Aortic Valve Replacement: Is Minimally Invasive Really Better? A Contemporary Systematic Review and Meta-Analysis

EL‐Andari, Ryaan; Fialka, Nicholas M.; Shan, Shubham; White, Abigail; Manikala, Vinod K; Wang, Shaohua

doi:10.1097/crd.0000000000000488

Cited by 8 publications

(10 citation statements)

References 61 publications

(258 reference statements)

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“…In addition, a similar result was observed in a previous paper published in 2021, focused on aortic valve surgery in obese patients [23] and confirmed by Abdelaal SA et al [24]. Moreover, similar results were published last year in a systematic review and meta-analysis published by El-Andari [25]; this study found that the in-hospital mortality rates were higher using full sternotomy than ministernotomy (p = 0.02) and that the 30-day mortality was higher using full sternotomy compared to right anterior thoracotomy (p = 0.006). Furthermore, both mini-thoracotomy and mini-sternotomy have been the first choice of approach in isolated aortic valve surgery for many years, while full sternotomy is used in only in a small percentage of patients (26.9%).…”

supporting

confidence: 84%

Less Is More? Combined Approaches to Improve Mortality and Morbidity after Aortic Valve Replacement

Mikus,

Fiorentino,

Sangiorgi

et al. 2023

Biomedicines

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Background: Nowadays, one of the main goals of aortic valve surgery is to reduce the biological impact, mortality, and complications. It is well-known that long operative times in terms of the extracorporeal circulation, but above all, of the aortic cross-clamp time (ACC), represent a risk factor for mortality in patients undergoing cardiac surgery. In order to shorten the aortic cross-clamp time, many technological improvements, such as sutureless prostheses, have been introduced, but their actual effectiveness has not been proven yet. The aim of this study was to assess the 30-day outcomes of patients undergoing aortic valve replacement surgery, focusing on the ACC length. Methods: All 3139 patients undergoing aortic valve replacement between January 2013 and July 2022 at our institution were enrolled. The data were retrospectively collected and the baseline characteristics and intraoperative variables were recorded. In order to adjust the results according to the differences in the baseline characteristics, propensity score matching was performed and four groups of 351 patients were obtained based on the first, second, third, and fourth quartile of the ACC time. Results: The patient population included 132 redo surgeries (9.4%) and 61 cases of active endocarditis (4.3%), with an overall median EuroSCORE II of 1.8 (IQR 1.2–3.1). An increase across the groups was observed in terms of the acute kidney failure (p < 0.001) incidence, the number of blood transfusions (p = 0.022), prolonged hospital stays (p < 0.001), the and respiratory failure (p < 0.001) incidence. A p of < 0.1 was found for the 30-day mortality (p = 0.079). The predictors of an early 30-day mortality were standard full sternotomy (OR 2.48, 95% CI 1.14–5.40, p = 0.022), EuroSCORE II (OR 1.10, 95% CI 1.05–1.16, p < 0.001), and a trend for a longer ACC time (Q4 vs. Q1: OR 2.62, 95% CI 0.89–7.68, p = 0.080). Conclusions: Shortening the operative times resulted in marked improvements of the patients’ outcomes. The combined use of minimally invasive approaches and sutureless aortic valve prostheses allows for a lower 30-day events rate. New technologies should be assessed to obtain the best results with the least risk.

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supporting

confidence: 84%

Less Is More? Combined Approaches to Improve Mortality and Morbidity after Aortic Valve Replacement

Mikus,

Fiorentino,

Sangiorgi

et al. 2023

Biomedicines

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“…Even so, some even reported that minimal access AVR may take longer with cross-clamp and bypass duration. However, due to the limitations, these analyses did not identify significant and robust evidence for deciding upon the appropriate approach [ 31 – 33 ].…”

Section: Discussionmentioning

confidence: 99%

Comparative effects of minimally invasive approaches vs. conventional for obese patients undergoing aortic valve replacement: a systematic review and network meta-analysis

