Restricted accessReview articleFirst published online 2026
Minimally invasive versus conventional techniques for proximal aortic surgery: A systematic review and meta-analysis of reconstructed patient-level data
Minimally invasive techniques represent a safe alternative to full sternotomy in proximal aortic surgery. This meta-analysis evaluates their efficacy in aortic root, ascending aortic, and aortic arch procedures compared with the conventional approach.
Methods
A PRISMA-compliant systematic review and meta-analysis of matched cohorts was conducted, comparing minimally invasive surgery with full sternotomy. MEDLINE was searched for eligible studies. Continuous variables were analyzed using standardized mean differences and categorical data with odds ratios. Kaplan–Meier-derived individual patient data were used to assess survival. Subgroup analysis for elective cases was performed.
Results
Seventeen studies with 3113 matched patients were included. Mean age was 58.1 ± 13.3 years for minimally invasive group versus 58.1 ± 12.8 years in full-sternotomy group (p = 0.29). Postoperative blood loss (612.5 versus 883.2 mL, p < 0.01), number of red blood cell units transfused (1.0 versus 2.2, p < 0.01) and postoperative ventilation time (15.3 versus 19.2 h, p < 0.01) were significantly lower in the minimally invasive group. Similarly, overall hospital (8.4 versus 9.4 days, p < 0.01) and intensive care unit stay (1.5 versus 1.8 days, p < 0.01) were decreased in minimally invasive group. Overall survival was significantly improved in minimally invasive patients (Hazard Ratio: 0.54, p = 0.045), which was not confirmed by two-stage meta-analysis (Hazard Ratio: 0.72, p = 0.29). Bypass and cross-clamp times, reinterventions, bleeding events and wound infections were comparable between the two groups.
Conclusion
Minimally invasive proximal aortic surgery reduces perioperative morbidity, hospitalization and transfusion requirements compared with full sternotomy. While a survival benefit requires further confirmation, these findings support minimally invasive approaches as an effective and safe alternative in selected patients.
PaparellaDFattouchKMoscarelliM, et al.Current trends in mitral valve surgery: a multicenter national comparison between full-sternotomy and minimally-invasive approach. Int J Cardiol2020; 306: 147–151.
2.
SchizasNSamiotisINazouG, et al.Perceval-S over time. Clinical outcomes after ten years of usage. J Cardiothorac Surg2024; 19: 192.
3.
BerrettaPGaleazziMCefarelliM, et al.Minimally invasive approach: is this the future of aortic surgery?Indian J Thorac Cardiovasc Surg2022; 38: 171–182.
4.
BeyerSESecemskyEAKhabbazK, et al.Elective ascending aortic aneurysm repair outcomes in a nationwide US cohort. Heart Br Card Soc2023; 109: 1080–1087.
5.
PageMJMcKenzieJEBossuytPM, et al.The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. Br Med J2021; 372: n71.
6.
WohlinC. Guidelines for snowballing in systematic literature studies and a replication in software engineering. In: Proceedings of the 18th international conference on evaluation and assessment in software engineering, pp.1–10. London England United Kingdom: ACM.
7.
OuzzaniMHammadyHFedorowiczZ, et al.Rayyan-a web and mobile app for systematic reviews. Syst Rev2016; 5: 210.
8.
HozoSPDjulbegovicBHozoI. Estimating the mean and variance from the median, range, and the size of a sample. BMC Med Res Methodol2005; 5: 13.
9.
WanXWangWLiuJ, et al.Estimating the sample mean and standard deviation from the sample size, median, range and/or interquartile range. BMC Med Res Methodol2014; 14: 135.
10.
AndradeC. Mean Difference, Standardized Mean Difference (SMD), and their use in meta-analysis: as simple as it gets. J Clin Psychiatry2020; 81: 20f13681.
11.
WeiYRoystonP. Reconstructing time-to-event data from published Kaplan-Meier curves. Stata J2017; 17: 786–802.
GuyotPAdesAEOuwensMJNM, et al.Enhanced secondary analysis of survival data: reconstructing the data from published Kaplan-Meier survival curves. BMC Med Res Methodol2012; 12: 9.
14.
DerSimonianRLairdN. Meta-analysis in clinical trials. Control Clin Trials1986; 7: 177–188.
15.
AngererMPollariFHitzlW, et al.Isolated or combined ascending aortic replacement through a partial sternotomy: early and midterm outcomes. Thorac Cardiovasc Surg2025; 73: 43–50.
16.
