Grossi et al. [39] found that a right thoracotomy was associated with 51% fewer blood products than a conventional Enzastaurin Phase 3 sternotomy. In robotically assisted MVR, transfusion requirements are even lower (20% to 45% require transfusions) [11, 78]. Furthermore, 4 comparative studies found less blood loss: a minithoracotomy was used in 3 [26, 30, 31] and a parasternal approach was used in 1 [42]. Three of 10 studies found reduced transfusion requirements with a minimally invasive approach compared with conventional surgery [8, 34, 38] whereas the others showed no difference [31, 33, 42, 46, 65, 67, 77]. More convincing evidence came from a subsequent study by the same group that showed 13% fewer total transfusions with 1.8 fewer units of red blood cells using a minithoracotomy compared to a sternotomy [39].
Similar data from Cohn et al. confirm that patients undergoing minimally invasive valve surgery are transfused 1.8 units less compared to a conventional cohort [8]. Two of seven studies [56, 65] demonstrated a reduced need for reoperation for bleeding with a minimally invasive approach [38, 42, 44, 46]. Further, 5 studies showed a significant reduction in reoperations for bleeding with a minimally-invasive approach [32, 38, 42�C44, 49, 64]. The recent data from the Leipzig group on postoperative course included reoperation for bleeding in 69 patients (5.1%) [3]. 7. Atrial Fibrillation It has been suggested that a less traumatic surgical approach would be a less potent trigger of postoperative AF.
Nonetheless, 5 of 6 studies demonstrated that this is not the case [10, 30�C33, 46], and on meta-analysis of four eligible studies, there was no significant difference between minimally invasive and sternotomy approaches (539 patients, OR 0.86, 95% CI 0.59�C1.27, P = 0.45). Asher et al. [33] addressed this question in a cohort of 100 patients having elective primary minimally invasive AV or MV surgery compared with a matched control group undergoing conventional sternotomy. They found a similar prevalence of post-operative AF using either method, even after stratifying for valve type. However, the PAIR registry reported a 10% incidence of new-onset AF with the port access technique, which is lower than that expected for sternotomy [33]. 8. Septic Complications The incidence of wound infections and septic complications is lower with a thoracotomy than with a median sternotomy.
Of the three studies of minithoracotomy mitral valve surgery that reported wound complications compared to median sternotomy, Grossi et al. reported an incidence of 0.9% and 5.7% for minithoracotomy and sternotomy cases, respectively (P = 0.05) [34]. This increased to 1.8% and 7.7%, respectively, in elderly patients (P = 0.03) [34], whereas Felger et al. reported no significant difference [30]. 9. Pain, Quality of Life and Speed of Recovery Compared with a complete sternotomy, thoracotomy incisions are associated with less pain, discomfort, Drug_discovery and postoperative analgesics [30].