Journal Article

Comparative Study of Different Minimally Invasive Aortic Valve Replacement Techniques: A Systematic Review and Network Meta-Analysis

Bidar, Elham, Nugroho, Aqilla Katrita Zaira, Vidya, Ananda Pipphali, Husen, Theresia Feline, Sardari Nia, Peyman, Prasetyo, Alfian, Maesen, Bart, Heuts, Samuel, Lorusso, Roberto

2025

Overview

Abstract Objectives This investigation aimed to compare different minimally invasive techniques, namely, mini-sternotomy (MS), mini-thoracotomy (MT), and totally thoracoscopic (TT) approaches for the surgical treatment of aortic valve disease, emphasizing their respective benefits and limitations to guide clinical decision-making. Methods A systematic search was conducted in Medline, Web of Science, Scopus, Wiley Online Library, Google Scholar, and ProQuest. Studies were appraised using the Newcastle-Ottawa Scale. A frequentist network meta-analysis (NMA) with a random-effects model was employed to give reflective ranks and compare outcomes across techniques. Treatment ranking was based on p-scores, with MS as the reference. Higher p-scores indicate greater certainty of superiority over competing interventions. The primary outcome was mortality. Results Twenty-five observational studies (n = 34 573 patients) were included. Mortality did not differ between techniques (p-score: MS [0.85] ∼ MT [0.34] ∼ TT [0.31]). TT had longer cardiopulmonary bypass (mean difference [MD]: 41.04 [95% CI, 10.98-71.10]) and cross-clamp times (MD: 30.31 [95% CI, 5.81-54.80]) but offered the shortest intensive care unit (ICU) length of stay (p-score: TT [0.98] > MT [0.51] > MS [0.01]; MD: −16.00 [95% CI, −26.62 to −5.38]), reduced hospital stay (MD: −2.07 [95% CI, −3.77 to −0.37]), and fewer complications, including neurological events (odds ratio: 1.79 [95% CI, 1.03-3.13]), blood loss (MD: 208.85 mL [95% CI, 102.29-315.40]) compared to MS. MT showed similar outcomes to MS, except for longer operative times (MD: 29.84 [95% CI, 8.35-51.32]) and shorter ICU stays (MD: −5.88 [95% CI, −11.10 to −0.67]). Conclusions TT may offer advantages such as shorter hospital stays, reduced neurological complications, and less bleeding as compared to MS, although it is associated with longer operative times. However, as all included studies were observational, the findings should be interpreted with caution, and further NMA including only randomized trials is warranted. Aortic valve replacement (AVR) is the mainstay of the surgical treatment of aortic valve disease. Graphical abstract

• Publisher: Oxford University Press,Oxford Publishing Limited (England)
• Subject: Aortic Valve - diagnostic imaging / Aortic Valve - physiopathology / Aortic Valve - surgery / Aortic Valve Disease - diagnostic imaging / Aortic Valve Disease - mortality / Aortic Valve Disease - physiopathology / Aortic Valve Disease - surgery / Heart Valve Prosthesis Implantation - adverse effects / Heart Valve Prosthesis Implantation - methods / Heart Valve Prosthesis Implantation - mortality / Humans / Length of Stay / Minimally Invasive Surgical Procedures / Mortality / Ostomy / Postoperative Complications - etiology / Postoperative Complications - mortality / Risk Factors / Sternotomy - adverse effects / Sternotomy - mortality / Thoracoscopy - adverse effects / Thoracoscopy - mortality / Thoracotomy - adverse effects / Thoracotomy - mortality / Treatment Outcome