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

Minimally invasive versus conventional methods for aortic root surgery: Choosing the right approach

OBJECTIVE

Partial upper sternotomy is preferred for isolated aortic valve replacement because of its optimal surgical visibility and favorable cosmetic outcomes; however, it is not commonly used for aortic root surgery, and the conventional median sternotomy is still the preferred method for most surgeons. We aimed to compare the safety and effectiveness of a minimally invasive approach (partial sternotomy [PS]) and conventional approach (median sternotomy [FS]) for aortic root surgery.

METHODS

Patients who underwent aortic root surgery at our hospital from 2016 to 2021 were retrospectively enrolled and divided into two groups. After propensity score matching, the conventional group included 156 patients and the minimally invasive group-57 patients.

RESULTS

Bicuspid aortic valves were observed in 63 (40.4%) and 33 (57.9%) patients in the FS and PS groups, respectively. Valve-sparing surgery was performed on 69 (44.2%) and 30 (52.6%) patients in the FS and PS groups, respectively. The minimally invasive approach was beneficial in terms of blood loss during the first 24 h after surgery (p = 0.029) and postoperative blood transfusion (p = 0.023). The survival rates and freedom from reoperation or severe aortic regurgitation after the David procedure were comparable between the standard and minimally invasive groups (p = 0.25; p = 0.66) at mid-term follow-up.

CONCLUSIONS

A minimally invasive approach for aortic root surgery can be safely performed as the standard approach. Partial upper sternotomy has the advantage of lower blood loss in the early postoperative period and does not negatively affect the results of valve-sparing root replacement.

Beyond Conventional Operations: Embracing the Era of Contemporary Minimally Invasive Cardiac Surgery

Over the past two decades, minimally invasive cardiac surgery (MICS) has gained a significant place due to the emergence of innovative tools and improvements in surgical techniques, offering comparable efficacy and safety to traditional surgical methods. This review provides an overview of the history of MICS, its current state, and its prospects and highlights its advantages and limitations. Additionally, we highlight the growing trends and potential pathways for the expansion of MICS, underscoring the crucial role of technological advancements in shaping the future of this field. Recognizing the challenges, we strive to pave the way for further breakthroughs in minimally invasive cardiac procedures.

The Feasibility of Less-Invasive Bentall Surgery: A Real-World Analysis

OBJECTIVE

Minimally invasive approaches are being used increasingly in cardiac surgery and applied in a wider range of operations, including complex aortic procedures. The aim of this study was to examine the safety and feasibility of a partial upper sternotomy approach for isolated elective aortic root replacement (a modified Bentall procedure).

METHODS

We performed a retrospective analysis of 768 consecutive patients who had undergone isolated Bentall surgery between January 2000 and January 2021 at our institution, with the exclusion of re-operations, endocarditis, acute aortic dissections, and root replacement with major concomitant procedures such as multi-valve or coronary bypass surgery. A total of 98 patients were operated on via partial sternotomy (PS) and were matched 2:1 to 196 patients operated on via full sternotomy (FS).

RESULTS

The procedure time was 12 min longer in the PS group (205 min vs. 192.5 min in the FS group, p = 0.002), however, cardiopulmonary bypass and aortic cross-clamp times were comparable between groups. Eight PS-procedures were converted to full sternotomy, predominantly for bleeding complications (n = 6). Re-exploration for acute bleeding was necessary in 11% of the PS group and 4.1% of the FS group (p = 0.02). Five FS patients and none in the PS group required emergency coronary bypass grafting for postoperative coronary obstruction (p = 0.2). PS patients were hospitalized for a significantly shorter period (9.5 days vs. 10.5 days in the FS group, respectively). There were no significant differences regarding in-hospital (p = 0.4) and mid-term mortality (p = 0.73), as well as for other perioperative complications.

CONCLUSIONS

Performing Bentall operations via partial upper sternotomy is associated with similar perfusion and cross-clamp times, as well as overall mortality, when compared to a full sternotomy approach. A low threshold for conversion to full sternotomy should be accepted if limited access proves insufficient for the handling of intraoperative complications, particularly bleeding.

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

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.

Comparison of minimally invasive versus conventional thoracic aortic operations: Early and midterm results in a series of 624 patients

OBJECTIVE

Despite minimally invasive techniques having gained wider application in cardiac surgery, current evidence on minithoracic aortic surgery is still limited. The aim of this study was to compare early and midterm outcomes of patients undergoing operations of the proximal thoracic aorta through ministernotomy (MS) versus full sternotomy (FS).

