1. Benefits of minimally invasive aortic valve replacement (MIS-AVR)
Evidence from meta-analyses and key studies

2. MIS-AVR is as safe as conventional AVR
Early mortality rates: comparable with conventional AVR (cAVR)
*Odds ratio 0.70 (95% CI 0.46–1.06), p=0.09
†Relative risk 0.74 (95% CI 0.52–1.06), p=0.10
‡Relative risk 0.74 (95% CI 0.56–0.96), p=0.02
Phan K et al. Ann Thorac Surg. 2014; 98: 1499–511
Lim JY et al. J Card Surg. 2015; 30: 125–34
Phan K et al. Ann Cardiothorac Surg. 2015; 4: 3–14

3. MIS-AVR is as safe as conventional AVR
Complication rates: comparable with cAVR1
Complication
% of MIS-AVR
% of cAVR
Neurological event
2.2
Atrial fibrillation
23.5
24.7
Pneumonia
3.6
2.9
Sternal infection
0.9
1.5
Pacemaker implant
3.3
4.0
Myocardial infarction
0.4
0.7
Phan K et al. Ann Thorac Surg. 2014; 98: 1499–511

4. MIS-AVR is as safe as conventional AVR
Complication rates: comparable with cAVR1
Complication
Risk ratio (RR)/odds ratio (OR) (95% confidence interval, p)
Phan et al.1
Phan et al.2
Lim et al.3
Brown et al.4
Stroke/neurological event
RR (0.73–1.34, 0.93)
RR (0.55–1.21, 0.20)
OR (0.55–1.56, 0.79)
OR (0.60–1.39)
Atrial fibrillation
RR (0.80–1.03, 0.13) –
OR (0.74–1.57, 0.67)
OR 0.87
(0.64–1.20, 0.41)
Pneumonia
RR (0.68–2.23; 0.49)
Wound/sternal complication
RR (0.47–1.08, 0.11)
RR (0.41–1.27, 0.26)
OR (0.28–1.14, 0.11)
OR (0.49–1.49)
Pacemaker implant
RR 0.82
(0.57–1.16, 0.26)
Myocardial infarction
RR (0.35–1.74, 0.54)
RR: risk ratio; RR<1: complication more likely in the cAVR group; RR>1: complication more likely in the MIS-AVR group; RR=1: surgery type does not affect the risk of the complication
OR: odds ratio; OR<1: cAVR associated with higher odds of complication than MIS-AVR; OR>1: MIS-AVR associated with higher odds of complication than cAVR; OR=1: surgery type does not affect the odds of complication
Phan K et al. Ann Thorac Surg. 2014; 98: 1499–511
Lim JY et al. J Card Surg. 2015; 30: 125–34
Phan K et al. Ann Cardiothorac Surg. 2015; 4: 3–14
Brown ML et al. J Thorac Cardiovasc Surg. 2009; 137: 670–9 e5

5. MIS-AVR is as safe as conventional AVR
Blood loss: tends to be less than cAVR (e.g mL [95% CI to 16.17, p=0.08]1)
Blood transfusion: comparable with cAVR (e.g. 43% MIS-AVR vs 54% cAVR2)
Lim JY et al. J Card Surg. 2015; 30: 125–34
Khoshbin E et al. BMJ Open. 2011; 1: e000266

6. Potential benefit in long-term survival
Survival: significantly higher than cAVR in a single centre retrospective study:1
Survival, %
At 5 years
At 8 years
MIS-AVR
89.3 ± 2.4
77.7 ± 4.7
cAVR
81.8 ± 2.2
72.8 ± 2.2
Merk DR et al. Eur J Cardiothorac Surg. 2015; 47: 11–17