HouBZhaoRWangD, et al.Outcomes of the valve-sparing root replacement procedure with partial upper sternotomy. J Cardiovasc Dev Dis2021; 8: 154.
17.
LamelasJChenPCLoorG, et al.Successful use of sternal-sparing minimally invasive surgery for proximal ascending aortic pathology. Ann Thorac Surg2018; 106: 742–748.
18.
KulacogluUKKayaM. Ministernotomy in aortic root and arch surgery: early outcomes. Braz J Cardiovasc Surg2023; 38: 15–21.
19.
LevackMMAftabMRoselliEE, et al.Outcomes of a less-invasive approach for proximal aortic operations. Ann Thorac Surg2017; 103: 533–540.
20.
MonsefiNRisteskiPMiskovicA, et al.Propensity-matched comparison between minimally invasive and conventional sternotomy in aortic valve resuspension. Eur J Cardio-Thorac Surg Off J Eur Assoc Cardio-Thorac Surg2018; 53: 1258–1263.
21.
PapadopoulosNNtinopoulosVHaeusslerA, et al.Less invasive replacement of aortic root, ascending aorta and hemiarch via partial upper sternotomy: a propensity-score-matched comparison with full sternotomy. Interdiscip Cardiovasc Thorac Surg2024; 39: ivae120.
22.
ShahVNBinongoJWeiJ, et al.Upper hemisternotomy versus full sternotomy for replacement of the supracoronary ascending aorta and aortic valve. Innov Phila Pa2024; 19: 39–45.
23.
StaromłyńskiJKowalówkaAGocołR, et al.Comparative analysis of long-term outcomes in valve-sparing aortic root reimplantation: full sternotomy versus mini-sternotomy approach. J Clin Med2024; 13: 2692.
24.
TabataMKhalpeyZArankiSF, et al.Minimal access surgery of ascending and proximal arch of the aorta: a 9-year experience. Ann Thorac Surg2007; 84: 67–72.
25.
WächterKFrankeUFWYadavR, et al.Feasibility and clinical outcome after minimally invasive valve-sparing aortic root replacement. Interact Cardiovasc Thorac Surg2017; 24: 377–383.
26.
van KampenAEtzCDHaunschildJ, et al.The feasibility of less-invasive Bentall surgery: a real-world analysis. Life Basel Switz2023; 13: 2204.
27.
BerrettaPChiuselliGGaleazziM, et al.Comparison of minimally invasive versus conventional thoracic aortic operations: early and midterm results in a series of 624 patients. J Card Surg2022; 37: 4732–4739.
28.
HastaogluİOTokozHOzgenA, et al.Proximal aortic surgery: upper ‘J’ or conventional sternotomy?Heart Surg Forum2018; 21: 004–E008.
WuYJiangWLiD, et al.Surgery of ascending aorta with complex procedures for aortic dissection through upper mini-sternotomy versus conventional sternotomy. J Cardiothorac Surg2020; 15: 57.
31.
XieX-BDaiX-FFangG-H, et al.Extensive repair of acute type A aortic dissection through a partial upper sternotomy and using complete stent-graft replacement of the arch. J Thorac Cardiovasc Surg2022; 164: 1045–1052.
32.
HarkyAAl-AdhamiAChanJSK, et al.Minimally invasive versus conventional aortic root replacement - a systematic review and meta-analysis. Heart Lung Circ2019; 28: 1841–1851.
33.
RaynerTAHarrisonSRivalP, et al.Minimally invasive versus conventional surgery of the ascending aorta and root: a systematic review and meta-analysis. Eur J Cardio-Thorac Surg Off J Eur Assoc Cardio-Thorac Surg2020; 57: 8–17.
34.
PiekarskiFRohnerMMonsefiN, et al.Anesthesia for minimal invasive cardiac surgery: the Bonn heart center protocol. J Clin Med2024; 13: 3939.
35.
BerrettaPDe AngelisVAlfonsiJ, et al.Enhanced recovery after minimally invasive heart valve surgery: early and midterm outcomes. Int J Cardiol2023; 370: 98–104.
36.
DiebergGSmartNAKingN. Minimally invasive cardiac surgery: a systematic review and meta-analysis. Int J Cardiol2016; 223: 554–560.
37.
SalengerRLobdellKGrantMC. Update on minimally invasive cardiac surgery and enhanced recovery after surgery. Curr Opin Anaesthesiol2024; 37: 10–15.
38.
