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ANTEGRADE AND RETROGRADE ARTERIAL PERFUSION STRATEGY IN MINIMALLY INVASIVE VALVE SURGERY PERFORMED THROUGH THE RIGHT CHEST: A PROPENSITY SCORE ANALYSIS ON 2379 PATIENTS
Michele Murzi, Alfredo G. Cerillo, Pierandrea Farneti, Enkel Kallushi, Marco Solinas.
Fondazione Toscana Gabriele Monasterio, Massa, Italy.

OBJECTIVE: Recent studies have suggested a link between postoperative stroke and retrograde perfusion in minimally invasive valve surgery. The aim of the present study is therefore to evalute the impact on early outcome of retrograde arterial perfusion strategy versus antegrade arterial perfusion strategy in a consecutive large cohort of patients who underwent minimally invasive mitral and aortic valve surgery through a right minithoracotomy.
METHODS: Between 2003 and 2015, 2379 consecutive patients underwent first-time minimally invasive mitral (1621 patients; 69.7%) and aortic (751 patients; 30.3%) valve surgery at our institution. 227 (9.5%) of these patients received a retrograde perfusion, while 2152 (90.5%) antegrade perfusion. Logistic analysis was used to evaluate outcomes and risk factors for stroke. Treatment selection bias was controlled by a propensity score from core patient characteristics. The propensity score was the probability of receiving retrograde perfusion and was included along with the comparison variable in the multivariable analyses of outcome.
RESULTS: The overall frequency of in hospital mortality was 0.8% (21/2379) and postoperative stroke was 1.8% (43/2379). After adjusting for the propensity score, retrograde arterial perfusion was associated with an higher incidence of stroke (3.8% vs 0.9%; p=0.02), postoperative delirium (13% vs 4%, p=0.001) and aortic dissection (1.2% vs 0%; p=0.01). The multivariable regression analysis revealed that the use retrograde perfusion was an independent risk factor for stroke (OR 3.57; p=0.02) and postoperative delirium (OR 2.96; p=0.001). Finally, the bootstrapping interaction model revelead that the use of retrograde arterial perfusion in patients with atheriosclerotic burden disease was the only significant risk factor for stroke (OR 4.38; p=0.03).
CONCLUSIONS: Minimally invasive valve procedure through the right chest can be performed with low morbidity and mortality. Retrograde perfusion is associated with an higher incidence of neurologic complications and aortic dissection when compared with antegrade perfusion. Central aortic cannulation avoids complications associated with retrograde perfusion while extends the suitability of minimally invasive procedures also to those patients who have an absolute controindication to femoral artery cannulation.
Risk-Adjusted Clinical Outcome
Variables %Retrograde Perfusion
(n = 227) 9.5%
Antegrade Perfusion
(n = 2152) 90.5%
ADJUSTED ORp-value
In-hospital mortality0.80.90.974 (0.3-6.6).862
Stroke3.80.93.57 (1.4-12.7).002
Delirium1342.96 (0.6-8.1).001
Aortic Dissection1.201.71 ( 0.9-14.6).001
Perioperative Myocardial Infarction1.60.91.96 (0.5-7.4).349
Renal Dysfunction0.41.80.24 (0.3-1.8).142
Reoperation for Bleeding43.61.23 (0.5-2.8).737
Pulmonary complications1.60.91.8 (0.51-6.83).453


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