Abstract Background Minimally invasive surgery has emerged as a relatively recent alternative to traditional procedures. The concept of minimizing the traumatic response and, consequently, the complications associated with metabolic stress has gained considerable traction in leading medical centers worldwide, necessitating that the evidence keeps pace with these advancements. Despite the challenge of limited access due to the smaller surgical space, the potential benefits, such as improved quality of life and earlier discharge, have drawn significant attention. However, the plausibility and effectiveness of certain key outcomes remain subjects for ongoing discussion. Purpose Given this context, the aim of this study was to compare mini-sternotomy with conventional sternotomy for aortic valve replacement and to assess its safety and efficacy through a range of outcomes. Methods We conducted a systematic search of PubMed, Embase, and Cochrane Central for studies comparing mini-sternotomy with conventional sternotomy for aortic valve replacement. Risk ratios (RR) with 95% confidence intervals (CIs) were pooled using a random-effects model to account for heterogeneity. Results We included eight randomized controlled trials, involving 1,296 patients, of whom 582 (44.9%) underwent minimally invasive surgery. At 30-day follow-up, mini-sternotomy was associated with a significantly lower chest drain volume compared to conventional sternotomy (MD -165.8; 95% CI -298.1 to -33.4; p = 0.01, Figure 1). The risk of stroke was numerically lower in the mini-sternotomy group, although this difference was not statistically significant (RR 0.64; 95% CI 0.31–1.31; p = 0.37; Figure 2). No significant differences were observed between groups for sternal wound infection (RR 1.05; 95% CI 0.48–2.57; p = 0.92; I² = 81%), all-cause mortality (RR 0.91; 95% CI 0.48–1.75; p = 0.975), bypass time (MD 7.8; 95% CI -2.8 to 19.5; p = 0.15), cross-clamp time (MD 3.2; 95% CI -4.1 to 10.4; p = 0.39), or major adverse cardiac events (RR 1.00; 95% CI 0.41–2.42; p = 0.99; I² = 0.0%). Conclusion Mini-sternotomy is a safe and effective procedure for aortic valve surgery. Notwithstanding some anatomical limitations, it demonstrates a significant and numerically superior advantage in chest drain volume compared to conventional sternotomy, along with a numerically lower incidence of stroke, although this difference is not statistically significant. However, the current analysis exhibits considerable heterogeneity, and the superiority of the minimally invasive technique may be influenced by factors such as the surgical team's experience and patient characteristics. Therefore, further studies are essential to enhance the robustness of these findings.Figure 1 - Forest Plot Chest Drain Figure 1 - Forest Plot Stroke
Sousa et al. (Sat,) studied this question.