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

Abstract

Background Outcome comparisons after surgical aortic valve replacement (SAVR) with minimally invasive approaches including mini‐sternotomy (MS) and right mini‐thoracotomy (RMT) and full sternotomy (FS) have been conflicting. Furthermore, the synthesis of mid‐term mortality has not been performed. Methods MEDLINE and EMBASE were searched through April 2022 to identify propensity score matched (PSM) studies or randomized controlled trial (RCT) which compared outcomes following SAVR among three incisional approaches: FS, MS, or RMT. The network analysis was performed to compare these approaches with random effects model. Mid‐term mortality was defined as 1‐year mortality. Results A total of 42 studies met the inclusion criteria enrolling 14,925 patients. RCT and PSM were performed in 13 and 29 studies, respectively. The operative mortality was significantly lower with MS compared to FS (risk ratio [RR]: 0.60, 95% confidence interval [CI]: 0.41–0.90, p = .01, I2 = 25.8%) or RMT (RR: 0.51, 95% CI: 0.27–0.97, p = .03, I2 = 25.8%). RMT had significantly higher risk of reoperation for bleeding compared to MS (RR: 1.65, 95% CI: 1.18–2.30, p = .003, I2 = 0%). Hospital length of stay was significantly shorter with MS compared to FS (mean difference: −0.89 days, 95% CI: −1.58 to −0.2, p = .01, I2 = 95.5%) while it was equivocal between FS and RMT. The mid‐term mortality was similar among the three approaches. Conclusions While mid‐term mortality was comparable among approaches, MS may be a safe and potentially more effective approach than FS and RMT for SAVR in the short term.

Update on minimally invasive cardiac surgery and enhanced recovery after surgery

“…In terms of quality of life, results were inconsistently reported, but ranged between not statistically different, to MICS being favorable over full sternotomy. The results were demonstrated for both the mini-sternotomy approach and the right anterior thoracotomy approach when each were compared to full sternotomy, as reported by Ogami et al (meta-analysis) and Stolinski et al (propensity score matched analysis), respectively [26,27]. Likewise, a best evidence analysis review concluded that both mini-sternotomy and right anterior thoracotomy, despite longer operative times, provide similar short term outcomes compared to full sternotomy, with reduced hospital LOS [28].…”

Minimal Learning Curve for Minimally Invasive Aortic Valve Replacement

“…In hospital mortality was equivalent between the two groups (MiAVR 1.82% vs FSAVR 3.52%). There were no significant differences in rates of reoperation for bleeding (MiAVR 9.09% vs FSAVR 10.56%), stroke (MiAVR 0% vs FSAVR 1.41%), atrial fibrillation (MiAVR 30.91% vs FSAVR 26.76%), or postoperative blood product usage (MiAVR 41.82% vs FSAVR 42.96%) Both groups had similar ventilation time (MiAVR 9 hours [6][7][8][9][10][11][12][13][14][15][16] Multivariable analysis of operative approach as a risk factor is shown in table 4. There were no differences between the two approaches in MACE (including in-hospital death, stroke, myocardial infraction (MI) and reoperation), sternal wound infection, significant PPM after surgery, readmission during 8 weeks after surgery, perioperative blood products usage and in hospital stay longer than 7 days.…”

“…An analysis of the Society of Thoracic Surgeons database made by Ghoreishi et al [5] showed similar mortality rates of 1.9% in both FSAVR, MiAVR via upper hemisternotomy and MiAVR via right thoracotomy. Ogami et al [6] preformed This article is protected by copyright. All rights reserved.…”

“…Minimally invasive aortic valve replacement (MiAVR) is usually done through two approaches: Upper hemisternotomy and right upper mini thoracotomy [4,5]. MiAVR enables non-inferior results to full sternotomy aortic valve replacement (FSAVR), with possible benefits including reduced bleeding, shorter ventilation time, shorter intensive care unit (ICU) stay and shorter hospitalization time but usually with longer cardiopulmonary bypass (CPB) and aortic cross clamp times [6][7][8]. Even though multiple studies have shown these non-inferior results, MiAVR has seen slow adoption [5].…”

Minimally invasive approach associated with lower resource utilization after aortic and mitral valve surgery

“…With thoughtful effort to curtail unnecessary surgical injury, minimally invasive techniques have gained favor in cardiac surgery, eventually propelling the popularization of minimally invasive approaches for valve operations. 11 , 12 , 13 Although studies on postoperative outcomes have been conducted on isolated valve surgeries, 14 , 15 , 16 , 17 , 18 minimally invasive valve operations have not been compared to open approaches comprehensively to include various valve types within 1 investigation. Furthermore, minimally invasive approaches to valve operations have not been compared to their full sternotomy (FS) counterparts in the context of patient resource utilization.…”