Surgical ablation by a right mini-thoracotomy versus a median sternotomy: A systematic review and meta-analysis of observational studies

Objectives A minimally invasive approach by a right minithoracotomy has been developed for surgical ablation of atrial fibrillation. However, the efficacy and safety compared to a median sternotomy remains unclear. Methods We searched PubMed, Embase and the Cochrane Library for eligible studies. Meta-analysis was performed for primary (recurrence of atrial tachyarrhythmias at 1 and 2 years) and secondary (hospital and ICU stay, adverse events, 30-day mortality, cardiopulmonary bypass and aortic cross-clamp time) endpoints. We compared endpoints using risk ratio (RR) for binary outcomes and mean difference (MD) for continuous ones. We calculated 95% confidence intervals (CI) and used the random-effects model for all outcomes. We performed subgroup analysis for the main outcome based on lesion set, energy source, type of surgery, and propensity score matching. Results We included 12 observational studies (n = 3122). No difference was found for the primary outcome at 1 (RR 0.8; [95% CI]: 0.62-1.03; p = 0.08) and 2 years (RR 0.9; [95% CI]: 0.74-1.13; p = 0.4). The thoracotomy group had lower complications (RR 0.72; [95% CI]: 0.55-0.97; p = 0.016), 30-day mortality (OR 0.26; [95% CI]: 0.10-0.70; p = 0.007), hospital stay (MD -5.35; [95% CI]: -7.94–2.77; p < 0.001) and ICU stay (MD -2.21; [95% CI]: -3.02–1.40; p < 0.001). Cardiopulmonary bypass and aortic clamping time were significantly higher in the thoracotomy group. Conclusion This meta-analysis found that surgical ablation by a minithoracotomy might achieve similar rhythm control to a median sternotomy while possibly improving safety and promoting faster recovery. However, conclusions are limited by the observational nature of the evidence and randomized trials are warranted.