METHODS

Data from 624 consecutive patients who underwent proximal aortic repair through MS (n = 214, 34.3%) and FS (n = 410, 65.7%) at two aortic centers were analyzed. Treatment selection bias was addressed using propensity score matching (MS vs. FS). After matching, two well-balanced groups of 202 patients each were created.

RESULTS

Median cardiopulmonary bypass and cross-clamp times were 88 and 68 min, respectively, with no difference between groups. Overall, 30-day mortality was 1% (n = 2) in MS and 0.5% (n = 1) in FS (p = .6). No difference was found in the rates of stroke (MS n = 5, 2.5%; FS n = 5, 2.5%), dialysis (MS n = 1, 0.5%; FS n = 4, 2%), bleeding (MS n = 7, 3.5%; FS n = 7, 3.5%), and blood transfusions (MS n = 67, 33.3%; FS n = 57, 28.4%). Patients receiving MS showed a lower incidence of respiratory insufficiency compared with FS (0% vs. 2.5%, p = .04). Intensive care unit and hospital stays were similar between groups. Two-year survival rate was 97.2% in MS and 96.5% in FS (p = .9).

CONCLUSIONS

Mini proximal aortic operations can be performed successfully without compromising the proven efficacy and safety of conventional access. In selected patients, MS was associated with very low mortality and morbidity rates. Additionally, MS demonstrated superior clinical outcomes as regards respiratory adverse events, when compared with FS.

Minimal access compared to sternotomy for aortic root and arch surgery

INTRODUCTION

Partial upper sternotomy is an established technique for aortic valve surgery in numerous centers. Based on the favorable results, this access can be extended for more complex procedures. We assessed the outcomes of aortic root and arch surgery through partial versus full sternotomy.

PATIENTS AND METHODS

From January 2013 to December 2020, 100 patients underwent proximal aortic surgery. The minimal access approach was used in 73 patients. Operative variables and outcomes were retrospectively analyzed and compared between both groups.

RESULTS

There was no significant difference in cross-clamping and extracorporeal circulation times, as well as no difference in postoperative acute renal failure, stroke, myocardial infarction, and re-exploration for bleeding. However, there was a significant difference in favor of partial upper sternotomy in red blood cell transfusion (0 vs. 234 mL; p = 0.01), postoperative drainage volume (300 vs. 750 mL; p < 0.001), ventilation time (median 3 vs. 24 h; p < 0.001), sepsis (1 [1.4%] vs. 4 [14.8%]; p = 0.02), intensive care unit (median 2 vs. 4 days; p = 0.002) and hospital stay (median 7 vs. 10 days; p < 0.001). Only one patient required intraoperative conversion due to massive bleeding. There was no difference in 30-day mortality between both groups.

CONCLUSION

The partial upper sternotomy approach is safe and feasible for aortic root and arch surgery with morbidity and mortality rates similar to full sternotomy, with the advantages of less blood loss and transfusions need, faster extubation, and shorter length of hospital stay.

Conventional Versus Minimally Invasive Aortic Valve Replacement Surgery: A Systematic Review, Meta-Analysis, and Meta-Regression

Objective: To assess the potential benefits of minimally invasive aortic valve replacement (MIAVR) compared with conventional AVR (CAVR) by examining short-term outcomes. Methods: A systematic search identified randomized trials comparing MIAVR with CAVR. To assess study limitations and quality of evidence, we used the Cochrane Risk of Bias tool and GRADE and performed random-effects meta-analysis. We used meta-regression and sensitivity analysis to explore reasons for diversity. Results: Thirteen studies (1,303 patients) were included. For the comparison of MIAVR and CAVR, the risk of bias was judged low or unclear and the quality of evidence ranged from very low to moderate. No significant difference was observed in mortality, stroke, acute kidney failure, infectious outcomes, cardiac events, intubation time, intensive care unit stay, reoperation for bleeding, and blood transfusions. Blood loss (mean difference [MD] = -130.58 mL, 95% confidence interval [CI] = -216.34 to -44.82, I² = 89%) and hospital stay (MD = -0.93 days, 95% CI = -1.62 to -0.23, I² = 81%) were lower with MIAVR. There were shorter aortic cross-clamp (MD = 5.99 min, 95% CI = 0.99 to 10.98, I² = 93%) and cardiopulmonary bypass (CPB) times (MD = 7.75 min, 95% CI = 0.27 to 15.24, I² = 94%) in the CAVR group. In meta-regression analysis, we found that age was the variable with the greatest influence on heterogeneity. Conclusions: MIAVR seems to be an excellent alternative to CAVR, reducing hospital stay and incidence of hemorrhagic events. Despite significantly greater aortic cross-clamp and CPB times with MIAVR, this did not translate into adverse effects, with no changes in the results found with CAVR.

