Minimally Invasive versus Conventional Surgery of the Ascending Aorta and Root: A Systematic Review and Meta-Analysis

Tom A. Rayner, Sean Harrison, Paul M Rival, Dominic E. Mahoney, Massimo Caputo, Gianni Angelini, Jelena Savović, Hunaid Vohra

Research output: Contribution to journalArticle (Academic Journal)peer-review

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Limited uptake of minimally invasive surgery (MIS) of the aorta hinders assessment of its efficacy compared to median sternotomy (MS). The objective of this systematic review is to compare operative and perioperative outcomes for MIS vs MS. Online databases Medline, EMBASE, Cochrane Library, and Web of Science were searched from inception until July 2018. Both randomized and observational studies of patients undergoing aortic root, ascending aorta, or aortic arch surgery by MIS vs MS were eligible for inclusion. Primary outcomes were 30-day mortality, reoperation for bleeding, perioperative renal impairment and neurological events. Intraoperative and postoperative timing measures were also evaluated. Thirteen observational studies were included comparing 1,101 MIS and 1,405 MS patients. The overall quality of evidence was very low for all outcomes. Mortality and the incidence of stroke was similar between the two cohorts. Meta-analysis demonstrated increased length of cardiopulmonary bypass (CPB) time for patients undergoing MS (standardized mean difference (SMD) 0.36, 95% confidence interval (CI) 0.15-0.58, p=0.001). Patients receiving MS spent more time in hospital (SMD 0.30, 95% CI 0.17-0.43, p<0.001), and intensive care (SMD 0.17, 95% CI 0.06-0.27, p<0.001). Reoperation for bleeding (risk ratio (RR) 1.51, 95% CI 1.06-2.17, p=0.024) and renal impairment (RR 1.97, 95% CI 1.12-3.46, p=0.019) were also greater for MS patients. There was substantial heterogeneity in meta-analyses for CPB and aortic cross-clamp timing outcomes. MIS may be associated with improved early clinical outcomes compared to MS, but the quality of the evidence is very low. Randomized evidence is needed to confirm these findings.
Original languageEnglish
Article numberezz177
Number of pages10
JournalEuropean Journal of Cardio-Thoracic Surgery
Publication statusPublished - 17 Jun 2019

Structured keywords

  • Centre for Surgical Research


  • Minimally invasive
  • Aortic surgery
  • Meta-analysis


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