Minimally invasive versus conventional surgery of the ascending aorta and root: a systematic review and meta-analysis

Abstract

Summary Limited uptake of minimally invasive surgery (MIS) of the aorta hinders assessment of its efficacy compared to median sternotomy (MS). The objective of this systematic review is to compare operative and perioperative outcomes for MIS versus MS. Online databases Medline, EMBASE, Cochrane Library and Web of Science were searched from inception until July 2018. Both randomized and observational studies of patients undergoing aortic root, ascending aorta or aortic arch surgery by MIS versus MS were eligible for inclusion. Primary outcomes were 30-day mortality, reoperation for bleeding, perioperative renal impairment and neurological events. Intraoperative and postoperative timing measures were also evaluated. Thirteen observational studies were included comparing 1101 MIS and 1405 MS patients. The overall quality of evidence was very low for all outcomes. Mortality and the incidence of stroke were similar between the 2 cohorts. Meta-analysis demonstrated increased length of cardiopulmonary bypass (CPB) time for patients undergoing MS [standardized mean difference 0.36, 95% confidence interval (CI) 0.15–0.58; P = 0.001]. Patients receiving MS spent more time in hospital (standardized mean difference 0.30, 95% CI 0.17–0.43; P < 0.001) and intensive care (standardized mean difference 0.17, 95% CI 0.06–0.27; P < 0.001). Reoperation for bleeding (risk ratio 1.51, 95% CI 1.06–2.17; P = 0.024) and renal impairment (risk ratio 1.97, 95% CI 1.12–3.46; P = 0.019) were also greater for MS patients. There was substantial heterogeneity in meta-analyses for CPB and aortic cross-clamp timing outcomes. MIS may be associated with improved early clinical outcomes compared to MS, but the quality of the evidence is very low. Randomized evidence is needed to confirm these findings.

The mini-Bentall approach: Comparison with full sternotomy

“…13 In our total cohort, the incidence of stroke (1.0%) was lower than or comparable to that of other studies (0%-5.0%). 5,10,14 No patient experienced postoperative renal failure or sternal infection. The most common complication observed in both groups was atrial fibrillation (27.8% overall).…”

“…However, these studies had significant heterogeneity related to procedure types, patient and study characteristics, incision types, and study periods. 7 , 10 To further complicate matters, the few studies focusing solely on Bentall procedures are hampered by less recent data, absence of an FS control group, or small numbers of patients. 3 , 11 , 12 To compare, we report postoperative outcomes in a contemporary cohort of 97 patients with similar baseline characteristics undergoing UMS and FS Bentall procedures performed by a single surgeon.…”

J-shaped sternotomy in aortic valve repair and ascending aorta replacement. Short-term results

“…Установлено, что летальность и частота инсультов были одинаковыми между двумя когортами. Метаанализ продемонстрировал высокую продолжительность времени искусственного кровообращения (ИК), госпитального периода и нахождение в отделении интенсивной терапии среди пациентов, прооперированных через стандартную срединную стернотомию в сравнении с мини-инвазивной хирургией корня и восходящего отдела аорты, также в этой группе были выше риски кровотечения и почечной недостаточности [24].…”

Guidelines for enhanced recovery after cardiac surgery. Consensus document of Spanish Societies of Anesthesia (SEDAR), Cardiovascular Surgery (SECCE) and Perfusionists (AEP)

“…La cirugía mínimamente invasiva (MICS) comprende una variedad de técnicas que no utilizan la esternotomía media completa y que han demostrado ser al menos igual de seguras [224][225][226][227][228][229][230][231][232][233] .…”