title: The role of minimal access valve surgery in the elderly. A meta-analysis of observational studies.
abstract: BACKGROUND
  Minimal access valve surgery, both mitral and aortic, may be related to improvement in specific post-operative outcomes, therefore may be beneficial for the subgroup of the elderly referred for valve surgery.
  
  
  METHODS
  A systematic literature review identified several different studies, of which 6 fulfilled criteria for meta-analysis. Outcomes for a total of 1347 patients (675 conventional standard sternotomy and 672 minimally invasive valve surgery) were assessed with a meta-analysis using random effects modeling. Heterogeneity, subgroup analysis with quality scoring were also assessed. The primary endpoint was early mortality. Secondary endpoints included intra and post-operative outcomes.
  
  
  RESULTS
  In the context of elderly patients, minimal access valve surgery conferred comparable early mortality to standard sternotomy (odd ratio (OR) 0.79, CI [0.40,1.56], p = 0.50) with no heterogeneity (p = 0.13); it was also associated with reduced mechanical intubation time (OR 0.48, CI [0.30,0.78], p = 0.003) and reduced post-operative length of stay (weighted mean difference (WMD) -2.91, CI [-3.09, -2.74] p < 0.00001), however both cardio-pulmonary bypass time and cross clamp time were longer (WMD 24.29, CI [22.97, 25.61] p < 0.00001 and WMD 8.61, CI [7.61, 9.61], p < 0.00001, respectively); subgroup analysis demonstrated statistically significant reduced post-operative length of stay for both minimally invasive aortic and mitral surgery (WMD -2.84, CI [-3.07, -2.60] p < 0.00001 and WMD -2.98, CI [-3.25, -2.71] p < 0.00001 respectively).
  
  
  CONCLUSIONS
  Despite a prolonged cardiopulmonary bypass and cross clamp time, minimally invasive valve surgery is a safe alternative to standard sternotomy in the elderly, with similar early mortality, and improvements in intubation time as well as length of stay.
authors.affiliation: Honorary Research Fellow, NHLI, Imperial College London, UK; GVM Care and Research, Anthea Hospital, Bari, Italy.
authors.forename: Marco
authors.initials: M
authors.lastname: Moscarelli
authors.affiliation: St Vincent's Hospital, Sydney, Australia. Electronic address: SamEmmanuel@Windowslive.com.
authors.forename: Sam
authors.initials: S
authors.lastname: Emmanuel
authors.affiliation: Department of Surgery and Cancer, Imperial College, Paddington, London, UK.
authors.forename: Thanos
authors.initials: T
authors.lastname: Athanasiou
authors.affiliation: GVM Care and Research, Anthea Hospital, Bari, Italy.
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Speziale
authors.affiliation: GVM Care & Research, Maria Eleonora, Palermo, Italy.
authors.forename: Khalil
authors.initials: K
authors.lastname: Fattouch
authors.affiliation: Department of Surgery and Cancer, Imperial College, Paddington, London, UK.
authors.forename: Roberto
authors.initials: R
authors.lastname: Casula
mesh_terms: D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D001021:Aortic Valve / Q000601:surgery*; D006348:Cardiac Surgical Procedures / Q000379:methods* / Q000401:mortality; D002315:Cardiopulmonary Bypass; D006801:Humans; D019060:Minimally Invasive Surgical Procedures / Q000379:methods* / Q000401:mortality; D008943:Mitral Valve / Q000601:surgery*; D015233:Models, Statistical; D064887:Observational Studies as Topic; D016896:Treatment Outcome
keywords: Aortic valve; Meta-analysis; Minimally invasive surgery; Mitral valve; Statistics