7. Operative times for MIS-AVR
Cross-clamp and cardiopulmonary bypass (CPB) times: generally slightly longer than cAVR:
But only minithoracotomy, not ministernotomy, is associated with significantly longer cross-clamp (+7.64 minutes) and cardiopulmonary bypass (CPB) times (+9.99 minutes) than full sternotomy2
RCT, randomised controlled trial
Phan K, Xie A, Di Eusanio M et al. A meta-analysis of minimally invasive versus conventional sternotomy for aortic valve replacement. Ann Thorac Surg. 2014; 98: 1499–511
Phan K, Xie A, Tsai YC et al. Ministernotomy or minithoracotomy for minimally invasive aortic valve replacement: a Bayesian network meta-analysis. Ann Cardiothorac Surg. 2015; 4: 3–14
Lim JY, Deo SV, Altarabsheh SE et al. Conventional versus minimally invasive aortic valve replacement: pooled analysis of propensity-matched data. J Card Surg. 2015; 30: 125–34
Brown ML, McKellar SH, Sundt TM et al. Ministernotomy versus conventional sternotomy for aortic valve replacement: a systematic review and meta-analysis. J Thorac Cardiovasc Surg. 2009; 137: 670–9 e5
5. Borger MA, Dohmen PM, Knosalla C et al. Haemodynamic benefits of rapid deployment aortic valve replacement via a minimally invasive approach: 1-year results of a prospective multicentre randomized controlled trial. Eur J Cardiothorac Surg. 2016: 50: 713–20
Phan K et al. Ann Thorac Surg. 2014; 98: 1499–511
Lim JY et al. J Card Surg. 2015; 30: 125–34
Phan K et al. Ann Cardiothorac Surg. 2015; 4: 3–14
Brown ML et al. J Thorac Cardiovasc Surg. 2009; 137: 670–9 e5

8. Potential of rapid deployment valves
Rapid deployment (RD) valves may help to speed up MIS-AVR:
MIS-AVR with RD valve vs cAVR with stented valve1
RCT, randomised controlled trial
Phan K, Xie A, Di Eusanio M et al. A meta-analysis of minimally invasive versus conventional sternotomy for aortic valve replacement. Ann Thorac Surg. 2014; 98: 1499–511
Phan K, Xie A, Tsai YC et al. Ministernotomy or minithoracotomy for minimally invasive aortic valve replacement: a Bayesian network meta-analysis. Ann Cardiothorac Surg. 2015; 4: 3–14
Lim JY, Deo SV, Altarabsheh SE et al. Conventional versus minimally invasive aortic valve replacement: pooled analysis of propensity-matched data. J Card Surg. 2015; 30: 125–34
Brown ML, McKellar SH, Sundt TM et al. Ministernotomy versus conventional sternotomy for aortic valve replacement: a systematic review and meta-analysis. J Thorac Cardiovasc Surg. 2009; 137: 670–9 e5
5. Borger MA, Dohmen PM, Knosalla C et al. Haemodynamic benefits of rapid deployment aortic valve replacement via a minimally invasive approach: 1-year results of a prospective multicentre randomized controlled trial. Eur J Cardiothorac Surg. 2016: 50: 713–20
Borger MA et al. Eur J Cardiothorac Surg. 2016; 50: 713–20

9. MIS-AVR leads to faster recovery
Intensive care unit stay: ~0.5 days less than cAVR
Overall hospital stay: ~1–2 days less than cAVR
*95% CI to (ICU stay); 95% CI to days (hospital stay); †95% CI to -0.2, p=0.003 (ICU stay); 95% CI to 0.05, p=0.06 (hospital stay); ‡95% CI to 0.09, p=0.14 (ICU stay); 95% CI to -0.46, p= (hospital stay); §95% CI to -0.25, p< (ICU stay); 95% CI to -0.95, p< (hospital stay)
CI: confidence interval; ICU: intensive care unit
Phan K et al. Ann Thorac Surg. 2014; 98: 1499–511
Khoshbin E et al. BMJ Open. 2011; 1: e000266
Lim JY et al. J Card Surg. 2015; 30: 125–34
Brown ML et al. J Thorac Cardiovasc Surg. 2009; 137: 670–9 e5

10. Key learnings MIS-AVR can be carried out safely1–4
Minimally invasive surgery improves long-term survival5
Minimally invasive surgery reduces pain1,3,4
Minimally invasive surgery reduces the time spent in the intensive care unit1,4,6 and hospital overall1,3,4,6
MIS-AVR with a rapid deployment valve requires a significantly shorter cross-clamp time than cAVR7
Adequately powered, prospective randomised trials are needed to fully assess the benefits/risks of MIS-AVR1,2,4
Phan K et al. Ann Thorac Surg. 2014; 98: 1499–511
Merk DR et al. Eur J Cardiothorac Surg. 2015; 47: 11–17
Phan K et al. Ann Cardiothorac Surg. 2015; 4: 3–14
Khoshbin E et al. BMJ Open. 2011; 1: e000266
Lim JY et al. J Card Surg. 2015; 30: 125–34
Borger MA et al. Eur J Cardiothorac Surg. 2016; 50: 713–20
Brown ML et al. J Thorac Cardiovasc Surg. 2009; 137: 670–9 e5