Minimally Invasive versus Complete Sternotomy for Reimplantation Valve-Sparing Aortic Root Replacement: A Systematic Review and Meta-Analysis.

Abstract

Despite growing interest, comparative data on the minimally invasive David procedure (MI-DP) versus the traditional complete sternotomy approach (CS-DP) remain scarce, largely due to the inherent complexity of the operation. The present meta-analysis compared the perioperative outcomes of MI-DP and CS-DP. We systematically searched MEDLINE, Scopus, and the Cochrane Library for studies comparing MI-DP and CS-DP. Pooled odds ratios and mean differences (MDs) with 95% confidence intervals (CIs) were calculated using RevMan ver. 8.13.0 (The Cochrane Collaboration). A subgroup analysis of exclusively propensity-matched data was also performed. Seven studies comprising 1,124 patients were included, with 394 (35%) in the MI-DP group. MI-DP was associated with reduced blood loss (MD, -123.1 mL; 95% CI, -150.1 to -96.1 mL; p<0.0001), intensive care unit (ICU) stay (MD, -0.5 days; 95% CI, -0.6 to -0.4 days; p<0.00001), and hospital stay (MD, -2.8 days; 95% CI, -4.9 to -0.7 days; p=0.01), albeit with a longer cross-clamp time (MD, 13.3 minutes; 95% CI, 2.8 to 23.9 minutes; p=0.01). Thirty-day mortality and complications, including neurological deficits and reoperation for bleeding, were similar between groups. The subgroup analysis restricted to propensity-matched data confirmed these benefits and revealed additional reductions in mechanical ventilation time (MD, -6.3 hours; 95% CI, -7.2 to -5.4 hours; p<0.00001) and red blood cell transfusion requirements (MD, -85.6 mL; 95% CI, -114.6 to -56.5 mL; p<0.00001). MI-DP offers reduced ventilation time, blood loss, and ICU and hospital stays without compromising safety. However, our findings should be interpreted cautiously pending validation by future prospective studies (PROSPERO CRD42025631006).