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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 variables | MIMS (n=97) | OMS (n=118) | p |
CK-MB max | 39.1 | 35.9 | 0.4413 |
CK-MB > 50 | 20 | 29 | 0.4738 |
CK-MB > 100 | 0 | 3 | 0.1125 |
Tropo T max | 0.39 | 0.65 | < 0.0001 |
Lactate max | 2.1 | 2.5 | 0.0022 |
Lactate increase | 1.4 | 1.6 | 0.1879 |
Difficult CPB weaning | 3 | 5 | 0.6591 |
Perioperative MI | 0 | 1 | 0.3685 |
Ischemic EKG change | 0 | 1 | 0.3635 |
Malignant post-op arythmia | 0 | 0 | 1.0000 |
NA arrival ICU | 93 | 107 | 0.1365 |
NA 24h post-op | 18 | 12 | 0.0774 |
2nd inotropic drug arrival ICU | 9 | 28 | 0.0052 |
2nd inotropic drug 24h post-op | 5 | 17 | 0.0276 |
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