Quality of Life After Minimally Invasive Aortic Valve Replacement Surgery: A Systematic Review

Abstract

Objective:

Aortic valve replacement surgery (AVR) via median sternotomy (MS) is the standard surgical intervention used for AVR. However, the minimally invasive approach is becoming more widely adopted. This review focuses on quality of life (QoL) after minimally invasive AVR (MIAVR). The aim of this review is to comprehensively analyze the current body of evidence for QoL after MIAVR. A second aim is to determine whether a conclusion can be made based on the literature to indicate whether MIAVR is more beneficial to the patient compared with MS and should be the preferred approach.

Methods:

A literature search was conducted in the PubMed database using relevant searches. Papers were either included or excluded based on their title. Through a cross-reference check from the papers identified by the search, further articles were identified. Initially, 375 manuscript titles and abstracts were screened, with 11 being included in this review.

Results:

The 11 studies comparing postoperative QoL between MIAVR and MS were comprehensively analyzed. Three studies showed no significant differences between the groups; however, 8 identified better QoL after surgery in the MIAVR group. Three studies investigated pulmonary function after MIAVR and MS, concluding that MIAVR demonstrated superior pulmonary function.

Conclusions:

Overall, MIAVR can be performed with acceptable postoperative QoL. However, the current literature is sparse, and it is not possible to say whether one approach is better than the other. MIAVR is certainly not inferior to MS in terms of QoL. Well-designed, randomized controlled trials are needed to draw more definitive conclusions.

Visual abstract.

Central Message.

Overall, this review found that MIAVR can be performed with acceptable postoperative quality of life, with exciting prospects for the future. For AVR, standard practice should be either MIAVR or MS depending on physician preference and expertise.

Introduction

Aortic valve replacement (AVR) via median sternotomy (MS) is the standard surgical intervention. However, minimally invasive (MI) approaches are becoming more widely used. Besides a better cosmetic result, AVR via right anterior thoracotomy (RAT; also known as minithoracotomy) has been shown to result in less postoperative blood transfusion requirements and shorter hospital and intensive care unit (ICU) stays despite longer aortic cross-clamp and cardiopulmonary bypass (CPB) times.^{1 –5} This review focuses on quality of life (QoL) after MIAVR, as no systematic reviews or meta-analyses have been carried out specifically regarding this topic. There are different ways of measuring QoL; however, the 36-Item Short Form Health Survey (SF-36) is the most reliable and most frequently used tool in the literature. This review analyzes the open approaches carried out via a small incision, other than MS. An MI approach, as defined by the American Heart Association, is “a small chest wall incision that does not include full sternotomy.” ⁶ There are various types of MI incisions for MIAVR. This study will focus on the RAT and ministernotomy approaches.

Objective

The aim of this review was to comprehensively analyze the current body of evidence for QoL after MIAVR. A second aim was to determine whether a conclusion can be made based on the current literature to indicate whether MIAVR is more beneficial to the patient compared with MS and should be the preferred approach.

Methods

A thorough literature search was conducted in the PubMed database in April 2024, using the following terms: “((minimally invasive aortic valve replacement) OR (minimally invasive aortic valve surgery)) AND ((quality of life) OR (pain control))” and “((minimally invasive aortic valve replacement) OR (minimally invasive aortic valve surgery)) AND ((quality of life) OR (patient satisfaction) OR (satisfaction) OR (mobility) OR (SF-36) OR (SF-36 questionnaire) OR (questionnaire)).” Through cross-reference checks from the articles identified by the search, further articles were identified. Papers were either excluded or included based on their title (reviewed by M.H.). More specifically, the inclusion criteria consisted of studies that investigated QoL after MIAVR or MS. The exclusion criteria for this study included studies that did not investigate QoL after MIAVR or MS and studies not written in the English language. Initially, 375 manuscript titles and abstracts were screened, with a total of 11 being included in this review.

