Anterolateral minithoracotomy versus median sternotomy for the surgical treatment of atrial septal defects: a meta-analysis and systematic review

Abstract

Background To compare the short-term safety and efficacy of right anterolateral minithoracotomy (ALMT) and median sternotomy (MS) for the surgical treatment of atrial septal defects (ASDs). Methods The PubMed, EMBASE, Web of Science, and Cochrane Library databases were searched for comparative studies focusing on surgical repair of ASDs via ALMT or MS published up to the end of April 27, 2020. We used random-effect or fixed-effect models to obtain pooled estimates. Results A total of 7 publications, including 665 patients (ALMT 296 and MS 369), were included. Age (WMD: 1.80 years, 95% CI 0.31–3.29), weight (WMD: − 0.91 kg, 95% CI − 5.57 to 3.75), sex distribution (OR: 1.00, 95% CI 0.74–1.35) and surgical type (patch or direct closure) (OR: 1.00, 95% CI 0.67–1.49) were comparable in the ALMT group and MS group. No significant differences in the success rate (OR 0.23; 95% CI 0.05–1.07) or severe complication rate (OR 1.46; 95% CI 0.41–5.22) were found between the ALMT group and the MS group. In addition, the differences in the cardiopulmonary bypass (CPB) time (WMD 6.33; 95% CI − 1.92 to 14.58 min, p = 0.13) and the operation time (WMD 5.23; 95% CI − 12.49 to 22.96 min, p = 0.56) between the ALMT group and the MS group were not statistically significant. However, the ALMT group had a significantly longer aortic cross-clamp time (2.37 min more, 95% CI 1.07–3.67 min, p = 0.0003). The intubation time was 1.82 h shorter (95% CI − 3.10 to − 0.55 h; p = 0.005), the intensive care unit (ICU) stay was 0.24 days shorter (95% CI − 0.44 to − 0.04 days; p = 0.02), and the postoperative hospital stay was 2.45 days shorter (95% CI − 3.01 to − 1.88 days; p < 0.00001) in the ALMT group than in the MS group. Furthermore, the incision length was significantly shortened by 8.97 cm in the ALMT group compared with the MS group (95% CI − 9.36 to − 8.58 cm; p < 0.00001). Conclusions In the surgical treatment of ASD, ALMT and MS are equally safe and effective in terms of success rates and severe complication rates. The surgical procedures are equally difficult, but ALMT is associated with a faster functional recovery and better cosmetic results. Compared to MS, ALMT is the better choice for select ASD patients.

Mini right axillary thoracotomy for congenital heart defect repair can become a safe surgical routine

“…2,4 Our current series cover the consecutive experience with minimally invasive approaches from three different North American centres spanning 8 years. Comparing our results and some of the previously published minimally invasive series, [1][2][3][4][5][6][7][8][9] with repairs done through median sternotomy, [10][11][12][13][14] the most denominator is the shortened intubation time and length of hospital stay for the minimal invasive series.…”

“…However, in cardiac surgery, lung damage is mainly ascribed to two factors: cardiopulmonary bypass times and sternotomy. 18 Indeed, the meta-analyses have shown shorter intubation times in the mini-thoracotomy groups versus patients after median sternotomy, [10][11][12][13][14] thereby implying at least no clinically detectable effect from lung injury during minimally invasive procedures that require some portion of procedural time under one lung physiology. All the relevant recent series describing the minimal invasive thoracotomy approaches seem to support this, with shorter to no post-operative intubation times and corresponding shorter intensive care and hospital stays.…”

“…All the relevant recent series describing the minimal invasive thoracotomy approaches seem to support this, with shorter to no post-operative intubation times and corresponding shorter intensive care and hospital stays. 5,6,[8][9][10][11][12][13][14] In their meta-analysis, Lei et al compared the anterolateral mini-thoracotomy approach versus median sternotomy for the surgical treatment of atrial septal defects and concluded that they were equally safe and effective in terms of success rates and severe complication rates. 12 The surgical procedures were equally difficult (no significant difference in the operation time between the two groups), but the anterolateral mini-thoracotomy approach was associated with significantly faster functional recovery and a better cosmetic result.…”

“…5,6,[8][9][10][11][12][13][14] In their meta-analysis, Lei et al compared the anterolateral mini-thoracotomy approach versus median sternotomy for the surgical treatment of atrial septal defects and concluded that they were equally safe and effective in terms of success rates and severe complication rates. 12 The surgical procedures were equally difficult (no significant difference in the operation time between the two groups), but the anterolateral mini-thoracotomy approach was associated with significantly faster functional recovery and a better cosmetic result. Severe complication rates, defined as reoperation for bleeding, severe residual disease, neurological complications, and renal failure, were comparable between the two groups (p = 0.56).…”

“…[1][2][3][4][5][6][7][8][9] As such, there has been recent growth in the published literature regarding outcomes of various minimally invasive approaches versus median sternotomy with relatively similar outcomes based on safety. [10][11][12][13][14] Due to the obvious cosmetic appeal combined with an ever increasing safety profile, minimal invasive repair of congenital heart defects through a mini right axillary thoracotomy is becoming routine in many centres, and even proposed as standard of care in those with experience. 2,4,5 We describe our current outcomes of the mini right axillary approach for the repair of common CHDs, and suggest it as a safe surgical routine, as otherwise performed classically through median sternotomy.…”