How We Perform a David Procedure With an Upper Hemisternotomy Approach

OBJECTIVE

Valve-sparing aortic root replacement (David procedure) is the technique of choice in appropriately selected patients with aortic root aneurysms. These procedures are seldom performed in a minimally invasive fashion. We describe our systematic approach to the David procedure using an upper hemisternotomy (UHS). Methods: Our method involves a J-type UHS exiting the right third or fourth intercostal space. Ascending aortic and femoral venous cannulation are performed using the Seldinger technique under transesophageal echocardiographic guidance. Between August 2005 and August 2014, 27 patients underwent an isolated elective David procedure using a full sternotomy (FS). Sixteen underwent an isolated elective UHS David procedure from May 2015 to February 2019. Perioperative safety outcomes were compared between the 2 cohorts. Results: The UHS and FS David cohorts were primarily male (87.5% and 85.2%, respectively) and 51 and 50 years old on average, respectively. Custodiol-histidine-tryptophan-ketoglutarate cardioplegia (93.8% vs 37.0%, P < 0.001) and Cor-Knot (100% vs 0%, P < 0.001) were used significantly more in the UHS David cohort. There were no significant differences in cardiopulmonary bypass (200 [183-208] vs 212 [183-223] min, P = 0.309) and aortic cross-clamp (169 [155-179] vs 188 [155-199] min, P = 0.128) times in the UHS and FS cohorts. There were no instances of hospital or 30-day mortality in either cohort. Intensive care unit and hospital stays were comparable between the 2 cohorts. Conclusions: The David procedure via UHS is a safe and reproducible technique for aortic root replacement.

Minimally invasive approach: is this the future of aortic surgery?

Median sternotomy incision has shown to be a safe and efficacious approach in patients who require thoracic aortic interventions and still represents the gold-standard access. Nevertheless, over the last decade, less invasive techniques have gained wider clinical application in cardiac surgery becoming the first-choice approach to treat heart valve diseases, in experienced centers. The popularization of less invasive techniques coupled with an increased patient demand for less invasive therapies has motivated aortic surgeons to apply minimally invasive approaches to more challenging procedures, such as aortic root replacement and arch repair. However, technical demands and the paucity of available clinical data have still limited the widespread adoption of minimally invasive thoracic aortic interventions. This review aimed to assess and comment on the surgical techniques and the current evidence on mini thoracic aortic surgery.

The mini-Bentall approach: Comparison with full sternotomy

Background

The upper mini sternotomy Bentall (mini-Bentall) procedure may result in less trauma and earlier recovery compared with the full sternotomy Bentall procedure (full Bentall). This study compares immediate and 1- and 3-year survival rates after mini- and full Bentall procedures.

Methods

Between February 2009 and July 2019, 48 patients underwent a mini-Bentall and 49 underwent a full Bentall. Patients who required concomitant procedures, reoperations, or hypothermic circulatory arrest were excluded from our analysis. The mean patient age was 60.7 years in the mini-Bentall group and 59.0 years in the full Bentall group.

Results

There were no in-hospital mortalities. The median cardiopulmonary bypass time (mini-Bentall: 165 minutes [interquartile range (IQR), 155.5-183 minutes]; full Bentall: 164 minutes [IQR, 150-187 minutes]; P = .619) and aortic cross-clamp times (139 minutes [IQR, 128.5-153 minutes] vs 137 minutes [IQR, 125-156 minutes]; P = .948) were not significantly different between the 2 groups. The mini-Bentall group had a significantly shorter median ventilation time compared with the full Bentall group (5.5 hours [IQR, 3-14 hours] vs 17 hours [IQR, 11-23 hours]; P < .001). None of the patients in the mini-Bentall group had postoperative bleeding necessitating reoperation, whereas 4 patients (8.2%) underwent reoperation after full Bentall (P = .043). The mini-Bentall group also had a shorter median hospital length of stay (6 days [IQR, 5-8 days] vs 7 days [IQR, 6-8 days]; P = .086). Survival at 1 and 3 years was 100% in both cohorts.