Abdelaal,

Abdelrahim,

Mamdouh

et al. 2023

BMC Cardiovasc Disord

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Background Minimally invasive approaches like mini-thoracotomy and mini-sternotomy for Aortic Valve Replacement (AVR) showed impressive outcomes. However, their advantages for obese patients are questionable. We aimed in this network meta-analysis to compare three surgical approaches: Full sternotomy (FS), Mini-sternotomy (MS), and Mini-thoracotomy (MT) for obese patients undergoing AVR. Methods We followed the PRISMA extension for this network meta-analysis. PubMed/Medline, Scopus, Web of Science, and Cochrane searched through March 2023 for relevant articles. The analysis was performed using R version 4.2.3. Results Out of 344, 8 articles met the criteria with 1392 patients. The main outcomes assessed were perioperative mortality, re-exploration, atrial fibrillation, renal failure, ICU stay, hospital stay, cross-clamp time, and bypass time. In favor of MS, the length of ICU stay and hospital stay was significantly lower than for FS [MD -0.84, 95%CI (-1.26; -0.43)], and [MD -2.56, 95%CI (-3.90; -1.22)], respectively. Regarding peri-operative mortality, FS showed a significantly higher risk compared to MS [RR 2.28, 95%CI (1.01;5.16)]. Also, patients who underwent minimally invasive approaches; MT and MS, required less need of re-exploration compared to FS [RR 0.10, 95%CI (0.02;0.45)], and [RR 0.33, 95%CI (0.14;0.79)], respectively. However, Intraoperative timings; including aortic cross-clamp, and cardiopulmonary bypass time, were significantly lower with FS than for MS [MD -9.16, 95%CI (-1.88; -16.45)], [MD -9.61, 95%CI (-18.64; -0.59)], respectively. Conclusion Our network meta-analysis shows that minimally invasive approaches offer some advantages for obese patients undergoing AVR over full sternotomy. Suggesting that these approaches might be considered more beneficial alternatives for obese patients undergoing AVR.

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“…This is consistent with a contemporary meta-analysis highlighting the benefits of minimally invasive AVR, with reduced early postoperative morbidity and mortality as compared with full sternotomy. 36 Increased application of minimally invasive SUAVR, as well as further experimentation with additional techniques, is integral to the future treatment of AS. 33 Small aortic annulus.…”

Section: Applications and Indicationsmentioning

confidence: 99%

The Perceval Sutureless Bioprosthetic Aortic Valve: Evolution of Surgical Valve Technology

Fialka,

EL-Andari,

Wang

et al. 2024

Innovations�(Phila)

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Objective: The surgical treatment of aortic stenosis continues to evolve, and sutureless aortic valve replacement (SUAVR) is an emerging technology. With the Perceval S (Corcym, London, UK) as the only true sutureless valve on the market, the objective of this review is to analyze the current literature on Perceval S. Focusing on valve design and deployment as well as applications of the technology for challenging pathology, clinical outcomes are assessed, including a comparison with transcatheter AVR (TAVR). Methods: PubMed and MEDLINE were searched by 3 authors for studies analyzing SUAVR from inception to May 19, 2023. Results: SUAVR facilitates minimally invasive surgery and offers an alternative strategy for patients with small aortic annuli. It also has a time-saving advantage for patients who require complex operations. SUAVR results in excellent long-term morbidity, mortality, durability, and hemodynamic function. In comparison with conventional surgical AVR (SAVR), SUAVR does have a greater risk of postoperative pacemaker implantation; however, increasing user experience and refinements in implantation technique have contributed to reductions in this outcome. SUAVR results in morbidity and mortality that is similar to rapid-deployment AVR. Midterm outcomes are superior to TAVR; however, further robust investigation into all of these comparisons is ultimately necessary. Conclusions: SUAVR bridges the gap in technology between SAVR and TAVR. The application of this exciting technology will undoubtedly grow in the coming years, during which additional investigation is paramount to optimize preoperative planning, valve deployment, and reintervention strategies.

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Aortic Valve Replacement: Is Minimally Invasive Really Better? A Contemporary Systematic Review and Meta-Analysis

Cited by 8 publications

References 61 publications

Less Is More? Combined Approaches to Improve Mortality and Morbidity after Aortic Valve Replacement

Less Is More? Combined Approaches to Improve Mortality and Morbidity after Aortic Valve Replacement

Comparative effects of minimally invasive approaches vs. conventional for obese patients undergoing aortic valve replacement: a systematic review and network meta-analysis

The Perceval Sutureless Bioprosthetic Aortic Valve: Evolution of Surgical Valve Technology

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