Results

QoL after surgery is an important factor in deciding which medical interventions benefit the patient more favorably. Several studies have investigated QoL after MIAVR (Table 1, Supplemental Table). Glauber et al. conducted a propensity score–matched study to compare the early outcomes and midterm survival of patients undergoing RAT and MS. ⁷ They discovered that the RAT approach was associated with a reduced incidence of postoperative atrial fibrillation and fewer blood transfusions. However, the rates of stroke, renal failure, re-exploration for bleeding, and wound infections were comparable between the 2 groups. They also concluded that further prospective randomized trials are necessary to validate their findings.

Table 1.

QoL After MIAVR Studies.

Authors (date)	Level of evidence and study type	Study design and patient groups	Minimal access approach
Glauber et al. (2013) 7	Retrospective, observational cohort study	138 patients underwent MIAVR matched to an MS control group of 138 patients	RAT
Gofus et al. (2020) 8	Prospective, level II	40 patients: 20 full sternotomy, 20 upper ministernotomy	Upper J ministernotomy
Al Jawad and Mourad (2022) 9	Prospective, questionnaire-based, nonrandomized study	189 patients underwent MIAVR: 96 ministernotomy, 93 right minithoracotomy	RAT, upper J sternotomy
Yamada et al. (2003) 10	Retrospective, level II	66 patients for MIAVR, 50 patients for MS Clinical records compared across intraoperative and QoL parameters	Upper J ministernotomy
Detter et al. (2002) 11	Prospective, level II	70 patients (mean age 64.3 ± 1.3 years) MIAVR, 70 patients conventional AVR during same time period Patients equally matched according to age, sex, valvular lesion, valve prosthesis, ejection fraction	L-shaped ministernotomy
Borger et al. (2015) 12	Prospective, randomized comparison trial, level II	100 patients: 51 underwent MIAVR, 49 underwent MS	Upper hemisternotomy
Rodriguez-Caulo et al. (2021) 13	Single-anonymized, randomized clinical trial, level II	100 patients involved, randomized in a 1:1 computational fashion Patients answered the QoL questionnaire Euro-QOL-Index at 1, 6, or 12 months after randomization	Partial upper J hemisternotomy
Aliahmed et al. (2018) 14	Retrospective propensity score matching, level II	70 patients who underwent MI AVR were compared with 70 patients who underwent MS
Stoliński et al. (2016) 15	Observational cohort study, level III	65 patients underwent MIAVR, 82 underwent MS PFTs performed preoperatively, 1 week, 1 month, and 3 months after surgery	RAT
Stoliński et al. (2017) 16	Prospective, propensity-matched, level II	212 patients scheduled for MI AVR and 212 patients scheduled for MS Respiratory function based on spirometry was assessed	RAT
Stoliński et al. (2017) 17	Retrospective, level III	201 patients scheduled for MIAVR and 316 for MS PFTs were carried out and analyzed	RAT

Abbreviations: AVR, aortic valve replacement; MI, minimally invasive; MS, median sternotomy; PFT, pulmonary function test; QoL, quality of life; RAT, right anterior minithoracotomy.

Gofus et al. compared 20 patients undergoing MIAVR via an upper “J” sternotomy with 20 patients undergoing MS. ⁸ When compared with the MS group, the MI group had significantly less blood loss postoperatively and showed a bigger improvement in physical function and general health status according to variance analysis. Al Jawad and Mourad conducted a prospective, nonrandomized study to examine the postoperative outcomes of 189 patients undergoing MIAVR via either RAT or ministernotomy. ⁹ The study used the SF-36 to evaluate the health-related QoL of the patients. They found that both surgical approaches significantly improved patient QoL. Notably, the RAT approach led to considerable enhancements in re-engagement in social and daily physical activities. In addition, the general health status of patients showed marked improvement compared with their condition 12 months prior to surgery.

A retrospective study conducted by Yamada et al. compared clinical records across intraoperative and QoL parameters of 66 patients undergoing MIAVR and 50 patients undergoing MS. ¹⁰ MIAVR was associated with decreased analgesic requirement after surgery, reduced incidence of postoperative delirium, and shorter ICU stay. Although there were longer CPB and aortic cross-clamp times, the results suggested MIAVR provides earlier recovery of activities of daily living and improved QoL during the early postoperative period.