TrivediVBleekerHKantorN, et al.Survival, quality of life, and functional status following prolonged ICU stay in cardiac surgical patients: a systematic review. Crit Care Med2019; 47: e52–e63.
39.
DiabMSBilkhuRSoppaG, et al.The influence of prolonged intensive care stay on quality of life, recovery, and clinical outcomes following cardiac surgery: a prospective cohort study. J Thorac Cardiovasc Surg2018; 156: 1906–1915.e3.
40.
SáMPBOVan den EyndeJCavalcantiLRP, et al.Mitral valve repair with minimally invasive approaches vs sternotomy: a meta-analysis of early and late results in randomized and matched observational studies. J Card Surg2020; 35: 2307–2323.
41.
KhoshbinEPrayagaSKinsellaJ, et al.Mini-sternotomy for aortic valve replacement reduces the length of stay in the cardiac intensive care unit: meta-analysis of randomised controlled trials. BMJ Open2011; 1: e000266.
42.
TemanNRHawkinsRBCharlesEJ, et al.Minimally invasive vs open coronary surgery: a multi-institutional analysis of cost and outcomes. Ann Thorac Surg2021; 111: 1478–1484.
43.
ObafemiTMullisDBajajS, et al.Results following implementation of a cardiac surgery ERAS protocol. PLoS One2023; 18: e0277868.
44.
SenageTGerrardCMoorjaniN, et al.Early postoperative bleeding impacts long-term survival following first-time on-pump coronary artery bypass grafting. J Thorac Dis2021; 13: 5670–5682.
45.
SankarARotsteinAJTejaB, et al.Prolonged mechanical ventilation after cardiac surgery: substudy of the Transfusion Requirements in Cardiac Surgery III trial. Can J Anaesth J Can Anesth2022; 69: 1493–1506.
46.
KinnunenE-MDe FeoMReichartD, et al.Incidence and prognostic impact of bleeding and transfusion after coronary surgery in low-risk patients. Transfusion (Paris)2017; 57: 178–186.
47.
KochCLiLFigueroaP, et al.Transfusion and pulmonary morbidity after cardiac surgery. Ann Thorac Surg2009; 88: 1410–1418.
48.
SultanIBiancoVBrownJA, et al.Long-term impact of perioperative red blood cell transfusion on patients undergoing cardiac surgery. Ann Thorac Surg2021; 112: 546–554.
49.
RemyKEHallMWCholetteJ, et al.Mechanisms of red blood cell transfusion-related immunomodulation. Transfusion (Paris)2018; 58: 804–815.
50.
MazerCDWhitlockRPFergussonDA, et al.Six-month outcomes after restrictive or liberal transfusion for cardiac surgery. N Engl J Med2018; 379: 1224–1233.
51.
HuRTRoyseAGRoyseC, et al.Health-related quality of life after restrictive versus liberal RBC transfusion for cardiac surgery: sub-study from a randomized clinical trial. Transfusion (Paris)2022; 62: 1973–1983.
52.
ShehataNMistryNda CostaBR, et al.Restrictive compared with liberal red cell transfusion strategies in cardiac surgery: a meta-analysis. Eur Heart J2019; 40: 1081–1088.
53.
ChengNGaoCYangM, et al.Analysis of the learning curve for beating heart, totally endoscopic, coronary artery bypass grafting. J Thorac Cardiovasc Surg2014; 148: 1832–1836.
54.
JonssonABinongoJPatelP, et al.Mastering the learning curve for robotic-assisted coronary artery bypass surgery. Ann Thorac Surg2023; 115: 1118–1125.
55.
MorrisTPFisherDJKenwardMG, et al.Meta-analysis of Gaussian individual patient data: two-stage or not two-stage?Stat Med2018; 37: 1419–1438.
56.
BurkeDLEnsorJRileyRD. Meta-analysis using individual participant data: one-stage and two-stage approaches, and why they may differ. Stat Med2017; 36: 855–875.
57.
WhiteleyJToolanCShawM, et al.Patient-reported outcome measures after mitral valve repair: a comparison between minimally invasive and sternotomy. Interact Cardiovasc Thorac Surg2021; 32: 433–440.
58.
WaltherTFalkVMetzS, et al.Pain and quality of life after minimally invasive versus conventional cardiac surgery. Ann Thorac Surg1999; 67: 1643–1647.
59.
SicouriSShahVNOrlovCP, et al.Assessment of pain, anxiety and depression, and quality of life after minimally invasive aortic surgery. J Card Surg2021; 36: 886–893.
Supplementary Material
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
