Surgical Ablation by a Right Mini-thoracotomy Versus a Median Sternotomy: A Systematic Review and Meta-analysis of Observational Studies.

Objectives: A minimally invasive approach by a right mini-thoracotomy has been developed for surgical ablation of atrial fibrillation. However, the efficacy and safety compared to a median sternotomy remains unclear.

Methods: We searched PubMed, Embase, and the Cochrane Library for eligible studies. Meta-analysis was performed for primary (recurrence of atrial tachyarrhythmias at 1 and 2 years) and secondary (hospital and ICU stay, adverse events, 30-day mortality, cardiopulmonary bypass, and aortic cross-clamp time) end-points. We compared end-points using risk ratio (RR) for binary outcomes and mean difference (MD) for continuous ones. We calculated 95% confidence intervals (CI) and used the random-effects model for all outcomes. We performed subgroup analysis for the main outcome based on lesion set, energy source, type of surgery, and propensity score matching.

Results: We included 12 observational studies (n = 3122). No difference was found for the primary outcome at 1 (RR 0.8; [95% CI]: 0.62-1.03; P = 0.08) and 2 years (RR 0.9; [95% CI]: 0.74-1.13; P = 0.4). The thoracotomy group had lower complications (RR 0.72; [95% CI]: 0.55-0.97; P = 0.016), 30-day mortality (OR 0.26; [95% CI]: 0.10-0.70; P = 0.007), hospital stay (MD -5.35; [95% CI]: -7.94 to 2.77; P < 0.001), and ICU stay (MD -2.21; [95% CI]: -3.02 to 1.40; P < 0.001). Cardiopulmonary bypass and aortic clamping time were significantly higher in the thoracotomy group.

Conclusions: This meta-analysis found that surgical ablation by a mini-thoracotomy might achieve similar rhythm control to a median sternotomy while possibly improving safety and promoting faster recovery. However, conclusions are limited by the observational nature of the evidence and randomized trials are warranted.