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MYOCARDIAL PROTECTION IN MINIMALLY INVASIVE MITRAL SURGERY, USING THE ENDOVASCULAR CORONARY SINUS CATHETER ALONE, IS AT LEAST EQUIVALENT TO OPEN MITRAL SURGERY
Jean-Sébastien Lebon, Pierre Couture, Christian Ayoub, Antoine Rochon, Alain Deschamps, Baqir Qizilbash, Éric Laliberté, Michel Pellerin, Denis Bouchard.
Montreal Heart Institute, Montréal, QC, Canada.

Objective
One of the most important challenges in minimally invasive mitral surgery (MIMS) remains to provide optimal endoscopic myocardial protection. We hypothesize that the quality of myocardial protection offered by an endoscopic retrograde cardioplegia alone in MIMS when a transthoracic aortic clamp is used could be equivalent to the combined antegrade and retrograde strategy in open mitral surgery (OMS).
Methods
After institutional approval, charts of patients admitted for MIMS were reviewed. Patients without coronary artery disease undergoing isolated elective OMS were used as a control group. Our primary end-point was to compare myocardial protection as illustrated by myocardial enzymes (troponin and CK-MB). We also gathered statistics regarding myocardial function, hemodynamic stability and complications.
MIMS requires retrograde cardioplegia to be administered through an endovascular coronary sinus (CS) catheter. After aortic transthoracic clamping, cardioplegia was administered at a variable rate to generate a CS pressure ≥ 30 mmHg. If after 5 minutes asystole was not attained, a needle was inserted in the aortic root for antegrade cardioplegia. Adequate retrograde cardioplegia administration was monitored by CS pressure (≥ 30 mm Hg) and asystole during CBP.
Results
Data was collected from 98 MIMS files and 118 OMS files. Adequate intra-operative cardioplegia administration was attained in 73 patients (74%) with retrograde alone and 23 patients (23%) needed the addition of an antegrade cardioplegia needle. Failure to adequately position the CS catheter was observed in only 2 patients (3%). Significantly less MIMS patients required administration of a second inotropic agent. No statistically significant difference was found for maximal CK-MB and number of patients with CK-MB levels > 50 or >100 UI/L. However, mean troponin and lactate levels in MIMS were significantly lower. In the MIMS group, mean troponins were even significantly lower in patients receiving retrograde alone.
Conclusions
A cardioplegia strategy based on the endovascular CS catheter alone with or without the addition of an antegrade needle in MIMS provides at least equivalent myocardial protection when compared to OMS.
Myocardial protection variablesMIMS
(n=97)
OMS
(n=118)
p
CK-MB max39.135.90.4413
CK-MB > 5020290.4738
CK-MB > 100030.1125
Tropo T max0.390.65< 0.0001
Lactate max2.12.50.0022
Lactate increase1.41.60.1879
Difficult CPB weaning350.6591
Perioperative MI010.3685
Ischemic EKG change010.3635
Malignant post-op arythmia001.0000
NA arrival ICU931070.1365
NA 24h post-op18120.0774
2nd inotropic drug arrival ICU9280.0052
2nd inotropic drug 24h post-op5170.0276


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