Minimally invasive versus full sternotomy for combined aortic valve and proximal aortic surgery: a systematic review and meta-analysis

Abstract

BACKGROUND: While minimally invasive cardiac surgery has gained widespread popularity, full sternotomy (FS) remains the standard approach, particularly for multi-component cardiac surgery due to concerns over restricted exposure and technical challenges with minimally invasive surgical (MIS) approaches. We sought to compare clinical outcomes in patients undergoing MIS approaches to full FS for combined aortic valve and aortic surgeries. METHODS: PubMed, Web of Science, Scopus, and Cochrane CENTRAL were systematically searched to identify studies comparing MIS to FS in patients undergoing combined aortic valve and aortic surgery. The primary endpoints were cardiopulmonary bypass time, cross-clamp time, operative time, and postoperative mortality. RESULTS: A total of 1,114 patients from nine studies were analyzed. Compared to FS, MIS approach for combined aortic valve and aortic surgery demonstrated comparable cardiopulmonary bypass time (MD = -3.2 min; 95% CI: [-10.10, 3.68]; P = 0.36), cross-clamp time (MD = -1.4 min; 95% CI: [-7.17, 4.34]; P = 0.63), operative time (MD = 6.6 min; 95% CI: [-10.2, 23.4]; P = 0.45), operative mortality (RR = 0.56; 95% CI: [0.20, 1.52]; P = 0.25), and overall mortality at follow up (RR = 0.46; 95% CI: [0.07, 3.21]; P = 0.43). MIS was associated with a significantly shorter mechanical ventilation duration (MD = -3.9 h; 95% CI: [-5.89, -2.06]; P < 0.0001), hospital stay (MD = -1.2 days; 95% CI: [-2.01, -0.47]; P = 0.002), risk of re-exploration for any cause (RR = 0.47; 95% CI: [0.23, 0.97]; P = 0.04). There was no significant difference for ICU stay, stroke, atrial fibrillation, permanent pacemaker implantation, acute kidney injury, and sternal dehiscence between the two groups. CONCLUSION: Our meta-analysis suggests that MIS is a feasible alternative to FS for combined aortic valve and aortic surgeries in carefully selected patients at experienced centers, offering shorter recovery times with comparable operative and long-term mortality. TRIAL REGISTRY NUMBER: This meta-analysis was registered on PROSPERO. REGISTRATION NUMBER: CRD42024597960.