Minimally Invasive Versus Conventional Aortic Root Replacement - A Systematic Review and Meta-Analysis

Background Mini-sternotomy has been proven superior to full sternotomy in aortic valve replacement by providing better perioperative outcomes. We investigated whether such technique provides better outcomes in patients undergoing aortic root surgery. Methods A comprehensive electronic literature search was undertaken among the four major databases (PubMed, Ovid, Scopus and EMBASE) to identify all published studies up to June 2018. The search terms used related to mini-sternotomy versus full sternotomy, aortic root, valve sparing, Bentall procedure. Only articles that compared mini against full sternotomy were considered in this analysis. After excluding articles based on title or abstract, the full text articles selected had reference lists searched for any potential further articles to be included in this review. Results A total of 2,765 patients were analysed from across eight comparative studies that were included in the quantitative analysis of the parameters of interest that fulfilled the criteria for meta-analysis. Mini-sternotomy aortic root replacement was associated with significantly shorter cardiopulmonary bypass time (p = 0.009), lower rate of blood transfusion (p = 0.01). additionally, they had lower operative mortality (p = 0.02), and shorter stay at intensive care and at hospital (p = 0.0009, p = 0.03 respectively). However, there was no difference between mini-sternotomy and conventional aortic root replacement in terms of aortic cross-clamp time (p = 0.28), total operation time (p = 0.31), re-exploration rate for bleeding (p = 0.28), stroke rate (p = 0.90), wound infection rate (p = 0.96), and length of mechanical ventilation (p = 0.10). Conclusion Mini-sternotomy is a safe, feasible alternative option to full sternotomy in aortic root repair. However, the significant heterogeneity in data points to the need for a larger, well-designed trial to support the currently limited literature evidences.