Kevin Phan1, Ashleigh Xie1, Yi-Chin Tsai1, Deborah Black1, Marco Di Eusanio1, Tristan D Yan1. 1. 1 The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia ; 2 Westmead Hospital, Sydney Medical School, University of Sydney, Sydney, Australia ; 3 Department of Cardiothoracic Surgery, The Prince Charles Hospital, Chermside, Australia ; 4 Faculty of Health Sciences, University of Sydney, Sydney, Australia ; 5 Cardiovascular Surgery Department, Sant'Orsola-Malpighi Hospital, Bologna University, Bologna, Italy ; 6 Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, University of Sydney, Sydney, Australia.
Abstract
BACKGROUND: Establishing the relative merits of ministernotomy (MS) and minithoracotomy (MT) approaches to minimally invasive aortic valve replacement (MIAVR) is difficult given the limited available direct evidence. Network meta-analysis is a Bayesian approach that can combine direct and indirect evidence to better define the benefits and risks of MS and MT. METHODS: Electronic searches were performed using six databases from their inception to June 2014. Relevant studies utilizing a minimally invasive approach for aortic valve replacement were identified. Data were extracted and analyzed according to predefined clinical endpoints. Both traditional and Bayesian meta-analysis approaches were conducted. RESULTS: Compared to full sternotomy, MT was associated with longer cardiopulmonary bypass (CPB) duration (WMD, 9.99; 95% CI, 3.91, 16.07; I(2)=55%; P=0.001) and cross-clamp duration (WMD, 7.64; 95% CI, 2.86, 12.42; P=0.002; I(2)=74%). When compared to MS using network meta-analysis, no significant difference in duration was detected. Postoperative outcomes including 30-day mortality, stroke, and reoperation for bleeding and wound infection were comparable between MS and MT using both traditional and Bayesian meta-analysis techniques. CONCLUSIONS: The current evidence demonstrates that MIAVR via MS or MT is a safe and efficacious alternative to conventional median sternotomy. MT may be associated with longer CPB and cross-clamp durations, but has similar post-operative outcomes compared to MS. An individualized approach tailored to both the patient and surgical team is likely to provide optimal outcomes.
BACKGROUND: Establishing the relative merits of ministernotomy (MS) and minithoracotomy (MT) approaches to minimally invasive aortic valve replacement (MIAVR) is difficult given the limited available direct evidence. Network meta-analysis is a Bayesian approach that can combine direct and indirect evidence to better define the benefits and risks of MS and MT. METHODS: Electronic searches were performed using six databases from their inception to June 2014. Relevant studies utilizing a minimally invasive approach for aortic valve replacement were identified. Data were extracted and analyzed according to predefined clinical endpoints. Both traditional and Bayesian meta-analysis approaches were conducted. RESULTS: Compared to full sternotomy, MT was associated with longer cardiopulmonary bypass (CPB) duration (WMD, 9.99; 95% CI, 3.91, 16.07; I(2)=55%; P=0.001) and cross-clamp duration (WMD, 7.64; 95% CI, 2.86, 12.42; P=0.002; I(2)=74%). When compared to MS using network meta-analysis, no significant difference in duration was detected. Postoperative outcomes including 30-day mortality, stroke, and reoperation for bleeding and wound infection were comparable between MS and MT using both traditional and Bayesian meta-analysis techniques. CONCLUSIONS: The current evidence demonstrates that MIAVR via MS or MT is a safe and efficacious alternative to conventional median sternotomy. MT may be associated with longer CPB and cross-clamp durations, but has similar post-operative outcomes compared to MS. An individualized approach tailored to both the patient and surgical team is likely to provide optimal outcomes.
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Authors: Marco Di Eusanio; Kevin Phan; Denis Bouchard; Thierry P Carrel; Otto E Dapunt; Roberto Di Bartolomeo; Harald C Eichstaedt; Theodor Fischlein; Thierry Folliguet; Borut Gersak; Mattia Glauber; Axel Haverich; Martin Misfeld; Peter J Oberwalder; Giuseppe Santarpino; Malakh Lal Shrestha; Marco Solinas; Marco Vola; Francesco Alamanni; Alberto Albertini; Gopal Bhatnagar; Michel Carrier; Stephen Clark; Federic Collart; Utz Kappert; Alfred Kocher; Bart Meuris; Carmelo Mignosa; Ahmed Ouda; Marc Pelletier; Parwis Baradaran Rahmanian; David Reineke; Kevin Teoh; Giovanni Troise; Emmanuel Villa; Thorsten Wahlers; Tristan D Yan Journal: Ann Cardiothorac Surg Date: 2015-03