Interact CardioVasc Thorac Surg 2009;9:314-317. doi:10.1510/icvts.2009.209445
© 2009 European Association of Cardio-Thoracic Surgery
Best evidence topic - Valves |
Is ministernotomy superior to conventional approach for aortic valve replacement?
Marco Scarci*,
Christopher Young and
Hazem Fallouh
Department of Cardiac Surgery, St Thomas Hospital, London, UK
Received 28 April 2009;
accepted 29 April 2009
*Corresponding author. Tel.: +44 75 15542899.
E-mail address: marco.scarci{at}mac.com (M. Scarci).
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Abstract
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A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: is ministernotomy superior to conventional approach for aortic valve replacement (AVR)? Altogether, more than 115 papers were found using the reported search, of which six represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that ministernotomy can be performed safely for AVR, without increased risk of death or other major complication; however, few objective advantages have been shown. Ministernotomy can be offered on the basis of patient choice and cosmesis rather than evident clinical benefit.
Key Words: Ministernotomy; Minimally invasive; Aortic valve replacement; Humans
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1. Introduction
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A best evidence topic was constructed according to a structured protocol. This is fully described in the ICVTS [1].
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2. Three-part question
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In [patients undergoing an aortic valve replacement] is [a ministernotomy] superior [to conventional approach].
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3. Clinical scenario
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You are at a national conference hearing about the benefits of a ministernotomy approach for aortic valve replacement (AVR). An eminent speaker from the floor then stands up and contends that there have been no definitively proven benefits over the median sternotomy. He continues saying that the implantation time is significantly higher with associated increased morbidity. You resolve to check the literature yourself.
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4. Search strategy
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Medline 1950 to May 2007 using OVID interface.
[aortic valve replacement OR exp aortic valve OR review OR ministernotomy OR minimally invasive AND aortic valve replacement OR AVR AND humans].
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5. Search outcome
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One hundred and fifteen papers were found using the reported search. From these, six papers were identified, that provided the best evidence to answer the question. These are presented in Table 1.
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6. Results
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Brown et al. [2] in 2009 performed a meta-analysis of 26 trials for a total of 4586 patients who underwent isolated AVR. They divided them into two groups: 2054 ministernotomy and 2532 full sternotomy. They found that there was no difference in mortality but the ministernotomy group had a longer cross-clamp and bypass time. In addition, they showed that ITU and hospital stay, ventilation time and blood loss were less in the ministernotomy group. Nevertheless few objective advantages have been demonstrated.
Murtuza et al. [3] in 2008 performed a meta-analysis of the published trials including 4667 patients. They showed marginal benefits in perioperative mortality (4667 patients; odds ratio, 0.72; 95% confidence interval (CI), 0.51–1.00; P=0.05), intensive care unit (ICU) stay, total hospital stay, and ventilation time in the minimal access AVR group, although cross-clamp, cardiopulmonary bypass, and total operation times were longer. Study heterogeneity and apparent benefits in perioperative mortality were related to study quality, although results for ICU and hospital stay were maintained according to the sensitivity analysis. This suggests that minimal access AVR can be offered on the basis of patient choice and cosmesis rather than evident clinical benefit.
Bakir et al. [4] in 2007 conducted a retrospective analysis including 506 patients split into two groups: 232 ministernotomy and 274 median sternotomy. The minimal access group had reduced aortic cross-clamp and cardiopulmonary bypass times compared with conventional group: 61.8±16.6 vs. 69.5±16.6 min (P<0.05) and 88.8±23.2 vs. 100.2±22.6 min (P<0.05), respectively. Mean blood loss was lower in the ministernotomy group compared with median sternotomy (P<0.05). ICU and hospital stays were shorter in the minimal access group: 2.1±2.5 vs. 2.5±5.3 days (P=non-significant) and 10.8±7.1 vs. 12.8±10.6 days (P<0.05), respectively. This is the only article found in the medical literature, which shows a shorter cross-clamp time and bypass time compared to the conventional approach.
