Minimally Invasive Versus Sternotomy For Mitral Valve Surgery In Elderly Patients After Previous Sternotomy: A Meta-analysis
Ali Hage1, Fadi Hage1, Hussein Al-Amodi1, Suruchi Gupta2, Stephania Papatheodorou2, Robert Hawkins3, Gorav Ailawadi3, Murray Mittleman2, Michael W.A. Chu1.
1Western University, London, ON, Canada, 2Harvard TH Chan School of Public Health, Boston, MA, USA, 3University of Virginia, Charlottesville, VA, USA.
BACKGROUND: Despite the evidence demonstrating similar outcomes of minimally-invasive, endoscopic mitral valve surgery (MIMVS) as compared to the conventional sternotomy (CS) approach, the safety of MIMVS in elderly patients with previous sternotomy is still unclear. We performed a systematic review and meta-analysis of observational studies comparing MIMVS with CS in elderly patients (≥65 years old) with previous sternotomy.
METHODS: We searched PubMed, EMBACE, Web of Science, clinicaltrials.gov, and Cochrane for trials and observational studies comparing the MIMVS technique with CS in patients ≥65 years old with previous sternotomy presenting for mitral valve surgery (repair or replacement). We performed a random-effects meta-analysis of all outcomes.
RESULTS: There were 7 retrospective observational cohort studies including 543 patients. The meta-analysis showed significantly lower mortality (odds ratio [OR] 0.37; 95% CI 0.18 to 0.76), acute renal failure (OR 0.27; 95% CI 0.12 to 0.62), wound infection (OR 0.13; 95% CI 0.02 to 0.79) and sepsis (OR 0.14; 95% CI 0.04 to 0.47) in favour of the minimally invasive, endoscopic approach. MIMVS also resulted in shorter hospital length of stay (LOS) (weighted mean difference [WMD]: -4.1 days; 95% CI -5.5 days to -2.7 days) and shorter intensive care unit LOS (WMD: -1.6 days; 95% CI -3.4 days to 0.3 days).
As compared to the re-sternotomy approach, MIMVS resulted in similar odds of reoperation for bleeding, stroke, blood transfusion, respiratory infection, atrial fibrillation, and long intubation. MIMVS was also associated with similar cross-clamp time and cardiopulmonary bypass times.
CONCLUSIONS: Current evidence suggests that MIMVS in elderly patients presenting for reoperation is associated with lower mortality, major morbidities and shorter hospital LOS. MIMVS is not associated with longer cross-clamp and bypass times in this population. 
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