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

Objective: 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. Methods: 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. Results: 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. Conclusions: 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.