Sharony et al. [5] in 2004 retrospectively reviewed 921 patients who underwent isolated AVR, 438 of those had ministernotomy access. Hospital mortality and major morbidity were similar in both groups: 5.6% vs. 7.3% (P=0.45) and 13.3% vs. 14.2% (P=0.79), respectively. Multivariable analysis of all patients revealed increased mortality with severe atheromatous aortic disease (P=0.001), COPD (P=0.002), and urgent operation (P=0.02). Freedom from any major peri-operative morbidity was similar in both groups (86.7% vs. 85.8%; P=0.79). However, the median length of stay was shorter with ministernotomy group (6 vs. 8 days; P<0.001). During the past 3 years, a greater percentage of minimally invasive patients than full sternotomy patients was discharged home rather than sent to rehabilitation facilities or nursing homes (65.7% vs. 52.9%; P=0.05).
Mihaljevic et al. [6] in 2004 reviewed retrospectively 526 patients. They showed that operative mortality was 12/526 (2%) in the AV. Freedom from re-operation at 6 years was 99% and late mortality was 5%.
Masiello et al. [7] in 2002 analyzed retrospectively 200 patients of whom 100 received ministernotomy approach. Operating times were significantly longer in the ministernotomy group (P<0.001). Mechanical ventilation time, ICU and total hospital stay, and total postoperative bleeding showed no significant difference. Adjunctive statistical evidenced the absence of learning curve. Mortality and other complications failed to reveal any significant difference between the two groups. In their experience, partial upper median sternotomy does not increase surgical risks but failed to demonstrate clear advantages. Apart from an increase in operating times, the surgical results are similar to those of a conventional median sternotomy with only improvement in the aesthetical aspect. In our opinion, this supports the conviction that this approach can be proposed to selected patients, to obtain a better cosmetic result for the same given risk.
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7. Clinical bottom line
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We conclude that ministernotomy can be performed safely for AVR, without increased risk of death or other major complication; however, few objective advantages have been shown. Ministernotomy can be offered on the basis of patient choice and cosmesis rather than evident clinical benefit.
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References
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- Dunning J, Prendergast B, Mackway-Jones K. Towards evidence-based medicine in cardiothoracic surgery: best BETS. Interact CardioVasc Thorac Surg 2003;2:405–409.[Abstract/Free Full Text]
- Brown ML, McKellar SH, Sundt TM, Schaff HV. Ministernotomy versus conventional sternotomy for aortic valve replacement: a systematic review and meta-analysis. J Thorac Cardiovasc Surg 2009;137:670–679; e5.[Abstract/Free Full Text]
- Murtuza B, Pepper JR, Stanbridge RD, Jones C, Rao C, Darzi A, Athanasiou T. Minimal access aortic valve replacement: is it worth it? Ann Thorac Surg 2008;85:1121–1131.[Abstract/Free Full Text]
- Bakir I, Casselman FP, Wellens F, Jeanmart H, De Geest R, Degrieck I, Van Praet F, Vermeulen Y, Vanermen H. Minimally invasive versus standard approach aortic valve replacement: a study in 506 patients. Ann Thorac Surg 2006;81:1599–1604.[Abstract/Free Full Text]
- Sharony R, Grossi EA, Saunders PC, Schwartz CF, Ribakove GH, Baumann FG, Galloway AC, Colvin SB. Propensity score analysis of a six-year experience with minimally invasive isolated aortic valve replacement. J Heart Valve Dis 2004;13:887–893.[Medline]
- Mihaljevic T, Cohn LH, Unic D, Aranki SF, Couper GS, Byrne JG. One thousand minimally invasive valve operations: early and late results. Ann Surg 2004;240:529–534; discussion 534.[Medline]
- Masiello P, Coscioni E, Panza A, Triumbari F, Preziosi G, Di Benedetto G. Surgical results of aortic valve replacement via partial upper sternotomy: comparison with median sternotomy. Cardiovasc Surg 2002;10:333–338.[CrossRef][Medline]
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Abstract
1. Introduction