Mini‐sternotomy vs right anterior thoracotomy for aortic valve replacement

Abstract

Background While minimally invasive techniques for aortic valve replacement (AVR) have been shown to be safe, limited data exist comparing the varying approaches. This study aimed to compare the outcomes between two minimally invasive approaches for AVR: mini‐sternotomy (MS) and right anterior thoracotomy (RAT). Materials and Methods A systematic search of MEDLINE, EMBASE, and OVID was conducted for the period 1990‐2019. Nine observational studies (n = 2926 patients) met the inclusion criteria. Results There was no difference in operative mortality between MS and RAT (odds ratio [OR]: 0.87, 95% confidence interval [CI]: 0.41‐1.85; P = .709). Meta‐analyses favored MS over RAT in reoperation for bleeding (OR: 0.42, 95% CI: 0.28‐0.63; P < .001), aortic cross‐clamp time (standardized mean difference [SMD]: −0.12, 95% CI: −0.20 to 0.029; P = .009), and the rate of conversion to sternotomy (OR: 0.32, 95% CI: 0.11‐0.93; P = .036). The rate of permanent pacemaker insertion approached borderline significance in favor of MS (OR: 0.54, 95% CI: 0.26‐1.12; P = .097). In‐hospital outcomes of stroke, atrial fibrillation, and surgical site infection were similar between the two groups. The length of hospital stay was shorter for RAT (SMD: 0.12, 95% CI: 0.027‐0.22; P = .012) and the length of postoperative ventilation was borderline significant in favor of RAT (SMD: 0.16, 95% CI: −0.027 to 0.34; P = .095). Conclusions This study highlights important differences in short‐term outcomes between MS and RAT as approaches for AVR. This has important implications for patient selection, especially in the elderly, where such approaches are becoming more common‐place.

Right anterior mini thoracotomy approach for isolated aortic valve replacement: Early outcomes at a Canadian center

“…There are advantages to the sternum‐sparing approach. Fewer blood transfusions have been required when RAMT AVR groups are compared to sternotomy‐based groups 51–54 . Our experience supports this, with only four patients requiring transfusion of pRBCs postoperatively and we believe sparing the sternum greatly contributes to this low incidence.…”

Minimally invasive aortic valve replacement with sutureless bioprosthesis through right minithoracotomy with completely central cannulation—Early results in 203 patients

“…There are several reports that have demonstrated similar, if not superior, results of mini‐AVR in comparison with conventional AVR 5,13,15 . The term “minimally invasive” refers to a small chest wall incision that does not include conventional full sternotomy 14 .…”

“…Alternatively, right minithoracotomy approach can be performed via the 2nd or 3rd intercostal space 5,7,12 . There is a growing evidence in literature that in comparison with conventional AVR, mini‐AVR can reduce postoperative morbidity allowing less blood loss, less pain, faster recovery, and a shorter hospital stay with no difference in mortality 13–16 . In addition, two arterial perfusion strategies are currently utilized, such as peripheral femoral arterial cannulation, which is the most frequently used, and central aortic cannulation 7,17–19 .…”

Minimally invasive versus conventional aortic valve replacement: The network meta‐analysis

“…The 1‐year mortality was comparable among the three approaches in the current meta‐analysis. While previous institutional studies reported their mid‐ or long‐term survival after AVR, synthesis of results has not been performed in the aforementioned meta‐analyses 8,9 . The similar 1‐year mortality in the current study is reassuring for surgeons when considering a surgical approach.…”