Detter et al. prospectively analyzed 140 patients who were equally matched according to age, sex, valvular lesion, valve prosthesis, and ejection fraction; ¹¹ 70 patients underwent MIAVR and 70 patients underwent MS. This study was unable to show any advantage of MIAVR in early or midterm follow-up in terms of QoL (no differences in any of the 8 QoL parameters) and early postoperative outcomes. Furthermore, in a prospective, randomized comparison trial carried out by Borger et al., 94 patients split into an MIAVR group (n = 51) and MS group (n = 49) were assessed. ¹² There were no significant differences between the 2 groups in terms of QoL. The results suggested that MIAVR may be associated with reduced myocardial ischemic time and better valvular hemodynamic function when compared with MS.

In 2021, Rodríguez-Caulo et al. conducted a single-blind clinical trial that involved 100 patients randomized in a 1:1 computational fashion. ¹³ The results, based on the EQ-5D index, showed that ministernotomy provides improved QoL and satisfaction with faster recovery at 1 month after surgery compared with MS. In a propensity score–matched study carried out by Aliahmed et al., 70 patients undergoing MIAVR and 70 patients undergoing MS were analyzed and their results compared. ¹⁴ In terms of QoL in the first 7 days after surgery, a greater number of patients in the MI group could cough, deeply inhale/exhale, walk for a short distance, and brush their teeth when compared with the MS group.

Lung function is regarded as an important parameter when investigating QoL. Various studies by Stoliński et al. have shown improvements of lung function after MIAVR when compared with MS.^{15 –17} An observational cohort study involving 65 patients undergoing MIAVR and 82 patients undergoing MS found that MIAVR led to improved pulmonary function recovery in elderly patients compared with MS. ¹⁵ Pulmonary function tests (PFTs) were worse in the MS group a week after surgery. At 1 month after surgery, forced expiratory volume in 1 s, forced vital capacity (FVC), and total lung capacity (TLC) were significantly higher in the MIAVR group. Although PFTs had not returned to baseline levels at 3 months after surgery, the significant differences between the groups had diminished. In addition, there was a higher incidence of respiratory complications postoperatively in the MS group (18.3%) compared with the MIAVR group (12.3%). In a propensity-matched study by Stoliński et al., 212 patients undergoing MIAVR and 212 patients undergoing MS were compared using spirometry assessments. ¹⁶ The study found that pulmonary function was less impaired in the MIAVR group, with statistically significant differences observed at 1 week after surgery. The authors concluded that this finding suggests a more efficient early recovery of lung function and quicker mobilization for patients who undergo MIAVR. Furthermore, Stoliński et al. conducted another comparison between MIAVR (n = 201) and MS (n = 316) using spirometry assessments. ¹⁷ The spirometric analysis indicated that at 7 days after surgery, the MIAVR group exhibited higher values for TLC and vital capacity (P < 0.001 for both) and maximum inspiratory pressure (P = 0.006). These findings demonstrate that lung function was more impaired following MS compared with MIAVR.

Discussion

Key Findings

QoL after surgical interventions is a critical metric for evaluating the effectiveness of different medical procedures. Numerous studies have demonstrated that MIAVR offers several advantages over traditional MS techniques. For instance, MIAVR is linked to a lower incidence of postoperative complications such as atrial fibrillation and a reduced need for blood transfusions. These factors not only contribute to a more favorable recovery trajectory but also enhance overall patient outcomes.

Research indicates that patients who undergo MIAVR typically experience less intraoperative blood loss, which is associated with improved physical functioning and better health-related QoL scores after surgery. Furthermore, the reduced analgesic requirements associated with MIAVR lead to fewer side effects, allowing for a more comfortable recovery period. Patients also benefit from shorter stays in the ICU and a decreased incidence of respiratory complications, which are critical for a speedy recovery.

