outcome measures or adverse events with minimally invasive limited sternotomy approaches to aortic valve replacement.There appears to be uncertainty between minimally invasive aortic valve replacement via upper hemi-sternotomy and conventional aortic valve replacement via a full median sternotomy. Before widespread adoption of the minimally invasive approach can be recommended, there is a need for a well-designed and adequately powered prospective randomised controlled trial. Such a study would benefit from performing a robust cost analysis. Growing patient preference for minimally invasive techniques merits thorough quality-of-life analyses to be included as end points, as well as quantitative measures of physiological reserve.

Minimally invasive surgical aortic valve replacement

“…A 2017 Cochrane review identified seven RCTs comparing median sternotomy with partial or mini-sternotomy; a total of 511 patients were included 31. Only one reported a power calculation, three out of seven did not cite the outcome measures, and none included a health economic analysis.…”

Minimally invasive aortic valve replacement with central cannulation: A cost-benefit analysis in a developing country

“…A recent Cochrane review [6] encompassed seven trials with 511 participants from 7 countries. The effects of minimally invasive limited upper MS on SAVR as compared with FS were investigated [7][8][9][10][11][12][13].…”

“…In agreement to our results, postoperative blood loss was lower in MS (MD − 158.00 ml, 95% CI − 303.24 to − 12.76; participants = 297;studies = 5; moderate quality). The literature did not attest a drop in DSWI (RR 0.71, 95% CI 0.22 to 2.30; participants = 511; studies = 7; moderate quality) or re-exploration (risk ratio (RR) 1.01, 95% CI 0.48 to 2.13; participants = 511; studies = 7; moderate quality) [5,6]. Dissimilar to our results, a review reported no change in pain scores by upper MS (standardized mean difference (SMD) − 0.33, 95% CI −0.85 to 0.20; participants = 197; studies = 3; I2 = 70%; very low quality) [8,10,11].…”

Minimally Invasive Septal Myectomy for Hypertrophic Obstructive Cardiomyopathy

“…These techniques have involved limited access, either via a mini-sternotomy or mini-thoracotomy. In a recent review of mini-sternotomy for aortic valve replacement, mini-sternotomy showed several advantages compared to full sternotomy in terms of lower blood loss, shorter ICU length of stay, and better postoperative pulmonary function (6). This is apart from the clear cosmetic advantage and patient preference towards a less invasive technique.…”