Mini-sternotomy for aortic valve replacement reduces the length of stay in the cardiac intensive care unit: meta-analysis of randomised controlled trials

Abstract

BackgroundMini-sternotomy for isolated aortic valve replacement aims to reduce operative trauma hastening recovery and improving the cosmetic outcome of cardiac surgery. The short-term clinical benefits from the mini-sternotomy are presumed to arise because the incision is less extensive and the lower half of the chest cage remains intact. The basic conduct of virtually all other aspects of the aortic valve replacement procedure remains the same. Therefore, similar long-term outcomes are to be expected.ObjectivesTo conduct a meta-analysis of the only available randomised controlled trials (RCT) in the published English literature.Data sourcesElectronic search for relevant publications in MEDLINE, EMBASE and CENTRAL databases were performed. Four studies met the criteria.Study eligibility criteriaRCT comparing minimally invasive (inverted C or L (J)-shaped) hemi-sternotomy versus conventional sternotomy for adults undergoing isolated aortic valve replacement using standard cardiopulmonary bypass technique.MethodsOutcome measures were the length of positive pressure ventilation, blood loss, intensive care unit (ICU) and hospital stay.ResultsThe length of ICU stay was significantly shorter by 0.57 days in favour of the mini-sternotomy group (CI −0.95 to −0.2; p=0.003). There was no advantage in terms of duration of ventilation (CI −3.48 to 0.36; p=0.11). However, there was some evidence to suggest a reduction in blood loss and the length of stay in hospital in the mini-sternotomy group. This did not prove to be statistically significant (154.17 ml reduction (CI −324.51 to 16.17; p=0.08) and 2.03 days less (CI −4.12 to 0.05; p=0.06), respectively).LimitationsThis study includes a relatively small number of subjects (n=220) and outcome variables. The risk of bias was not assessed during this meta-analysis.ConclusionMini-sternotomy for isolated aortic valve replacement significantly reduces the length of stay in the cardiac ICU. Other short-term benefits may include a reduction in blood loss or the length of hospital stay.

Anterolateral minithoracotomy versus median sternotomy for mitral valve disease: a meta-analysis

“…Ding et al (2012) evaluated ALMT in congenital heart disease and suggested that this had a longer CPB time and ACCT, but shorter intubation time, ICU time, and LOHS. The remaining three studies compared a minimally invasive procedure with conventional sternotomy for aortic valve replacement (Murtuza et al, 2008;Brown et al, 2009;Khoshbin et al, 2011) and included RCTs and non-randomized studies. They concluded that a mini-sternotomy can be performed safely for aortic valve replacement without an increased risk of death, major complications (Khoshbin et al, 2011), a reduction in ICU stay time (Brown et al, 2009), or clinical benefit (Aybek et al, 2000).…”

“…The remaining three studies compared a minimally invasive procedure with conventional sternotomy for aortic valve replacement (Murtuza et al, 2008;Brown et al, 2009;Khoshbin et al, 2011) and included RCTs and non-randomized studies. They concluded that a mini-sternotomy can be performed safely for aortic valve replacement without an increased risk of death, major complications (Khoshbin et al, 2011), a reduction in ICU stay time (Brown et al, 2009), or clinical benefit (Aybek et al, 2000). Moreover, we excluded 12 studies because they had no control groups (Loulmet et al, 1998;Mishra et al, 1999;Riess et al, 2001;Grossi et al, 2002;Onnasch et al, 2002b;Aybek et al, 2006;Martin et al, 2006;Seeburger et al, 2008;Glaubera et al, 2009;Müller et al, 2011;Reser et al, 2012), which ranged from 22 to 1339 in sample size.…”

Aortic Valve Surgery: Minimally Invasive Options

“…15 This analysis demonstrated trends towards the expected benefits of minimally invasive surgery, i.e., blood loss and length of stay, but the small number did not allow for statistical significance to be reached. Most of what we know comes from retrospective studies.…”

Minimally invasive aortic valve replacement in high risk patient groups

“…Historically, Cosgrove and Cohn were the first clinicians to pioneer smaller incisions for both mitral and aortic procedures (1). Despite longer cardiopulmonary bypass (CPB) times compared to conventional surgery (1)(2)(3)(4)(5)(6)(7)(8)(9)(10)(11)(12), preservation of the sternal integrity and minimisation of dissection had been advocated to improve the cosmetic result, reduce bleeding, provide better respiratory function, yield shorter hospital stays and therefore lower costs and improved patient satisfaction. A large meta-analysis by Phan et al demonstrated that minimally invasive AVR (mini-AVR) is also associated with a reduced incidence of renal failure and has comparable mortality and morbidity to conventional surgery (13).…”