Limited versus full sternotomy for aortic valve replacement

• Published in: Cochrane database of systematic reviews 2017-04, Vol.4 (4), p.CD011793-CD011793
• Main Authors: Kirmani, Bilal H, Jones, Sion G, Malaisrie, S C, Chung, Darryl A, Williams, Richard Jnn
• Format: Article
• Language: English
• Subjects: Aged; Aortic Valve - surgery; Atrial Fibrillation - etiology; Blood Loss, Surgical - statistics & numerical data; Cardiopulmonary Bypass - statistics & numerical data; Heart & circulation; Heart Valve Diseases - surgery; Heart Valve Prosthesis Implantation - adverse effects; Heart Valve Prosthesis Implantation - methods; Heart Valve Prosthesis Implantation - mortality; Humans; Length of Stay; Middle Aged; N. Heart Valve Disease; Operative Time; Pain Measurement; Postoperative Complications - epidemiology; Randomized Controlled Trials as Topic; Reoperation - statistics & numerical data; Sternotomy - adverse effects; Sternotomy - methods; Sternotomy - mortality; Surgical Wound Infection - epidemiology
• ISSN: 1469-493X
• DOI: 10.1002/14651858.CD011793.pub2

Aortic valve disease is a common condition that is easily treatable with cardiac surgery. This is conventionally performed by opening the sternum longitudinally down the centre ("median sternotomy") and replacing the valve under cardiopulmonary bypass. Median sternotomy is generally well tolerated, but as less invasive options have become available, the efficacy of limited incisions has been called into question. In particular, the effects of reducing the visibility and surgical access has raised safety concerns with regards to the placement of cannulae, venting of the heart, epicardial wire placement, and de-airing of the heart at the end of the procedure. These difficulties may increase operating times, affecting outcome. The benefits of smaller incisions are thought to include decreased pain; improved respiratory mechanics; reductions in wound infections, bleeding, and need for transfusion; shorter intensive care stay; better cosmesis; and a quicker return to normal activity. To assess the effects of minimally invasive aortic valve replacement via a limited sternotomy versus conventional aortic valve replacement via median sternotomy in people with aortic valve disease requiring surgical replacement. We performed searches of CENTRAL, MEDLINE, Embase, clinical trials registries, and manufacturers' websites from inception to July 2016, with no language limitations. We reviewed references of identified papers to identify any further studies of relevance. Randomised controlled trials comparing aortic valve replacement via a median sternotomy versus aortic valve replacement via a limited sternotomy. We excluded trials that performed other minimally invasive incisions such as mini-thoracotomies, port access, trans-apical, trans-femoral or robotic procedures. Although some well-conducted prospective and retrospective case-control and cohort studies exist, these were not included in this review. Two review authors independently assessed trial papers to extract data, assess quality, and identify risk of bias. A third review author provided arbitration where required. The quality of evidence was determined using the GRADE methodology and results of patient-relevant outcomes were summarised in a 'Summary of findings' table. The review included seven trials with 511 participants. These included adults from centres in Austria, Spain, Italy, Germany, France, and Egypt. We performed 12 comparisons investigating the effects of minimally invasive limited upper hemi-ster