Conclusions

Patients required significantly less ventilation time and reoperations for bleeding after the mini-Bentall procedure. There were no significant differences in cardiopulmonary bypass, aortic cross-clamp times, or intensive care unit and hospital length of stay between the mini-Bentall and full Bentall groups. The mini-Bentall approach is associated with low morbidity and mortality.

Minimally invasive surgery versus transcatheter aortic valve replacement: a systematic review and meta-analysis

Transcatheter aortic valve replacement (TAVR) has recently been approved for use in patients who are at intermediate and low surgical risk. Moreover, recent years have witnessed a renewed interest in minimally invasive aortic valve replacement (miAVR). The present meta-analysis compared the outcomes of TAVR and miAVR in the management of aortic stenosis (AS). We conducted an electronic search across six databases from 2002 (TAVR inception) to December 2019. Data from relevant studies regarding the clinical and length of hospitalisation outcomes were extracted and analysed using R software. We identified a total of 11 cohort studies, of which seven were matched/propensity matched. Our analysis demonstrated higher rates of midterm mortality (≥1 year) with TAVR (risk ratio (RR): 1.93, 95% CI: 1.16 to 3.22), but no significant differences with respect to 1 month mortality (RR: 1.00, 95% CI: 0.55 to 1.81), stroke (RR: 1.08, 95% CI: 0.40 to 2.87) and bleeding (RR: 1.45, 95% CI: 0.56 to 3.75) rates. Patients undergoing TAVR were more likely to experience paravalvular leakage (RR: 14.89, 95% CI: 6.89 to 32.16), yet less likely to suffer acute kidney injury (RR: 0.38, 95% CI: 0.21 to 0.69) compared with miAVR. The duration of hospitalisation was significantly longer in the miAVR group (mean difference: 1.92 (0.61 to 3.24)). Grading of Recommendations Assessment, Development and Evaluation assessment revealed ≤moderate quality of evidence in all outcomes. TAVR was associated with lower acute kidney injury rate and shorter length of hospitalisation, yet higher risks of midterm mortality and paravalvular leakage. Given the increasing adoption of both techniques, there is an urgent need for head-to-head randomised trials with adequate follow-up periods.

Outcomes in techniques of valve sparing aortic root replacement: A systematic review and meta-analysis

OBJECTIVE

To compare clinical outcomes of reimplantation versus remodeling in patients undergoing valve-sparing aortic root replacement (VSRR) surgery.

METHOD

Electronic database search at PubMed, Scopus, Embase, Ovid, and Google scholar was performed from inception to January 2020. Primary outcomes were aortic valve (AV) reintervention and postoperative grade of aortic insufficiency (AI) while secondary outcomes were 30-day mortality, reoperation for bleeding, and operative times.

RESULTS

A total of 21 articles met the inclusion criteria. A total of 1283 patients had reimplantation while 1150 had remodeling. No difference in preoperative demographics was noted except reimplantation patients were younger (48 ± 16 vs. 56 ± 15 years; p < .00001). The cardiopulmonary bypass and aortic cross-clamp times were shorter in the remodeling cohort (168 ± 38 vs. 150 ± 37 min; p = .0001 and 133 ± 31 vs. 112 ± 30 min; p = .0002, respectively). No difference in concomitant total arch surgery (14% in reimplantation vs. 15% in remodeling; p = .53). Postoperatively, there were similar stroke rates (3% in both cohorts; p = .54), rates of reoperation for bleeding (9% in reimplantation vs. 12% in remodeling; p = .88), and 30-day mortality (3% in reimplantation vs. 4% in remodeling; p = .96). No difference in early AV reintervention (1% in reimplantation vs. 2% in remodeling; p = .07), and late AV reintervention (4% in reimplantation vs. 7% in remodeling; p = .07). The AI of +2 grade was significantly lower in the reimplantation cohort (5% vs. 8%; p = .01).

CONCLUSION

Our study shows comparable clinical outcomes between both techniques. The practice of each technique is largely center and surgeon dependent. Larger sample size cohorts with minimal confounding factors are required to confirm the above findings.

