Left Atrial or Transeptal Approach for Mitral Valve Surgery: A Systematic Review and Meta-analysis

•Longer operative times with transeptal approach in patients undergoing double valve surgery.•Higher rate of permanent pacemaker and atrial fibrillation in double valve surgery.•Similar outcomes, operatively and postoperatively, in isolated mitral valve surgery cases. To compare outcomes of mitral valve surgery through conventional left atriotomy and transeptal approach (TS). Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. Primary outcomes were operative mortality and permanent pacemaker (PPM) implantation; secondary outcomes were new onset of atrial fibrillation (AF), stroke and operative times. Sixteen articles met the inclusion criteria with 4537 patients. Cardiopulmonary bypass was longer with TS (weighted mean differences - 16.44 minutes [−29.53, −3.36], P = 0.01). Rates of PPM implantation (risk ratio 0.65 [0.47, 0.89], P = 0.007) and new onset AF (risk ratio 0.87 [0.78, 0.97], P = 0.02) were higher with TS. Subgroup analysis of isolated mitral valve surgery cohort showed no difference in operative times, mortality, new onset of AF, stroke, and PPM implantation. There is equal outcomes between both approaches during isolated mitral valve surgery; however, TS was associated with longer operative times and higher postoperative AF and PPM rates when pooling combined procedures. A large randomized controlled trial is required to confirm those findings.