Axillary Versus Sternotomy Access in Minimally Invasive Mitral Valve Surgery: A Systematic Review and Meta-Analysis

Minimally invasive cardiac surgery for mitral valve (MV) disease is a rising strategy. Axillary access is linked to reduced pain and faster recovery, but its efficacy and safety compared with median sternotomy for MV surgery (MVS) remain unclear. We conducted a meta-analysis comparing the clinical outcomes of MVS via axillary access and median sternotomy.

Four databases were analyzed. The primary endpoint was perioperative mortality. Secondary endpoints included cardiopulmonary bypass (CPB) and cross-clamp times, rethoracotomy, wound complications, mechanical ventilation duration, stroke, hospital and intensive care unit (ICU) stay, and residual moderate mitral regurgitation. A random-effects model was used.

We included 2,129 patients from 4 studies, with 1,135 (53.3%) undergoing axillary access. Perioperative mortality was comparable between approaches (odds ratio [OR] = 0.34, 95% confidence interval [CI]: 0.09 to 1.23, P = 0.10). Axillary access was associated with longer CPB times (mean difference [MD] = 16.38, 95% CI: 6.42 to 26.34, P = 0.001), fewer wound complications (OR = 0.41, 95% CI: 0.21 to 0.80, P = 0.009), shorter ventilation time (MD = -4.93, 95% CI: -8.79 to -1.08, P < 0.01), and shorter hospital (MD = -0.78, 95% CI: -1.41 to -0.14, P = 0.02) and ICU stays (MD = -10.84, 95% CI: -19.54 to -2.14, P = 0.01). No difference was found in cross-clamp time, rethoracotomy, stroke, or residual mitral regurgitation.

Axillary access for MVS shows comparable mortality to median sternotomy, with benefits in wound complications, ventilation, and recovery but longer CPB times. Further research is needed to confirm long-term safety and efficacy.