Results of Minimally Invasive Valve-Sparing Aortic Root Valve Surgery: Propensity Score Matching Analysis

Aim      Evaluation of efficacy and safety of minimally invasive, valve-sparing interventions on the aortic root and a comparative analysis of outcomes versus a group of patients with a complete sternotomy intervention using the method of propensity score matching (PSM).Materials and methods From 2016 through 2019, 458 interventions on the aortic root were performed, including 160 (36.6 %) interventions with mini-sternotomy. The study included 106 patients with the valve-sparing surgery (David procedure). Two groups of 30 patients each were formed using PSMC: group 1, complete sternotomy (CS) and group 2, J-shaped mini-sternotomy (MS). Immediate and long-term outcomes were evaluated at 13.8±10.3 (1-38 months (min-max) in the MS group and 42±21 (1-61 months (min-max) in the CS group.Results Statistically significant differences in death rate, echocardiographic indexes, absence of reoperations and complications in the postoperative period were not observed. In group 2, durations of extracorporeal circulation (p=0.04) and period of myocardial ischemia (p=0.004) were increased. The same group showed decreased intraoperative blood loss (p=0.001), postoperative drainage losses (p=0.0001), extubation time (р=0.0001), duration of stay in resuscitation and intensive care units and in the department of reconstructive recovery cardiovascular surgery (p=0,005).Conclusion      The David procedure with mini-sternotomy is a safe and effective alternative to the traditional approach. This technique significantly reduces the time of rehabilitation and duration of patients' stay in the hospital without significant differences in the long-term period, which suggests advantages of this method. However, despite these promising results, the retrospective nature of this study, a small sample of patients, and a short follow-up period warrant further study.

Pregnancy and cardiac interventions: What are the optimal management options?

Cardiac disease is the leading cause of maternal mortality in the United Kingdom. Major causes of cardiac death in pregnant women include cardiomyopathies, myocardial infarction, ischemic heart disease, and aortic dissection. Uncorrected congenital heart disease and women who have had corrective or palliative surgery may have complicated pregnancies as well. Some women with significant cardiac disease are unable to meet the increased physiological demands of pregnancy. Of these, those who do not respond to medical treatment may require surgical correction such as coronary artery bypass grafting. The risk of cardiac operations for pregnant women is similar to that for nonpregnant women but the fetal mortality rate remains high. Contributing factors to high fetal mortality rates include timing, urgency of operation, and the fetal/fetoplacental response to cardiopulmonary bypass. The aim of this review is to summarize current evidence in utilizing the different management approaches of cardiac issues during pregnancy.

Minimally invasive surgical versus transcatheter aortic valve replacement: A multicenter study

OBJECTIVES

Treatment of aortic valve stenosis is evolving, indications for transcatheter approach (TAVI) have increased but also surgical valve replacement has changed with the use of minimally invasive approaches. Comparisons between TAVI and surgery have rarely been done with minimally invasive techniques (mini-SAVR) in the surgical arm. Aim of the present study is to compare mini-SAVR and TAVI in a multicenter recent cohort.

METHODS

Evaluated were 2904 patients undergone mini-SAVR (2407) or TAVI (497) in 10 different centers in the period 2011-2016. The Heart Team approved treatment for complex cases. The primary outcome is the incidence of 30-day mortality following mini-SAVR and TAVI. Secondary outcomes are the occurrence of major complications following both procedures. Propensity matched comparisons was performed based on multivariable logistic regression model.

RESULTS

In the overall population TAVI patients had increased surgical risk (median EuroSCORE II 3.3% vs. 1.7%, p ≤ 0.001) and 30-day mortality was higher (1.5% and 2.8% in mini-SAVR and TAVI respectively, p = 0.048). Propensity score identified 386 patients per group with similar baseline profile (median EuroSCORE II ~3.0%). There was no difference in 30-day mortality (3.4% in mini-SAVR and 2.3% in TAVI; p = 0.396) and stroke, surgical patients had more blood transfusion, kidney dysfunction and required longer ICU and hospital length of stay while TAVI patients had more permanent pace maker insertion.

CONCLUSIONS

Mini-SAVR and TAVI are both safe and effective to treat aortic stenosis in elderly patients with comorbidities. A joint evaluation by the heart-team is essential to direct patients to the proper approach.