Minimally invasive approaches versus conventional sternotomy for aortic valve replacement in patients with aortic valve disease: a systematic review and meta-analysis of 17 269 patients

Background: Aortic valve replacement (AVR) is a common procedure for aortic valve pathologies, particularly in the elderly. While traditional open AVR is established, minimally invasive techniques aim to reduce morbidity and enhance treatment outcomes. The authors’ meta-analysis compares these approaches with conventional sternotomy, offering insights into short and long-term mortality and postoperative results. This study provides valuable evidence for informed decision-making between conventional and minimally invasive approaches for AVR. Materials and methods: Till August 2023, PubMed, Embase, and MEDLINE databases were searched for randomized controlled trials (RCT) and propensity score matched (PSM) studies comparing minimally invasive approaches [mini-sternotomy (MS) and right mini-thoracotomy (RMT)] with full sternotomy (FS) for AVR. Various outcomes were analyzed, including mortality rates, bypass and clamp times, length of hospital stay, and complications. Risk ratios (RR) and the weighted mean differences (WMD) with corresponding 95% CIs were calculated using Review Manager. Results: Forty-eight studies were included having 17 269 patients in total. When compared to FS, there was no statistically significant difference in in-hospital mortality in MS (RR:0.80; 95% CI:0.50–1.27; I 2 =1%; P =0.42) and RMT (RR:0.70; 95% CI:0.36–1.35; I 2 =0%; P =0.29). FS was also linked with considerably longer cardiopulmonary bypass duration than MS (MD:8.68; 95% CI:5.81–11.56; I 2 =92%; P =0.00001). The hospital length of stay was determined to be shorter in MS (MD:−0.58; 95% CI:−1.08 to −0.09; I 2 =89%; P =0.02) with no statistically significant difference in RMT (MD:−0.67; 95% CI:−1.42 to 0.08; I 2 =84%; P =0.08) when compared to FS. Conclusions: While mortality rates were comparable in minimally invasive approaches and FS, analysis shows that MS, due to fewer respiratory and renal insufficiencies, as well as shorter hospital and ICU stay, may be a safer approach than both RMT and FS.