Comparative study of different minimally invasive aortic valve replacement techniques: A systematic review and network meta-analysis.

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 Newcastle-Ottawa Scale. A frequentist network meta-analysis with a random-effects model was employed to give reflective ranks and compare outcomes across techniques. Treatment ranking was based on p-scores, with mini-sternotomy 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; -5.38)], reduced hospital stay [MD: -2.07 (95% CI: -3.77; -0.37)], and fewer complications, including neurological events [Odds ratio (OR): 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; -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 are warranted.