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Minithoracotomy versus sternotomy in mitral valve surgery: meta-analysis from recent matched and randomized studies

BACKGROUND: There is still ongoing debate about the benefits of mini-thoracotomy (MTH) approach in mitral valve surgery in comparison with complete sternotomy (STER). This study aims to update the current evidence with mortality as primary end point. METHODS: The MEDLINE and EMBASE databases were se...

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Autores principales: Al Shamry, Adel, Jegaden, Margaux, Ashafy, Salah, Eker, Armand, Jegaden, Olivier
Formato: Online Artículo Texto
Lenguaje:English
Publicado: BioMed Central 2023
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10080824/
https://www.ncbi.nlm.nih.gov/pubmed/37024952
http://dx.doi.org/10.1186/s13019-023-02229-x
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author Al Shamry, Adel
Jegaden, Margaux
Ashafy, Salah
Eker, Armand
Jegaden, Olivier
author_facet Al Shamry, Adel
Jegaden, Margaux
Ashafy, Salah
Eker, Armand
Jegaden, Olivier
author_sort Al Shamry, Adel
collection PubMed
description BACKGROUND: There is still ongoing debate about the benefits of mini-thoracotomy (MTH) approach in mitral valve surgery in comparison with complete sternotomy (STER). This study aims to update the current evidence with mortality as primary end point. METHODS: The MEDLINE and EMBASE databases were searched through June 2022. Two randomized studies and 16 propensity score matched studies published from 2011 to 2022 were included with a total of 12,997 patients operated on from 2005 (MTH: 6467, STER: 6530). Data regarding early mortality, stroke, reoperation for bleeding, new renal failure, new onset of atrial fibrillation, need of blood transfusion, prolonged ventilation, wound infection, time-related outcomes (cross clamp time, cardiopulmonary bypass time, ventilation time, length of intensive care unit stay, length of hospital stay), midterm mortality and reoperation, and costs were extracted and submitted to a meta-analysis using weighted random effects modeling. RESULTS: The incidence of early mortality, stroke, reoperation for bleeding and prolonged ventilation were similar, all in the absence of heterogeneity. However, the sub-group analysis showed a significant OR in favor of MTH when robotic enhancement was used. New renal failure (OR 1.67, 95% CI 1.06–2.62, p = 0.03), new onset of atrial fibrillation (OR 1.31, 95% CI 1.15–1.51, p = 0.001) and the need of blood transfusion (OR 1.77, 95% CI 1.39–2.27, p = 0.001) were significantly lower in MTH group. Regarding time-related outcomes, there was evidence for important heterogeneity of treatment effect among the studies. Operative times were longer in MTH: differences in means were 20.7 min for cross clamp time (95% CI 14.9–26.4, p = 0.001), 36.8 min for CPB time (95% CI 29.8–43.9, p = 0.001) and 37.7 min for total operative time (95% CI 19.6–55.8, p < 0.001). There was no significant difference in ventilation duration; however, the differences in means showed significantly shorter ICU stay and hospital stay after MTH compared to STER: − 0.6 days (95% CI − 1.1/− 0.21, p = 0.001) and − 1.88 days (95% CI − 2.72/− 1.05, p = 0.001) respectively, leading to a significant lower hospital cost after MTH compared to STER with difference in means − 4528 US$ (95% CI − 8725/− 326, p = 0.03). The mid-term mortality was significantly higher after STER compared to MTH: OR = 1.50, 1.09–2.308 (95% CI), p = 0.01; the rate of mid-term reoperation was reported similar in MTH and STER: OR = 0.76, 0.50–1.15 (95% CI), p = 0.19. CONCLUSIONS: The present meta-analysis confirms that the MTH approach for mitral valve disease remains associated with prolonged operative times, but it is beneficial in terms of reduced postoperative complications (renal failure, atrial fibrillation, blood transfusion, wound infection), length of stay in ICU and in hospitalization, with finally a reduction in global cost. MTH approach appears associated with a significant reduction of postoperative mortality that must be confirmed by large randomized study. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s13019-023-02229-x.