In terms of functional recovery, MIAVR patients demonstrate improved mobility and a quicker return to daily activities, positively affecting their social engagement and mental well-being. Although some studies have found no significant differences in midterm QoL between MIAVR and MS, the early postoperative benefits of MIAVR are well-documented, particularly in pulmonary function and overall recovery. Given the promising findings, further prospective randomized trials are warranted to confirm these advantages and enhance our understanding of how MIAVR can improve postoperative QoL in these patients.

Strengths

This study presents a comprehensive literature review with a clearly defined objective, enhancing the reliability and transparency of findings. It is the first systematic review consolidating all primary research on the QoL of patients undergoing MIAVR. The review incorporates a variety of studies, including randomized, prospective, and retrospective trials that encompass diverse patient populations and contribute to a robust evidence base, improving the generalizability of the findings. In addition, it emphasizes validated QoL assessment tools, such as the SF-36 and EQ-5D, ensuring consistent and reliable outcomes across studies.

While often seen as a drawback, heterogeneity in the scientific literature can provide significant advantages. This study’s inclusion of diverse patient groups allowed for a broader range of data, enhancing the understanding of how various factors influence QoL after MIAVR versus MS. Such diversity can uncover trends related to QoL variations based on age, comorbidities, or surgical techniques, which might be missed in more homogenous studies. By incorporating various study designs and demographics, this review enriches the analysis and strengthens findings through multiple lines of evidence. This approach also improves the applicability of results to real-world settings, where patient populations are rarely uniform, enhancing the external validity of the review without diminishing its impact on existing literature.

The criteria for assessing QoL in AVR have also been used to compare minimally invasive mitral valve surgery (MIMVS) with full sternotomy MVS.^{18 –20} Commonly employed tools include the SF-36 and EQ-5D questionnaires, which align with the findings of this study. These validated instruments offer a standardized approach to measuring health-related QoL, facilitating comparisons across studies, and enhancing reliability. They evaluate multiple health aspects, providing a comprehensive view of patient outcomes, and their adaptability to diverse cultural contexts increases the relevance of research results. Overall, the use of these tools improves the scientific integrity and practical significance of studies comparing MIAVR or MIMVS with MS.

Limitations

Most studies identified in this review were single center with small sample sizes, and neither physicians nor patients were anonymized to treatment modalities. This review focused solely on the PubMed database, and studies were included in this review based on their title, which may have potentially excluded other relevant studies. Evidence suggests that QoL may improve after MIAVR compared with MS, but many studies analyzed QoL at only specific postoperative periods, often in the short term. Although some studies attempted to balance groups through propensity score or EuroSCORE matching, selection bias remains a concern, and confounding variables such as surgeon expertise and patient comorbidities were not thoroughly controlled. Although this review emphasized the RAT and ministernotomy approaches, some studies using different techniques were included to ensure there were sufficient data for a comprehensive analysis. Other studies using different approaches are cited in the bibliography for further reference.^{21 –26}

Furthermore, this study may benefit from a meta-analysis, but limitations of this include considerable heterogeneity in methodologies, patient demographics, and surgical techniques, complicating the synthesis of results. In addition, small sample sizes, lack of anonymization, and varied QoL assessment tools such as the SF-36 and EQ-5D introduce potential biases and challenges in comparison. There is also potential for publication bias, as studies with favorable outcomes are more likely to be published, which may skew the findings. Lastly, many studies do not uniformly control for confounding variables, affecting the validity of a meta-analysis.

Conclusions

The current evidence surrounding QoL after MIAVR is mainly based on prospective, observational studies. These studies have shown that MIAVR is performed with comparable postoperative QoL as conventional surgery. The data also show that MIAVR is associated with shorter hospital and ICU stays leading to earlier mobilization, quicker recovery, and overall more cost-effectiveness. However, for QoL after AVR, the literature is sparse, and randomized controlled trials are needed to draw more definitive conclusions regarding which approach is best, MI or MS. After reviewing the literature, standard practice should be either MIAVR or MS depending on the physician’s preference and expertise, as the data currently support making the MI approach the sole standard practice for AVR surgery. Overall, MIAVR can be performed with acceptable postoperative QoL, with exciting prospects for the future. By no means is it inferior to MS in the context of QoL after surgery.