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spelling pubmed-100808242023-04-08 Minithoracotomy versus sternotomy in mitral valve surgery: meta-analysis from recent matched and randomized studies Al Shamry, Adel Jegaden, Margaux Ashafy, Salah Eker, Armand Jegaden, Olivier J Cardiothorac Surg Review BACKGROUND: There is still ongoing debate about the benefits of mini-thoracotomy (MTH) approach in mitral valve surgery in comparison with complete sternotomy (STER). This study aims to update the current evidence with mortality as primary end point. METHODS: The MEDLINE and EMBASE databases were searched through June 2022. Two randomized studies and 16 propensity score matched studies published from 2011 to 2022 were included with a total of 12,997 patients operated on from 2005 (MTH: 6467, STER: 6530). Data regarding early mortality, stroke, reoperation for bleeding, new renal failure, new onset of atrial fibrillation, need of blood transfusion, prolonged ventilation, wound infection, time-related outcomes (cross clamp time, cardiopulmonary bypass time, ventilation time, length of intensive care unit stay, length of hospital stay), midterm mortality and reoperation, and costs were extracted and submitted to a meta-analysis using weighted random effects modeling. RESULTS: The incidence of early mortality, stroke, reoperation for bleeding and prolonged ventilation were similar, all in the absence of heterogeneity. However, the sub-group analysis showed a significant OR in favor of MTH when robotic enhancement was used. New renal failure (OR 1.67, 95% CI 1.06–2.62, p = 0.03), new onset of atrial fibrillation (OR 1.31, 95% CI 1.15–1.51, p = 0.001) and the need of blood transfusion (OR 1.77, 95% CI 1.39–2.27, p = 0.001) were significantly lower in MTH group. Regarding time-related outcomes, there was evidence for important heterogeneity of treatment effect among the studies. Operative times were longer in MTH: differences in means were 20.7 min for cross clamp time (95% CI 14.9–26.4, p = 0.001), 36.8 min for CPB time (95% CI 29.8–43.9, p = 0.001) and 37.7 min for total operative time (95% CI 19.6–55.8, p < 0.001). There was no significant difference in ventilation duration; however, the differences in means showed significantly shorter ICU stay and hospital stay after MTH compared to STER: − 0.6 days (95% CI − 1.1/− 0.21, p = 0.001) and − 1.88 days (95% CI − 2.72/− 1.05, p = 0.001) respectively, leading to a significant lower hospital cost after MTH compared to STER with difference in means − 4528 US$ (95% CI − 8725/− 326, p = 0.03). The mid-term mortality was significantly higher after STER compared to MTH: OR = 1.50, 1.09–2.308 (95% CI), p = 0.01; the rate of mid-term reoperation was reported similar in MTH and STER: OR = 0.76, 0.50–1.15 (95% CI), p = 0.19. CONCLUSIONS: The present meta-analysis confirms that the MTH approach for mitral valve disease remains associated with prolonged operative times, but it is beneficial in terms of reduced postoperative complications (renal failure, atrial fibrillation, blood transfusion, wound infection), length of stay in ICU and in hospitalization, with finally a reduction in global cost. MTH approach appears associated with a significant reduction of postoperative mortality that must be confirmed by large randomized study. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s13019-023-02229-x. BioMed Central 2023-04-06 /pmc/articles/PMC10080824/ /pubmed/37024952 http://dx.doi.org/10.1186/s13019-023-02229-x Text en © The Author(s) 2023 https://creativecommons.org/licenses/by/4.0/Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ (https://creativecommons.org/licenses/by/4.0/) . The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/ (https://creativecommons.org/publicdomain/zero/1.0/) ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.
spellingShingle Review
Al Shamry, Adel
Jegaden, Margaux
Ashafy, Salah
Eker, Armand
Jegaden, Olivier
Minithoracotomy versus sternotomy in mitral valve surgery: meta-analysis from recent matched and randomized studies
title Minithoracotomy versus sternotomy in mitral valve surgery: meta-analysis from recent matched and randomized studies
title_full Minithoracotomy versus sternotomy in mitral valve surgery: meta-analysis from recent matched and randomized studies
title_fullStr Minithoracotomy versus sternotomy in mitral valve surgery: meta-analysis from recent matched and randomized studies
title_full_unstemmed Minithoracotomy versus sternotomy in mitral valve surgery: meta-analysis from recent matched and randomized studies
title_short Minithoracotomy versus sternotomy in mitral valve surgery: meta-analysis from recent matched and randomized studies
title_sort minithoracotomy versus sternotomy in mitral valve surgery: meta-analysis from recent matched and randomized studies
topic Review
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10080824/
https://www.ncbi.nlm.nih.gov/pubmed/37024952
http://dx.doi.org/10.1186/s13019-023-02229-x
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